May 4, a Wednesday.
Luis Mariscal Munoz called the Phoenix VA Health Care System to say he wouldn’t be coming in to work. He drove to a shooting range at the Table Mesa Recreation Area off Interstate 17 and parked. At about 6:30 p.m., having walked about 70 feet from the car, he put a borrowed nine-millimeter handgun to his head and pulled the trigger.
An hour later, Luis’ wife, Lisa Mariscal, arrived at the West Phoenix home the couple shared with their two dogs. Luis had texted her: something about how he was sorry and to read the note he’d left for her. She’d tried to call and text him back, but there was no reply.
Lisa knew that for the past month, her husband had been attending weekly therapy appointments at the VA on Indian School Road, where he worked as a medical laboratory technologist. She was aware that a psychiatrist there had prescribed an antidepressant. But Luis had told her he was just suffering from anxiety.
Then she read the note.
“Please do not feel guilt about my decision,” he had written. “I would like you to feel happy or relieved that I am no longer suffering. You never did anything wrong. No one could have changed my mind.”
Though the note did not explicitly mention suicide, Lisa knew. And she was blindsided. She called Luis’ mother. She called her parents and she called his friends. Everyone hurried to the house.
At about 9:30 p.m., the police came to the door. Luis had killed himself. He was 29.
“Everyone in his life was just in shock and upset,” says Lisa, who is 26. “No one ever would have thought he would have done something like that.”
Weeks later, seeking closure, Lisa requested copies of her husband’s medical records from the VA. When she read through his therapy “Progress Notes,” she was stunned.
A month prior to his death, when Luis had first sought help at the VA, he confided that he’d been having suicidal thoughts. The medical staff members who saw him noted that Luis had said he’d attempted suicide twice before — once at age 17 and again in March 2016.
“Based on my evaluation of this patient, I have determined that: The patient is acutely suicidal and is at personal risk,” a registered nurse had noted. “The patient is being sent for further evaluation by psychiatry today.”
The psychiatrist who saw Luis that day started him on an antidepressant and prescribed an anti-anxiety medication.
But the VA did not take the further step of admitting Luis for inpatient treatment.
Nor did doctors clue in Lisa about the extent of her husband’s inner turmoil — or, for that matter, anything at all about his condition. This, despite the fact that Luis signed a consent form explicitly naming her and authorizing VA officials to inform her if the “patient may do harm to him/herself.”
Paul Coupaud, chief media officer for the Phoenix VA Health Care System, told New Times he is unable to publicly comment on Luis’ case owing to laws preventing the disclosure of a patient’s health information.
“We are deeply saddened by the loss of any veteran, and want to express our sorrow and condolences to Mr. Mariscal-Munoz’s family,” Coupaud says.
Coupaud adds that all veterans are assessed annually to determine whether they’re dealing with complex mental-health issues such as depression and suicidal ideations.
“I feel like he reached out to appropriate people, he reached out to professionals,” Lisa Mariscal says. “And for them not to have done their job — that’s where I am mad.”
Lisa Mariscal was born and raised in Phoenix. Her mother worked at a bank; her dad owned a fast-food franchise. She was 16 and a junior at Barry Goldwater High School when she met Luis at a wedding. He was three years older and training as a combat medic at a military base in Texas.
“He was very handsome and very fit. He was funny — he had a really good sense of humor,” Lisa remembers.
Luis was born in Nayarit in western Mexico, but grew up mostly in Virginia. When he was 15, his mother moved to Arizona and later had four other children. (His parents never married, and his father left when he was a baby.) Lisa says he loved music, fishing, technology, and animals. He was very social, she says, and he had a large network of friends. He’d been inspired to go into the medical field because his brother had a brain tumor as a kid but recovered.
The two began dating, and in 2008, right after Lisa’s high school graduation, they married. Lisa moved to Texas and they lived together in military housing. In 2009, Luis became a U.S. citizen.
But sometime earlier, he’d injured his foot during a training exercise and it didn’t heal properly. Nine months after the wedding, he was medically discharged owing to the injury. He had served in the military for just three years.
