Terrance O’Hearn #IwasLutz

Terrance (Terry) Jeffery O’Hearn Born Jan 20, 1986 – Died by Hanging Feb 5, 2016. About 2 weeks after his 30th birthday. His body found 7 days after being released from the Mather VA Behavioral Health clinic for a severe suicide attempt on Jan 11th 2016. I have no proof of life after the Feb 1st. 2016. Feb 5th 2016 is the day they found him and called his death.  His last meal was some hostess little chocolate covered donuts and a can of coke.

From the mother of SPC O’Hearn

Here are the basic facts of Terry’s death:
He was an Army Specialist and honorably discharged in 2010 after tours in Iraq and Afghanistan. Terry was not really the same after his return to civilian life and in 2012, I took him to the Mather VA Medical Center because he was quite anxious and having trouble sleeping. The VA saw him right away. He was prescribed some medications that seemed to provide some immediate help.

In May 2013, Terry tried to commit suicide by cutting his wrists. He called the Veterans Crisis Line. Who answered and treated Terry’s call for help  with respect all the while getting him to the Local Law Enforcement.  He was taken to the Palo Alto VA Center HVRP. (Homeless Veterans Rehabilitation Program). While there he was diagnosed with PTSD and rated to 70%. In the beginning, Terry was accessible and none of his family had any concerns for his care or issues with the VA. But at the same time no one from the VA engaged us in his care. In January 2014, they moved him to a “shelter” while he was looking for employment and housing.

In April 2014, we received word from Terry by mail. The letter was disconcerting and raised red flags. We immediately took action to reach him. I was working at Ramstein AB in Germany and my daughter, Megan, was in North Carolina. We could not get answers via the phone. This is the first time we could not talk with the “VA” regarding Terry. So my daughter, Megan, boarded a plane to Palo Alto to find her brother.

Once there, she was met with more difficulties in place by the VA. Finally, her concerns fell upon a doctor’s sympathetic ears, who was then able to “locate” Terry. He agreed to have contact by telephone but not disclose his location.

They spoke and she asked Terry to come home with her and told him how much she loved him; Terry just laughed at her and told her to “forget about him he wasn’t worth the trouble” and basically ended the call. That was the last conversation she had with her brother.

The good news, we knew they had eyes on him and they knew he was not right. In the VA records, the doctor annotated Megan’s visit; and that Terry had been returned to a mental health medical facility.. That once again he was high risk suicide. No one from the VA engaged Megan while she on site with Terry’s plan of care. No Chaplin was offered, no PTSD website or literature. This is what we refer to as the VA Wall. Terry was behind the wall and he had pulled his HIPAA and we could not access him. Although I continued to write to him, I did not get any letters in return.

In August 2014, I returned to California after my USAFE contract was up. I went to Palo Alto to locate my son. No one would/could help me. I searched for two days and repeatedly heard “sorry, I can’t help you.” Some said they didn’t know how to help me and others just plain ignored me. I was asked to sit in lobbies and wait, “and someone would be out to see me” and no one ever came. Three different lobbies all the same response. I had one offer to have a look and call me. That call never came.

In August 2014, the VA gave Terry up to 70% disability rating and back paid him to the May 2013 – his initial visit at HVRP. The checks were sent to the last address on record, my ex-husband’s house in San Leandro. We set them aside not sure what to do with them since we did not know where he was. Then nearing the end of September, I received a call from Terry. He was looking for his checks/mail and had made arrangements to come by. He’d been living in a halfway house for veterans awaiting his benefits from the VA. He spent the night. We had a good time. We had dinner and breakfast together.

Terry’s compensation benefits turned out to be one check for $20,000 (back pay), and one for $1400 (monthly benefits) due to disabilities linked to his military service. I helped cash his checks; we talked about where he would go and what he could afford to live on. We talked about a road trip across the US, up Northern California with a brother in Oregon and sister in Louisiana at that time. He said he would call once he knew what direction and he was settled. I remember watching him drive away thinking this just can’t be good.

We did not know where Terry was for a year. Christmas came and went with no word; then New Year’s, his birthday and Mother’s Day. By my birthday in August 2015, we were full on worried for him. “Have you heard from Terry” was a common question.

