Death By Suicide Charles Ingram Northfield VA

REPORT: Veteran Charles Ingram Suicide By Fire Linked To Massive VA Fails

Death By Suicide Charles Ingram Northfield VA
Photo at Atlantic County CBOC of Charles Ingram burn site.

Northfield, NJ – VA OIG finally issued its report on the death of the veteran Charles Ingram, a veteran who lit himself on fire and later died.

Ingram, a veteran from Egg Harbor Township, engaged in self-immolation by dowsing himself with gasoline and then lighting himself on fire on one Saturday, in March 2016, in front of the Atlantic County CBOC (aka Northfield VA). He was then taken by helicopter to Temple University Hospital in Philadelphia where he later died.

IG’s report revealed 11 health care failures linked to Ingram’s death that included a failure to reach out to veterans needing mental health care who had not been seen in one year or more.

The Northfield, New Jersey location is new as of 2011.

At the time, VA moved the outpatient clinic to help improve access to services with upgraded technology and better care using the VA telemedicine platform. The facility was apparently created to utilize the cheaper but more technology dependent telemedicine model.

RELATED: VA Clinic Moves To Bigger, Better Facility In Northfield

However, reports circulated, and are now confirmed by VA OIG, that VA did not adequately staff the clinic, like elsewhere around the country.

As we now know, veterans seeking access to mental health care are reportedly not receiving the timely services the community was promised when the facility opened. And, unfortunately, at least one of them committed suicide by fire.

RELATED: Money Laundering Scheme Rips Off VA By $11M

Charles Ingram Suicide By Fire

Ingram reportedly waited longer than one month for appointments on a regular basis since 2011, when he started getting care at the Northfield VA facility. Prior to his death, he had not been seen for more than one year after repeated cancellations where follow-up appointment attempts were never made. VA did not reach out to him despite requirements to do so.

RELATED: VA Busted On Mental Health Failures

“We found no attempts to follow this process,” the inspector general said. Ingram died while waiting for VA to schedule non-VA health care from a mental health care provider. At the speed with which VA processes non-VA mental health care, Ingram would probably still be waiting.

“(S)taff failed to follow up on no-shows, clinic cancellations, termination of services, and Non-VA Care Coordination consults as required,” the inspector general wrote in a report released Wednesday. “This led to a lack of ordered (mental health) therapy and necessary medications… and may have contributed to his distress.”

RELATED: VA Reveals Apple iPad Program

Ingram was seen at the Northfield VA locate in New Jersey. Media was rather quiet about the suicide at the time, trying to manage political correctness while reporting on news America needs to know about.

As for the list of failures, here is my tally of the noteworthy failures from the IG summary:

  1. failure to provide timely appointment
  2. failure to follow overbooking instructions
  3. failure to follow up after clinic cancels appointments
  4. failure to follow up on patient no-shows
  5. failure to provide follow-up appointments
  6. failure to refill prescribed medications
  7. failure to document lack of appointments
  8. failure to acknowledge lack of appointments
  9. failure to provide outreach to a veteran in distress
  10. failure to schedule community care
  11. failure to supervise clinic processes

After reading the report, I wonder how only one veteran committed suicide given the shoddy care VA dished out at the location. Numerous removals and reported terminations followed the suicide due to the colossal failures evidenced.

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Sadly, while veterans face tragedy on the regular basis, the agency seems focused on maintaining its quest for political correctness, supporting transgender veteran awareness goals, all the while failing to provide safe and timely mental health services.

IG Report – Charles Ingram Suicide By Fire

The patient was in his fifties when he completed suicide in 2016. He had been receiving VHA care for a variety of medical conditions, including obsessive-compulsive disorder (OCD) and a particular neurodevelopmental disorder (NDD). The patient received medical care intermittently at several VA hospitals since 1997. In 1997, the patient indicated he had been treated for depression in the past. His first VHA MH treatment began with management of OCD in 2000. At that time, the patient reported to the psychiatrist that he had been treated for the past 2 years by a non-VA therapist and a non-VA psychiatrist and had been taking fluvoxamine (Luvox®).