“He really wanted to deploy with his unit,” Lisa says now. “And I think not being able to do what he signed up for was kind of devastating for him.”
After Luis’ discharge, the couple moved to Phoenix to be closer to their families. He attended Arizona State University and earned a degree in biochemistry in 2013. He’d go on to graduate from DeVry University with a second bachelor’s degree in medical laboratory science. In 2015, he was hired to work at the VA.
“He figured he would give back by working at the VA hospital,” Lisa says. “Even though he didn’t have patient contact, he felt good working in that environment.”
“He was very ambitious,” says Vince Tsang. A fellow veteran, Tsang met Luis at ASU, and they became close friends. “When he had his mind set to something, he would definitely do it.”
Lisa, meanwhile, graduated from ASU and began her career as a vet tech, planning to go back to school to become a veterinarian.
After eight years of marriage, Lisa says, she was excited for the future.
“He finally got a job he liked, and I was supposed to move further along with my education,” she says. “We wanted kids. That was the talk the last few months: when we were going to have a kid.”
But the pain from Luis’ injury lingered.
“He was always in pain from his ankle and his back,” says Tsang. “He told me sometimes it’s just excruciating, and he can’t even sit down, so he’d have to sleep on the floor.”
Two months before his death, the pain was so bad that Lisa had to drive Luis to the ER. He followed up with the VA to schedule an MRI on his back.
It took more than three weeks to get an appointment. Thinking back, Lisa believes the medical issues triggered Luis’ depression. But at the time, she had no idea he was battling anything more than physical pain.
In early 2012, an emergency-room physician at the Phoenix VA Health Care System raised a red flag with the facility’s director, Sharon Helman, about conditions in the ER. As other doctors came forward over the ensuing two years and the VA’s Office of the Inspector General investigated, it became apparent that veterans were dying while awaiting medical care at the VA, even as higher-ups were falsifying records to make it seem as if conditions were improving.
The scandal spread to other states, ultimately costing U.S. Secretary of Veterans Affairs Eric Shinseki his job. Arizona was something of a Ground Zero: Helman was fired and subsequently convicted of criminal misconduct in office, a felony.
Dr. Sam Foote, an internist who was the director of the Phoenix VA’s outpatient clinic, was one of the more vocal whistleblowers. Testifying before Congress, he estimated that 9,000 patients came to the VA in 2013, and 293 of them died while awaiting treatment.
“How many of those patients, if they’d known that the VA was not going to have an appointment, might have gone elsewhere to seek treatment?” Foote says today.
Like most of the VA whistleblowers, Foote endured retribution from his superiors. He wound up taking early retirement, citing the harassment.
“I had no idea the magnitude of what this would all take and how hard I was going to have to defend myself,” he says. “They made life miserable.”
Most of the whistleblowers received settlements; some have returned to work at the VA. Paula Pedene, a public-affairs officer at the Phoenix VA, is one of those who went back.
“Our exposure actually opened Pandora’s box,” Pedene says now. “That was a good day for veterans, because it shone a spotlight on what was happening. But it was a horrible day for the VA.”
And it took its toll on Pedene.
“I was the number-one VA cheerleader,” she says. “I just don’t feel that way any more. It affected me. It affected my family. There’s no coming out ahead on any of it.”
It’s difficult to assess suicide rates among military veterans nationwide, because many states don’t reliably track military service when compiling vital statistics. But in 2012, when the U.S. Department of Veterans Affairs published a report on its ongoing study on vet suicide, the authors wrote that “[a]mong cases where history of U.S. military service was reported, Veterans comprised approximately 22.2 percent of all suicides reported during the project period. If this prevalence estimate is assumed to be constant across all U.S. states, an estimated 22 Veterans will have died from suicide each day in the calendar year 2010.”
In 2014, citing state records, the Arizona Republic’s Dennis Wagner reported that 226 Arizona veterans had taken their own lives in 2013. “More than 2,000 vets from metro Phoenix dialed the VA’s central crisis line that year; 61 were ‘rescued’ after they threatened to kill themselves. It was the second-highest number nationwide,” Wagner wrote.