Megan’s birthday, October 1st, she called me to say that she had a dream about her brother and said, “We NEED to find him.” In the dream, he was in a dark place and he was scared and looking for us. Strange as but may sound, I had a very similar dream a few days before. That day I committed to finding Terry even if I had to hire a Private Detective.

After some quick thinking, and doing some research on Google, I was able to find him in Marysville, California, a town where we used to live. All attempts at making contact with him, whether by letters, notes left outside or by the cell phone that I left for him, went unanswered. I left my number with the woman who lived next door. I asked her to call me if she ever saw something that a “mom” would want to know.

Over the next weeks, I dropped off cards, food, gift cards and pictures of our family — he never opened the door. Even an “appointment” made to take him to dinner was answer by a note on the window that read, “he loved me, he was not going to open the door until the 3rd of Nov for me or anyone else, and he was safe and well. To come back then.” I thought about going to the VA, again, but you must understand that I felt the VA was my adversary. Plus, I thought Terry would have been really mad at me. On November 3rd, I received a text from random phone number that said, “Don’t come. I will explain in a letter.” The letter never came.

Over the next few weeks I would go by and leave gift cards for food and then a gift card for Walmart for a Christmas present. I let him know I would not be back until after the New Year as I was going out of town for the holiday to see Megan. I was hoping he would be able to relax knowing that I was not coming by.
On January 11, 2016, I received a text from the woman next door who said the police were at his apartment. On January 11, Terry tried to commit suicide at his home in Marysville with a homemade shot gun. The gun just wasn’t powerful enough or he made it wrong and it only gave him a good thump in his chest. He was taken to the local civilian hospital (Rideout Memorial) then after about 30 hours in ICU he was moved to their mental ward. I was able to see and speak with Terry twice during his stay at Rideout. In both conversations he was very angry and combative with me. He NEVER spoke to me like that in his entire life, and I swear to you, Terry, Megan and I have never had cross words. Ever.

On January 14th, he was transferred and admitted at the Mather VA in Sacramento. They certified him MH 1760, notice of Certification (5250) on January 16th, which stayed in effect until the 29th day of his discharge. During his visit I tried to visit at least every other day. I was told he is not taking visitor’s time and turned away each time. I did not see him any time while he was there.

January 20th, Terry spent his 30th birthday on the unit. I tried to visit and was turned away, again, without explanation. I thought Terry was saying not to let me in, but after reading his records, there was not one entry that I was there for a visit and was turned away by him, nothing about me being there and being turned away. I don’t know if he even knew I was there!

On the 22nd, I spoke with a VA patient advocate and they explained as part of the PTSD “disorder” Terry has removed everyone his life and he has no one who is looking out for him. I asked for help with family re-integration while he was there, like “on site family counseling.” She couldn’t help, but suggested I write the Social Worker a letter explaining some of the details of Terry’s life and the request for family re-integration.

January 25th, I went to Behavioral Health to drop off the letter and was surprised to actually meet with the Social Worker who explained to me she wasn’t going to take the letter and that she could not “talk” to me about Terry due to privacy laws. I have been dealing with the VA long enough now to know this, I said, “I don’t want YOU to talk to ME about Terrance. I want to talk with YOU about him.”

I explained that the Terry I spoke with the Rideout Hospital was not MY Son. He was not “right” and worse as I have ever seen him, and I went on to say, “he has no one in his personal life looking out for him because he has systematically isolated himself from anyone who knows him; to include moving to a town over two hours away and not letting anyone know where he was.” Isolation, another wonderful effect of PTSD. I said, “he won’t even open the door when people come to the door.” I asked her, “please” while he was there, “let’s get him to have family re-integration at least as part of his care plan. He has no safety net at home and please don’t let him go until there is a plan in place.” She said, “Terry has (privacy) rights and the VA cannot make him reintegrate with his family, or anyone else.” He would be released when HE says he is ready to go, and the VA will put a suicide safety plan in place to protect him.

I will say I did get snippy when she told me that they will put a “Suicide Safety Plan” in place when Terrance goes home. I did say “was that that the same suicide safety plan he was working when he got here this time?? In case you hadn’t noticed, that boy in there, hand crafted a shotgun and put it up to his chest and pulled the trigger! Where was your safety plan then?”