The patient continued on Luvox® and remained in psychiatric treatment. In 2005, he indicated that he was doing well and performing better at work with reduced compulsiveness. He attributed this improvement to the medication Luvox®. During the visit in 2005, the psychiatrist continued treatment for OCD with Luvox®. At his next psychiatry visit in February 2008, he indicated he had run out of his medication and was experiencing increased OCD symptoms that were contributing to problems at work. For the remainder of 2008, the patient reported adherence in taking his medication and fewer symptoms. 

In mid-2011, after a period of stressful life events, he had a MH Initial Assessment Consult with the Licensed Clinical Social Worker (LCSW) and began psychotherapy. During the initial session, the patient denied active thoughts of suicidal ideation. However, he stated that he had experienced suicidal ideation in the past with no history of a suicide attempt. He continued with ongoing individual therapy sessions until early 2013.

In 2012, according to the LCSW’s clinical notes, the patient exhibited negative thought patterns that he attributed to his OCD. This created difficulty for him in maintaining personal relationships and employment. The LCSW also noted “Pt’s mood and affect remains dysphoric [a mood of unhappiness]. He denies SI/HI [suicidal ideations/homicidal ideations], however, he admits to feeling hopeless at times. Thoughts were tangential but he responded to redirection, which was reinforced. Insight and judgment is limited.”     The patient attended several individual psychotherapy visits with the LCSW in 2012, then a final visit with the LCSW in early 2013.

A psychiatrist’s note shows he started the patient on sertraline (Zoloft®) in early 2013, at which time his compliance with Luvox® was in question. In late 2013, the patient reported he was seeking care from a non-VA “therapist, and she is helping with ocd [sic].” He did not provide records for these visits. He noted that he wanted to keep his medications the same as his obsessive symptoms were reduced; he was sleeping better, and was calmer. He reported he felt his OCD was worse after stopping his medication and that he felt better after restarting it. In mid-2014, the patient provided a written outline of work history (dates, employers, and reasons for being terminated) to his psychiatrist. According to the psychiatrist, this large number of different types of jobs demonstrated “…a long extensive pattern of severe work impairment that is caused directly by his obsessive compulsive disorder [OCD] despite being [on] multiple medications and [seeing a] therapist… referring to a new therapist.”

One month later, a VA psychologist assessed the patient for psychotherapy. She noted “DIAGNOSIS: OCD, will add new diagnosis of [neurodevelopmental disorder (NDD)]…Diagnosis of NDD due to patient’s report of difficulties in social situations and rigid thinking patterns.”

Two months later, the psychologist requested individual psychological testing to clarify the patient’s diagnoses “between OCD and [NDD] or both. As well as treatment recommendations.” While the psychology providers agreed his diagnosis was [a particular NDD], the psychiatrist disagreed and noted, “…this is classic ocd [sic]” and “… consistent with a diagnosis of obsessive-compulsive disorder [OCD], in my opinion.”

In early 2015, the psychologist saw the patient three times.   During each of these 50-minute individual therapy visits for both of his diagnoses of a particular NDD and OCD, the patient denied suicidal and homicidal thoughts, plans, or ideation. He reported stress and frustration about financial and employment issues. According to the psychologist in early 2015, the patient’s “thought process was goal oriented with no evidence of thought disorder noted.” He denied auditory or visual hallucinations, unusual experiences, special powers, etc. No contrary evidence was elicited during this interview.” Orientation and memory “appeared intact for both long term and short term memory recall. He demonstrated fair insight and judgment.” His prognoses during two of these three visits were documented as fair; his prognosis the following month was documented as guarded. 

