Veteran Suicide at Outpatient Clinic in South Carolina Highlights Tragic Missteps in Patient Care

Veteran Oversight Now

Jul 26 2023 • 47 mins

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses missteps in the care of a veteran who eventually committed suicide on the grounds of the Aiken Community Based Outpatient Clinic, part of the Charlie Norwood VA Medical Center in Augusta, Georgia. This edition also includes highlights of the VA OIG’s work from June 2023.


“In VA you're assigned a primary care provider called your PCP, that, in theory, should be the main provider you see. That's where all of your referrals start for specialty care, and that's how you gain continuity of care. Unfortunately, with this veteran he saw one provider, and then the next appointment saw a different provider, and then the third appointment saw a third provider.”

– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

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