MINNEAPOLIS (WCCO) — A healthcare inspection of the VA hospital in Minneapolis found some major issues when it comes to dealing with veterans in crisis.

The probe came at the request of Representative Tim Walz, who is now running for Governor. Walz was contacted by a family of a veteran who killed himself after being released from the Minneapolis VA.

“He was my little baby brother,” Alissa Harrington said.

To say Alissa Harrington and her brother Justin Miller were close is an understatement.

“I am extremely proud of him for his military service and for him deciding to serve our country,” said Harrington.

Justin was an artist, a trumpet player with the Marine Corp Band. But he was a Marine first.

“In 2005 in that summer his unit was deployed to Iraq to the Al Asaad air base. He wasn’t the same when he came back,” Harrington said.

Alissa says Justin reached out for help, first from a private therapist before reaching out to the VA.

“He kind of had a crisis and at that point he reached out to the VA crisis hotline. The crisis line told him to go into the emergency department,” Harrington said.

Justin was admitted for four days and was discharged. He killed himself 24 hours later.

“An investigation by the Federal government found several problems with the care Justin got at the VA mostly importantly there was no follow up plan.

“It’s maddening to see a bureaucracy having all these checks and balances and these safeguards in place and have them not used appropriately and with amazingly devastating consequences,“ Harrington said.

The Office of Inspector General’s report provided recommendations to the VA, like improving care collaboration across departments and engaging family members in Veteran’s mental health treatment plans.

“And we’ll never know if they had followed the rules and know why they were following the rules and those sets of regulations if he would still be alive today,” Harrington said.

The VA is starting to implement the recommendations. All but one will be completed this year.

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