A specialist in the particular NDD was not available at the facility. In early 2015, the psychologist requested and received authorization for the patient to have several outpatient non-VA visits for his NDD. The non-VA provider, who had been contacted by the psychologist, told us the patient had not been seen despite the non-VA provider’s attempts to schedule an appointment with the patient and telephone calls to the facility on more than one occasion.

Also in early 2015, at the request of the treating psychologist, the patient and his wife attended a 50-minute marital therapy appointment at the MH clinic with a marriage and family therapist. No other MH visits occurred in 2015 or 2016. However, the patient did seek medical and surgical care unrelated to his MH issues from other VA outpatient clinics during 2015 and early 2016. In late 2015, the patient walked in to the MH clinic to request an appointment with his therapist and, after speaking with the therapist briefly, was directed to a scheduling clerk who scheduled an appointment months later. The patient completed suicide before this scheduled appointment in 2016.


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  1. Too bad that the hospital isnt closer to where i live for i am not allowed to drive right now. But maybe T shirts can be worn with how to make napalm so a memorial & internal flame could be errected at the hospital

  2. we keep finding more problems yet the government cant even fix the problem. how do we start a veteran coalition?. this is going to get so bad in the future. as a veteran i see all other alternatives from the united states and senate is going to have to shut down the VA if another public epidemic of this is unresolved .if they dont its going to get violent .

  3. I know what other vets have gone through for i was lied to, accused of liing, denied help, etc. and just had another Grand mal seizure and high blood pressure because of the Va,
    Every time i try to appeal an decision they give me an different answer even though i go through the Patient Advocate, next step is head of hospital, american disability association, then political if i live that long. For i over do but enjoy it st the vost of my health. Thank goodness for president Trump for he restored my right to own a weapon. I guess we will just have to restore to other means to receive what we are pomised . They even liec in Vietnam when they said they had no more troops in Cambodia. For we hadnt moved a foot so thry just changrd the border. I remember asking my CO. If we still grt combat pay for being in vietnam!

  4. Off-Topic but Gov’t screw-up that most of us can agree we saw it coming and here it unfortunately is: “[AMHERST, S.D. — TransCanada Corp.’s Keystone pipeline has been shut down after it leaked an estimated 210,000 gallons of oil in northeastern South Dakota, the company and state regulators reported Thursday…]”

  5. Rest in Peace you are now free of your pain my brother. What you did and how you did was horrific but your word or statement came through loud and clear. You are not the only get to feel the way you did. I am sorry for your loss as my brother but I am more happy that your pain and suffering has ended. Shame on you VA no one really believes you care.

  6. Delaware has the least funding for health care in the in the county. It receives about a 1000 per veteran less than the rest of VISN 4. Delaware has no inpatient care for mental health Veterans have to go to Coastville Pa 21/2hrs away.

  7. Charles Ingram, a Gulf War Veteran, committed Seppuku (also called hara-kiri — ritual disembowelment) Self-immolation. To make a point. Selflessly Gave his life for one BIG reason. To shine a FIRERY LIGHT on the NEGLIGENCE of his fellow Veterans that the VA is ultimately accomplishing their goal of “a Dead Veteran is a good one”. More money for them. What could be better? He ended his pains. The VA and MSM does not bring this to light, but Mr. Charles Ingram literally gave his life to bring light in the hopes that this system could someday be as efficient and squared away as ALL Veterans remember when they served Active Duty, because it was never operated by a paycheck. It was ran and operated for a laundry list of a Service Member’s MORALS & BELIEFS. The VA is so far off from that and EVERYBODY knows it. BUT THEY JUST DONT FUK’N FIX IT.

    #SurvivorGuilt #Neglected just another number. VA is broke. Somebody take charge. Please GOD, Recruit the Veterans that have Leadership and the Welfare of their Soldiers and the accomplishment of the Mission always in the forefront and its NEVER NEVER EVER ABOUT MONEY & POWER & GREED. AN OATH, A VA TEAM MEMBER OATH.



