A newly published report from Iowa's Office of Inspector General says there were several "shortcomings" in the treatment of a Davenport veteran who committed suicide last year.
Brandon Ketchum was deployed three times during his military service and was being treated for PTSD by the veteran's affairs office in Iowa City when he died.
According to the report, and a Facebook post by Ketchum, he asked to be admitted to a hospital the day before he killed himself, but was told it was at capacity.
Ketchum's psychiatrist also reported he did not show additional signs of distress.
The report added that if his psychiatrist was aware of Ketchum's history of suicidal thoughts and attempts, his doctor would have admitted him to a community hospital.
The OIG offers several recommendations including the VA more closely follow policies regarding follow-ups, update mental-health treatment plans, and ensure each veteran has a case coordinator.
The report specifies that it's difficult to tell whether or not the shortcomings in these processes at the Iowa City VA contributed to Ketchum's death.
View the full report here.