She then told me to go AWAY and to let them (the VA) do THIER job. Up until this point I was trying 1. Not cry and 2. Not to get angry and still try and think clearly. She told me again I should leave, I thanked her for her time and left the building. Her entry in the records said I came by wanted to know “where does the family came in” and how she explained the HIPPA laws to me. That was it. I don’t even know if she told Terry I was there. Again no one from the VA engaged me or family while I was on site multiple times. Again, No Chaplin was offered, no PTSD website was offered – not even a brochure.

I was truly defeated after that conversation with the social worker. I truly feel she is personally responsible for Terry’s death! She did nothing for him, or for me! AND Terry was behind the VA WALL again. But we felt he had eyes on him, hot meals, and regular sleep. We expected that after he “evened” out we would be able to see him. Due to work (having missed days the time while Terry was in the previous hospital) and personal obligations, I was not able to return to the VA Hospital until the morning of January 31st. When I checked in I was told Terry was no longer in this facility. I asked if he was moved to another (assumed the Palo Alto Facility as he been there in the HVRP), the desk clerk said there is no way he can tell where Terry went.

Honestly, I just didn’t believe they would send him home alone, (I will have Mothers Guilt for this fact forever!!). I knew from past experiences, if he was in the VA system, I would have to wait until he reached out before I could know where he was. While Terry was in the VA MH, we, as a family, tried to decide if we should do a medical/legal conservatorship intervention due to his mentally ill status. Getting a lawyer and going before the court is much like suing someone; we couldn’t just go to the court and get the document as it turns out. Terry would have had the opportunity to tell the judge his side of the story. It all takes time and money and we felt it would really piss him off since he already thought I was out to get him.

Friday night, on the 5th of February, I received a text from Terry’s neighbor to let me know that the police were at Terry’s apartment again. I placed a call to the Maryville PD, and after a short wait for a detective to return my call, was told that Terry had been found dead in his apartment hanging by his neck. Suicide.

Remember that we did not even know he was out of the hospital.

Here are GAPS in Care I would like share:
Terry was released on a Friday (Jan 29th 2016).  Which meant no one from the VA was looking out for him over the weekend.   GAP
Terry Discharged as High Risk Suicide Flag with Major Depressive Disorder.  He clearly reported 3 previous Suicide attempts with Jan 11 2016 being the most severe, and yet there was no one at home (No known support network) to help facilitate his care.
Terry was discharged to take the shuttle back to his home because it was over 40 miles away. He was taken to the VA Clinic Yuba City. No one met him there. He walked the remaining distance to his home about 2 miles away on a cold and rainy day.   GAP
Terry was discharged without his prescribed medications in hand. There is speculation that maybe he did not have enough time to meet the shuttle if he waited on his medications or he just didn’t stop by and get them. The pharmacy called Terry to let him know they were ready, (Terry of course did not answer the phone)and then they sent the medications by mail.  High Risk Flags says that any missed calls are to be escalated to the Suicide Prevention Coordinator (SPC).  Pharmacy did not escalate missed calls. The medications were still at the post office when I arrived after his death.