    1. Airborne Hoosier, well said. Charles Ingram was a man, a Desert Storm Vet and a hero.

      Fuck VA, Fuck AFGE.

    2. Who wouldn’t feel hopeless here? The VA’s atrocities are reported in the news, Congress passes laws, etc.. .and nothing changes.

      If a VA employee walked up to a veteran and shot the veteran in the head in the middle of the White House lawn, not only would that VA employee not be held accountable but OIG, MSPB, OSC, DOJ would find a way to whitewash the murder and the VA employee would be given a promotion to “Director” of some VA facility.

      Yes, and I’m not being sarcastic. Become a VA and/AFGE thug and the mafia would wet their pants when you walk through a door.

    3. I hear what you are saying, AirborneHoosier, but as long as Shulkin pisses away billions on things like IT records management so some congressional crony can get rich, veterans will always get the short end of the stick.

      Imagine waiting a year for an appointment, and Ingram couldn’t even get face time with a camera doc with their telemedicine bullshit.

      If he had a telemedicine appointment before, then had to wait over a year for another one, imagine how he thought about how much the VA cares for vets.

      Telemedicine that was sold as a way of providing timely care to veterans, particularly in rural areas.

      It was nothing more than a way to claim a veteran got an appointment, a damn sight cheaper than seeing a human…so VA managers could direct that savings to boondoggles.

  8. I did not see PTSD as a diagnosis. Did they not give the PTSD diagnosis so they would not have to pay him and treated him for something different and never addressed the real issue.

    Documentation or Progress notes if a veterans should get a copy and really look at these progress notes, you will see that many of these notes are repeated by each visit or by another provider such as social worker.

    All most word for word. I did not see anything of this guys service was he in combat, did he receive a traumatic Brain Injury, was he denied disability for PTSD.

    The VA as stated by the Secretary of Veterans Affairs, “The VA is very Adversarial towards veterans. Veterans suffering from PTSD, Traumatic Brain injury or other mental problems are nothing more that people who are Malingers, Fakers, and just want a disability to obtain Money.

    This is the way too many employees think about veterans. These veterans have real problems and instead of treating them, they ignore the real problem and should the veteran shows any signs of disagreement with the treatment or treatment staff and say anything about them.

    The veterans disability is not being considered, what the VA is doing is Accusing these veterans of Disruptive Behavior and Restricts the care they should be receiving and other VA employee start treating these veterans as being crazy and will belittle them or treat them as a threat and will Ignore them.

    The VA is NOT for Veterans it is only for Employees and Employees come first !

    If a VA employee harm a veteran and the veteran speaks up, the Veterans will be Ignored or Punished for speaking up. The VA Retaliates against any employee who tries to do the right thing and may be fired !

    Veterans that try and do the right thing CAN NOT be fired, so what happens is the VA set up the Disruptive Committee to Punish veterans at will. I guess they think if they threaten Veterans with Federal Charges, Arrest and Banished from all VA care, will shut them up.

    Not this veteran I will continue to Expose this Illegal Committee, who is acting as part of the United States Judiciary System, where they are being the Accuser, Prosecutor, Judge , Jury and Executioner. At the VA you are NOT innocent until proven Guilty, you are just Guilty !

    Every right we are to have such as Freedom of Speech, Civil, Human and Constitutional Rights have been taken Away affording the Veterans to be able to face their accuser, or seek Counsel or a fair trial.

    The VA has made the Veterans an Enemy and they are harming whom ever they want and no one seems to give to Cents if we veterans are being harmed.

    Secretary Shulkin has ignored my Whistle Blowing against management Abuse or Abuse of Power.

    1. James. Good point James.
      1. Shooting from the hip. I would say. Most likely. The VA withheld “the PTSD injury diagnosis”, and then gave him some other bull sh*t disorder(s) or genetic bull sh*t disorder so they would not have to put(pay him) any badly needed money in his pocket…SO to ease up the stress already in his suffering life. Life falling apart and destroyed, he ended up having to work factory work (stressful employment), because he was too disturbed (injured from the military) to work in a professional atmosphere, or service related field as the nation has progressed towards.