Among Phoenix-area veterans who committed suicide over the past several years:
• On June 10, 2013, U.S. Army Sgt. Daniel Somers took a handgun from his Phoenix home, walked several blocks away, and fatally shot himself in the head. He was 30 years old. In 2007, Somers had returned from his second deployment in Iraq with post-traumatic stress disorder, fibromyalgia, a traumatic brain injury suffered in combat, and a slew of other medical issues. Frustrated in his efforts to get mental-health and medical care, he wrote to the VA describing his symptoms as worsening and stating that his health “drives me to consider suicide very seriously on a daily basis.”
• On May 10, 2015, U.S. Army veteran Thomas Michael Murphy killed himself in the parking lot outside the VA’s Phoenix Regional Benefit Office. At the age of 53, he was homeless. Before shooting himself, he e-mailed a suicide note to New Times, in which he blamed the VA for his death. “Thanks for nothing VA,” he wrote.
“[W]ith the arthritis in my left hip, sleeping is often difficult, and I now cannot do most of the work I used to do,” Murphy elaborated. “I cannot stand on my feet for more than an hour without massive doses of painkillers, and now I cannot put a camera on my shoulder and operate it successfully for any amount of time. In TV, it’s often 14 hours on your feet. Also, VA wants to take my painkillers away from me, because of what some hillbillies do with it illicitly. Thanks for that, too, VA. Not that I can afford them, anyway.”
• On July 23, 2015, former U.S. Army Ranger Antouine Castaneda shot and killed himself. He was 32. After serving in Iraq and Afghanistan, Castaneda had sought help at the Phoenix VA, where psychiatrists noted that he was at high risk for committing suicide. VA whistleblowers would later allege that he had not been provided with proper mental-health care.
Earlier this year, Ashleigh Barry, a news reporter at CBS’s Phoenix affiliate, KPHO-TV, received an anonymous letter bearing the signature “Concerned Employees of the Phoenix Veterans Affairs Health Care System.” Written in response to the station’s recent series about ongoing problems at the VA, the letter closed with descriptions of the circumstances surrounding the suicides of four veterans, all from 2015. Two of those cited were Murphy and Castaneda.
In compiling a report about the letter, Barry sought comment from Brandon Coleman, an addiction therapist at the VA who’d come forward the prior year to speak out about the mishandling of suicidal vets in Phoenix, only to lose his job.
“The Phoenix VA, there’s blood on all of our hands at this point,” Coleman told Barry when she shared the letter with him. “This is a small sample of the amount of veterans, the dozens and dozens that commit suicide in the Phoenix area every year.”
Coleman declined to comment for this story, explaining that he has since won reinstatement at the VA.
Dr. Sam Foote, the retired director of the Phoenix VA’s outpatient clinic, says that combat veterans, especially those diagnosed with PTSD, are particularly at risk for depression and suicidal ideation. Extended and multiple tours in Iraq and Afghanistan, Foote says, have made it increasingly difficult for veterans to transition from combat to civilian life.
Luis didn’t serve overseas. But a screening during his initial exam at the VA in April indicated that he showed signs of PTSD. The same day, an assessment for depression resulted in a score “suggestive of moderately severe depression.” Luis also disclosed that the lingering effects of his injury were causing chronic pain — a frequent precursor of depression and thoughts of suicide among veterans.
On March 31, armed with a gun he’d borrowed from a friend, Luis used the internet to research the most effective way to end his life with a bullet.
“I didn’t want to be a vegetable,” he would later tell the staff at the VA.
But as he was about to pull the trigger that day, Luis reported, he thought of his wife and couldn’t go through with it.
“Veteran stated two weeks ago he researched how to shoot self without failure of not dying,” the medical notes read. “He had a gun out and did research to make sure if he did it, it would be fatal.”
Especially in hindsight, the staff’s assessment of that suicide attempt is stark:
Patient’s stated: Level of INTENT of this event was: High
Staff assessment: Level of INTENT of this event was: High
Staff assessment: Level of LETHALITY of this event was: High
On a questionnaire that asked him to characterize his average level of physical pain on a scale of 1 to 10, Luis put 9.
