Francis Guilfoyle, a 55-year-old homeless veteran, drove his 1985 Toyota Camry to the Department of Veterans Affairs campus in Menlo Park early in the morning of Dec. 3, took a stepladder and a rope out of the car, threw the rope over a tree limb and hanged himself.
It was an hour before his body was cut down, according to the county coroner’s report.
“When I saw him, my heart just sank,” said Dennis Robinson, 51, a formerly homeless Army veteran who discovered Guilfoyle’s body. “This is supposed to be a safe place where a vet can get help. Something failed him.”
Guilfoyle’s death is one of a series of recent suicides by veterans who live in the jurisdiction of the Department of Veterans Affairs Palo Alto Health Care System. The Palo Alto V.A. is one of the agency’s elite campuses, home to the Congressionally chartered National Center for Post-Traumatic Stress Disorder. The poor record of the Department of Veterans Affairs in decreasing the high suicide rate of veterans has already emerged as a major issue for policy makers and the judiciary.
On Wednesday, the V.A. Inspector General in Washington released the results of a nine-month investigation into the May 2010 death of another veteran, William Hamilton. The report said social workers at the department in Palo Alto made “no attempt” to ensure that Hamilton, a mentally ill 26-year-old who served in Iraq, was hospitalized at a department facility in the days before he killed himself by stepping in front of a train in Modesto.
The Bay Area was also shocked by the March 14 death of Abel Gutierrez, a 27-year-old Iraq war veteran, who the police said killed his mother and his 11-year-old sister before shooting himself. Two weeks earlier the Gilroy Police Department intervened to ask the V.A. to help Gutierrez.
An examination of each case reveals faulty communication inside the V.A. system, which missed opportunities to help the veterans.
“I know people at the V.A. care a lot and work hard, but it’s a pattern that’s disturbing,” said Representative Jerry McNerney, a Democrat from Pleasanton who serves on the House Veterans Affairs Committee. “It doesn’t look good.”
Last May, a three-judge panel of the United States Court of Appeals for the Ninth Circuit accused the department of “unchecked incompetence” and ordered it to overhaul the way it provides mental health care and disability benefits.
Noting that an average of 18 veterans commit suicide every day, Judge Stephen Reinhardt wrote, “No more veterans should be compelled to agonize and perish while the government fails to perform its obligations.” The department appealed, and Judge Reinhardt’s opinion has been temporarily vacated, pending a ruling from a an 11-judge panel of the Ninth Circuit.
Gordon Erspamer, a San Francisco lawyer representing the two groups that brought the suit, Veterans for Common Sense and Veterans United for Truth, said it was “incredible that this sorry record of ineptitude and lack of procedures for emergency cases continues even under the watchful eye of the Ninth Circuit.”
Two weeks before Gutierrez’s death, his family called the Gilroy Police Department and asked for officers to come to their home “to get him some help,” according to Sgt. Chad Gallacinao, a spokesman for the police department. Sergeant Gallacinao said a police officer who was also a military veteran was dispatched to the house and took notes.
Two days later, Sergeant Gallacinao said, the officer returned to the Gutierrez home with a representative of the Community Veterans Project, a nonprofit organization that trains law enforcement officials in interaction with psychologically wounded veterans.
“They made contact with the V.A. specifically to obtain services for Gutierrez,” Sergeant Gallacinao said.
Dave Bayard, a V.A. spokesman in Los Angeles, confirmed that a call had been placed to the Vet Center in Santa Cruz, but said the request was mild. “It wasn’t like ‘This guy is really in need of mental health,’” Bayard said.
The V.A. said Gutierrez had briefly received care at a department facility in Washington State, where he was a National Guardsman, but never visited a department campus in California.
In an e-mail, Kerri Childress, spokeswoman for the V.A. Palo Alto Health Care System, said that despite the intervention of the Gilroy Police Department in Gutierrez’s case, “We had no way of knowing he was even in the area.”
Shad Meshad, a Vietnam War veteran and former combat medic who heads the National Veterans Foundation, was unpersuaded. “It’s about time that they don’t make excuses,” Meshad said. “Why would you say it’s not serious when the police called?”
Meshad said the responses of Bayard and Childress were typical of the “finger-pointing” exhibited by the department when tragedy strikes.
Before Hamilton killed himself, he said he saw demon women and regularly talked to a man he had killed in Iraq. He had been admitted to the Palo Alto V.A.’s psychiatric ward before on nine separate occasions. Three days before he died, Hamilton’s father brought him to a community hospital in Calaveras County, which, according to hospital records obtained by The Bay Citizen, tried to transfer him to three V.A. hospitals, including the one in Palo Alto. But at 4:39 p.m., a department social worker wrote that day in his notes, the Palo Alto facilities “would not accept a transfer of a veteran for admittance this late in the day.”
Later that night, Hamilton was admitted to David Grant Medical Center at Travis Air Force base in Fairfield. That Sunday, the medical center discharged Hamilton. Within hours, he was dead.
V.A. officials have said they have no record of Hamilton being denied care and that their records do not show any telephone calls between the Calaveras County hospital and the Palo Alto V.A. But the inspector general’s report revealed that the Palo Alto hospital had no method of tracking incoming calls and that “no outgoing calls were recorded” from any Veterans Affairs Medical Center extension.
During the investigation into Hamilton’s death, the inspector general learned of yet another incident, in May 2011, when the doctor on duty refused to accept a veteran for treatment. According to the report, the psychiatrist said, “We don’t accept patients for transfer at night.”
In an e-mailed response to questions, Dr. Stephen Ezeji-Okoye, deputy chief of staff of the Palo Alto V.A., said that since Hamilton’s death his network had “revised our tracking mechanism so we are better able to analyze the disposition of any cases referred to the V.A. Palo Alto Health Care System.” Dr. Ezeji-Okoye said the Palo Alto V.A. had always accepted psychiatric patients 24 hours a day, every day of the year.
Childress, the agency spokeswoman, said the Palo Alto V.A. was committed to improving the quality and availability of mental health care. The hospital is building a new 80-bed inpatient mental health center, she said, which is scheduled to open in June. It will have “patient access to enclosed, landscaped gardens” and “ample use of natural light to all internal patients,” she said, with a color scheme “specifically selected to support the healing process.”
This article also appears in the Bay Area edition of The New York Times.