      2. Years ago, after WWII vets, and Vietnam soldiers (vets) could walk right off the battlefield (be discharged) and get a job in any one of a dozen factories near them. Lose your job, walk to the next factor next door.

      3. Now our world has changed, now it is more competitive, professional, more education is needed in order to gain employment in our modern world (economy). A veteran and former soldier injuried and disabled with a disturbed (broken mind) is left behind. With NO factories left. No safety net for (VA rating money) the injured soldier (ptsd diagnosis) a veteran is left to the elements.

      4. And then people and citizen and VA employees ask “WHY?” And they wonder why WE kill ourselves, live in poverty, go nutz, lose our wives, children, fail out of school, live alone, self destruct, and lose our jobs over and over again. And turn to alcohol and drugs, and end up in prison! And the people wonder why this happens to veterans and former soldiers. And they wonder “WHY?”

      5. Thanx you VA Hospital staff and non veteran employees, and VA Benefits dept.

      1. Well said, VA Ohio Nepotism. That “Why?” seems such an easy answer from our vantage point yet so far far away from any VA mental health hack and NOW they think dishing-out the mental health via telemedicine, making it even further away and impersonal is better? I personally do not think the VA will ever ‘get-it’ regarding the Northern American veteran Species.

  9. And they didn’t do a brain scan and EEG or a neuropsychological assessment! Hope this link copies!

    1. At least I was able to copy from the above. Ben you need to do some work on this. Find out about the results of the brain section of the Las Vegas shooter.

  10. Regarding Michael J. Missal: after reading the report issued by the VAOIG office on the investigation of the death of Charles Ingram. It is profoundly clear that Mr. Michael J. Missal need to be removed from the position of Veterans Affairs Investigator General immediately for the safety of Veterans who use VA Health Care.

    The report is written with the sole purpose of covering up the names, policies, actions and laws broken that led to the death of Veteran Charles Ingram.

    1. Robin Aube is the culprit, and the OIG never named this director in the report, but she mysteriously moved on to NASA “”

      1. CorpsmanUp,
        I’m confused by something. What kind of job (title) could a person, who had worked at VA, do at NASA!?
        What would/could entice a person, from VA to NASA? Are they believing there’s “easier pickings of taxpayers monies” at NASA?

        See where my mind had wandered off to! “Following the money!” ???

      2. From a joke [VA] to a HOAX [NASA]
        BUZZED up ARMSTRONG Is telling me to be Quiet so I got to run…To the green room, latter

    2. I have heard from insiders that his report was a whitewash just like the Phoenix VA OIG report. Total joke.

  11. Y’all are NOT going to believe this shit! Or, maybe you will!
    “ News”
    15 Nov 2017

    “VA Seeks $782 Million for Electronic Health Records Overhaul”

    “Stars and Stripes | Nikki Wentling

    “Shithead Shulkin” wants the monies by the end of the year! VA is nothing more than a “black hole money pit” the majority of Americans have no knowledge about!
    Oh, wait until you read what a Florida Democrat had to say about this FUBAR! And, WHO that Florida Democrat is [will astound you!]!!!!!!

    1. “We have to do this quickly,” he said. “The right thing to do is act with urgency, be aggressive and implement strict timelines.”

      Urgency LOL Couldn’t do it before with billions spent on it must want a Christmas kickback from Cerner Corp…Nothing but a bunch of con men working at the VA…HANG THEM ALL IT’S THE RIGHT THING TO DO…We could save a lot of money before the NEW YEAR….LOL

      1. Can we use bungee cord rope instead so we can watch and listen to them scream a few times and study the Doppler effect?

      2. “Bringing VistA up to health industry standards would cost $19 billion over 10 years, Shulkin said.”