On Friday Jan 29th 2016  (Day of Discharge)the OIF/OEF Housing  Coordinator called Terry to discuss Housing possibilities.  OIF Coordinator annotated in Terry records missed call.  SPC was notified in an email string not out right.  No escalation was made. GAP On Monday Feb 1st 2016  Terry missed 1st Outpatient appointment at Yuba City VA Clinic.  MH Dr called Terry no Answer.  MH Dr. Called Local Law Enforcement (LEO) for welfare check. LEO knocked on door, no answer at door and informed MH DR and closed call.  SPC was notified in email string not out right.  No escalation was made. GAP GAP GAP On Tuesday Feb 2 2016. MH Dr. called Terry one last time. (This is the last time VA tried to contact Terry). SPC was notified in email string not out right.  No escalation was made. GAP on Tuesday SPC “signed Off” all email notifications in medical records. AT NO time did the SPC make attempts to directly contact Terry to ensure his safety.  HUGE GAP
In Terry’s medical records;
It is noted that Terry lives by himself. Under patient Limitations Lack of Support Network is noted nearly every day of his stay.
Terry had not been to his MH Dr. Since May of 2015. Which means he did not get his prescriptions filled for 6 months prior to his shooting attempt.   This went unnoticed by VA. HUGE GAP
The Suicide Safety Plan was missing information.  This has HUGE GAPS In the Suicide Safety Plan dated Jan 17 2016 (12 days before discharge) and not Updated for Day of Discharge.
Step 4.1 The VA Suicide Prevention Coordinator typed “No One” for people who Terry would be willing to call if he was having thoughts of suicide.
Step 6.2 Terry states no weapons in the home; but yet he made his own shot gun not three weeks before.
Step 6.2 Terry did not identify a person (Blank) that would be good support for him. If this is left blank there is a place to explain why. This was left blank too.
In almost every GAP noted above there are VA guidelines in place to prevent the patient to fall through these gaps. They just were not implemented.
Above is the VA version of this story. It doesn’t take into account what was happening where the VA was not privy to the information.   At Terry’s apartment; the power was out and had been for two days before the Jan 11 2016 suicide attempt.   Terry was sent home to a “dark home”. Terry had broken down all his furniture in an attempt to throw everything out before the suicide attempt.  Terry was sent to a home of broken and destroyed furniture.  The door would not open the day the day he was discharged and he called his landlord thinking the landlord had changed the locks. The landlord knew Terry had PTS so he came and used Terry’s key to open the door for him to show him he didn’t changed the locks. (The door had swelled a little and was jammed).  Without a home check or a assigned person to ensure he made it home safely Terry was sent to an unhealthy environment where he had to walk in the cold and rain, to find the door jammed, to a home with no power (heat)  and chopped up furniture.
As far as I know the landlord is one of the last time someone who knew him, saw him alive.  There was two newspapers for the Jan 29/30and a 7/11 receipt Feb 1st. There is no proof he was alive after that time. The landlord left a note on the door on the 3rd that he came to collect the rent. Then he left a 24 hour notice to enter on the 4th. And on the 5th when the landlord could not open the door as it was locked from the inside he called 911. These notes were still all on the door on 5th.
I have all the records and more information than you can imagine. From the guidelines for high risk patients and how to fill in a suicide safety plan to how many suicide deaths there are by every VISN.
Here is a disturbing fact; that at Mather Behavioral Health Clinic; I asked for a FOIA request as to how many OIF/OEF PTSD related Suicides happened. Terry’s death was number 8 in the previous 26 months. That is 1 OIF/OEF suicide every three months. And Terry was number 8.  I am sorry I see that as a pattern? And the Mather VA couldn’t get it right by number 8?   Also in that FOIA request; I found out the proper way for the VA to report a “missing at risk veterans” such as Terry was when he missed his appointment on Feb 1st 2016, the MH Dr should have called the VA police who would have called and worked with the Local Law Enforcement agency until face to face contact had been made.

This story doesn’t even touch on the care (or lack thereof) he received while being on ward.  They just dosed him up every time he said he was still feeling suicidal. They did not provide any counseling or anything except “group”.  Terry had asked several times so to go somewhere while he got better, he said he was afraid at home. . He told them; that EVERYONE he knows; his family and friends are trying to frame him for crimes he did not commit. He told them he does not have one person in his life he can trust. Not one question of ooh really why would you think that?? Not ONE! Not one offer to help mend family relationships. On day of discharge Dr. says Terry makes his problems out to be bigger than they are. He is still feeling depressed and sad but much better since his arrival (oh yeah cuz you drugged him up).  At discharge, Terry told them” he was never going to come back to a mental health clinic again. He was going to do things differently next time, much differently”. It’s in his records. Not 1 question as to what he might mean about that.   Well Terry spoke the truth that day; he did do things differently and he will never go back to a mental health clinic again.

The VA called Terry a forward thinking man.  I have read every line of every record, there was nothing that remotely was forward thinking in his records.

This still doesn’t cover everything like once diagnosed with PTSD; there was not any change in his care, as he progressed deeper in paranoia and isolation.  Or even that once Terry died, the VA STILL failed to provide the information to our family we need to get through the death benefits process.

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