LoBiondo, Menendez, Booker Statement on VA IG Report on Death of Charles Ingram III

Nov 15, 2017

WASHINGTON, D.C. – U.S. Congressman Frank LoBiondo (NJ-02) along with the offices of U.S. Senators Bob Menendez and Cory Booker today were briefed by the U.S. Department of Veterans Affairs (VA) Office of the Inspector General (IG) on its findings and recommendations regarding the death by suicide of Charles Ingram III at the community-based outpatient clinic (CBOC) in Northfield in March 2016. The lawmakers requested the IG investigate the incident to determine potential failures in VA procedures and to make corrective recommendations. The full report is available here.

 “The IG’s report clearly details systematic failures at the Northfield clinic that contributed to the horrific death of Charles Ingram. While a different outcome is not known had procedures been properly followed, we do know that Mr. Ingram’s death served as a wake-up call to the VA for its years of neglect to South Jersey veterans,” said LoBiondo. “In the past 18 months the VA has made measurable progress to rebuild a trust with our veterans through increased services, proactive outreach and expanded care in our communities. However, maintaining that relationship is a mission that will never end and I will not let them forget.”

“Sadly, this IG report confirms what we have learned from our veterans about the operations and management of the Northfield CBOC,” said Sen. Menendez.  “Our veterans and their families should not have to worry whether or not VA procedures and systems are working properly.  I am appreciative of the leadership of Dr. Adelman who took over supervision of our CBOCs to address these failures.  While progress is being made to improve delivery of care for our veterans, I will continue to hold the VA to the highest standards of accountability for our veterans.”

“Today’s report makes clear that important policies and procedures weren’t followed in the lead-up to Charles Ingram’s death last year,” said Booker. “Ingram’s death was a tragedy that shook us to the core and reminded us of what’s at stake when it comes to providing care for veterans suffering from mental health issues. I appreciate the VA’s response to our request and the efforts undertaken to produce an account of the circumstances surrounding Ingram’s death. Today’s report outlines clear recommendations for improvement and I’ll be monitoring their implementation closely with my New Jersey colleagues in Congress.”

In response to Mr. Ingram’s death, the lawmakers held a press conference in May 2016 in Northfield to outline immediate changes they demanded, including the hiring of more than a dozen additional medical and administrative staff and removal of the Wilmington VA Medical Center’s oversight of the South Jersey CBOCs (Northfield, Cape May and Vineland). At this time the South Jersey CBOCs remain under stewardship by the VA under the direct supervision of the VISN (Veterans Integrated Service Network) 4 Director.

The previous leadership team in Wilmington was subsequently removed or restricted and three (3) Veterans Community Outreach Specialists have also been hired for South Jersey. Vince Kane was named the new Director of the Wilmington VA Medical Center in May 2017 with the support of LoBiondo, Menendez and Booker.

“We fully support Vince and his team’s approach to expanding community-based services and proactive engagement with South Jersey veterans. After years of neglect and run-arounds by the previous Wilmington leadership, we are encouraged by the measurable progress made on the ground at both the CBOCs and through more than 400 service provider agreements. We will continue to work closely with Dr. Adelman and Vince Kane on fulfilling the promises made to South Jersey veterans, including a new CBOC with expanded care in Cape May County in 2018,” concluded LoBiondo, Menendez and Booker.

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