        Your right ELF biggest black hole ever, The VA……That’s as bad as I need a new pair of boots because my shoestrings are broke…LOL

      3. In 10 yrs the VA will have made 45 brand new systems that are not compatible with anything to ensure this train wreck keeps skidding sideways at terminal velocity.

    2. And I’m pretty sure this has all happened before. IBM Watson was part of a multi-BILLION IT overhaul electronics records…and that black hole $$ replaced a few other prior electronic records overhauls attempts…anyone else see a pattern of flatulence?

      1. They Retired Mr Watson he’s to old, Now they have the D-Wave computer it goes straight down to the ABYSS

  12. if a horrific form of suicide does not capture the attention of the powers to be in the VA, I’m afraid nothing will


    Charles Ingram, and LOTS of other veterans, would still be alive IF those in charge: ie; “Shithead Shulkin” were to recommend or initiate a “purge” of ALL VA employees! Only, “Shithead Shulkin” is afraid of all the “bad publicity” it would generate!

    We’ve seen this bullshit time and time again. VA employees generate poor healthcare, veterans are harmed or worse, and the perpetrators are transferred. Then, the same cycle begins again!

    Shut down the VA. Allow ALL veterans to use outside healthcare! The amount needed, from the taxpayers, would be FAR less than it is now! Especially since VA has to “pay out” for the fuck-ups caused by its managements! That includes ALL the corruption, waste, fraud and abuse caused by its management and contractors!

  14. When all bullshit fumes have cleared at end of the day, am betting the VA was more concerned about two things: 1) Public Affairs Image, and 2) Replacing ALL the ground’s grass with asbestos-based Astroturf to prevent a future unsightly burn mark near employee parking…and wait for #3 when the assholes decide to install an “Eternal Flame” event marker right at that spot where Charles Ingram set himself on fire…with a VA CARES drinking fountain right next to it. Fuck The VA.

    1. Is that true snout the eternal flame? If so that is the straw that does it! They want to see an enternal flame? We do still know how to make napam! And maybe it will get out on how to even make it better as a flame thrower as we did in a compressed form shot put by the air hose from a truck. It eorked very well to get rid of vegetetion. And mixed with JP4 it was a sight to behold! I will have to find my photos from 50 years ago. For we wete told to be resourceful in developing new ways to disrupt the Ho Chi Mi. trail movement of arms and goods to the South. And we did !

  15. ” waiting for VA to schedule non-VA health care from a mental health care provider.”
    Ha… It doesn’t have to be just mental health,It’s all outside care, Their schedulers don’t know what they are doing or their is not enough of them, Or better yet If the outside providers don’t get paid who the f$$k wants to work for nothing… I have been waiting to get a outside app. for about 4 months now they called about 2 weeks ago and left a message I called them up the next day and left a message, Still waiting what a joke…
    But I do get outside care if it is important enough so this is just a test of their great care…LOL
    Fuck you VA

    1. I’m less inclined to blame nurses or doctors for scheduling outside care. They make the recommendations, and it goes into the abyss of Tri West/Care or other beltway bandits who troll the best deals and bill the VA double. Follow the money. Always, now more than ever, follow the money.

  16. Wilmington VA oversaw that clinic where bullshitter Carper. COONS AND Carney knew about a lot of things. This is the same facility that wrote in my medical record in which I presented evidence to DOJ, Hhs, OSC and the OIG. The director later got a job at NASA after this self – immolation event was reported in the news. OIG never does what they were meant to do and they need to stop embarrassing the law enforcement crest they wear.
    Vince Kane who is in charge at Wilmington was caught interfering with an IG investigation in the past at another facility.
    Goes to show you how full of shit Shuilkin is, when it comes to vetting and appointing Directors.
    In keeping with good housekeeping and rollcall, “Fuck the VA” and all the canteen shopping, bow-legged,buffalo back ,big fat government employees that are dishonest!

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