The staff also noted that Luis was overweight, suffered from chronic back pain, stress, and anxiety, and disclosed “social, interpersonal, and economic problems.”
In accordance with VA policy, he also signed a “Consent for Treatment” form that included a clause waiving confidentiality “if the patient may do harm to himself.”
The staff’s notes list one person to be contacted in case of emergency: Lisa.
The psychiatrist scheduled a follow-up appointment, and Luis began weekly therapy sessions at the VA.
“I don’t know why they didn’t admit him to the psych ward,” Lisa says as she flicks through screenshots of the medical records she captured on her cellphone. “He needed intense counseling — more than what they were offering. If they needed to observe him for a week, do it.”
Most disturbing to Lisa is the fact that no one at the VA told her that her husband might be a danger to himself or that he had repeatedly disclosed that he was suicidal.
“No one at the VA ever reached out to me in any way,” she says. “They told me nothing.”
Dan Reidenberg, executive director of the Minnesota-based nonprofit group Suicide Awareness Voices of Education (SAVE), says psychiatrists should always inform loved ones if a patient’s life is in danger, signed release or no.
“The consent form is irrelevant. Doctors don’t need that to disclose that information to the family,” Reidenberg says. “Any time somebody is determined to be at risk to themselves or others, there should be disclosure of that information to people who might be at risk or might be able to prevent such an attempt.”
Dr. Sam Foote won’t comment specifically about Luis’ case, which he knows nothing about, but speaking generally, he characterizes suicide among military personnel and veterans as “an epidemic” and agrees that looping in a patient’s family members is usually a no-brainer.
“The more family you can get on your side, the better for the patient,” Foote explains. “Almost always, as a physician, you will ask to get the family involved.”
Foote cautions that it’s unfair to blame the psychiatrist for not doing enough to prevent a suicide.
“One of the most difficult problems in all of medicine is the treatment of depressed individuals, especially those who are suicidal,” he says. “Of the people who come in who are suicidal, the vast majority of them do not commit suicide. There’s never been a good way to determine who is going to really do it and who isn’t.”
In Arizona, Foote continues, a doctor can involuntarily commit a patient for 24 hours and petition to extend inpatient care for up to 72 hours. Alternatively, a patient can voluntarily commit himself. Had Luis been admitted for inpatient treatment, he would have been given a bed in a mental-health-care facility whose staff would have checked on him at 15-minute intervals.
And at the VA, there’s another variable at play: “It’s up to the [doctor] to determine the risk and look at the resources,” Foote says. “Did they have a bed to put this guy in? How bad did it seem?”
“There’s been times at the VA where someone has come into the ER who is actively suicidal, wasn’t properly seen or evaluated, was sent out the door, and they committed the act within 24 hours. I don’t think anybody would suggest that that is appropriate,” Foote adds.
Then he repeats his central caveat: “It is very, very difficult to prevent suicide, even when you have a warning.”
Jef Gazley, a longtime Phoenix-area therapist who did not treat Luis, says it’s up to the therapist to assess whether a patient poses an immediate threat to himself or others.
“The individual therapist is making a judgment call on how serious they feel the person is, because there are a lot of people who are either gamey about the suicidal threat or they are crying out for help,” says Gazley, who has worked as a therapist for more than 30 years and founded the website www.asktheinternettherapist.com.
“If the person said they are feeling suicidal on a pretty consistent basis, certainly the idea of raising the treatment so that he was inpatient would probably make sense,” Gazley suggests.
Instead, after seeing the VA psychiatrist, Luis was sent home.
“The patient was given the phone # for the National Suicide Hot Line,” the intake notes read. “The patient was also given phone numbers for emergency contact with medical providers if the need should arise.”
On the last day of his life, Luis hand-wrote goodbye letters to his wife, family, and a few close friends, apologizing for what he was about to do.
“I beg you to pursue your dreams with an even stronger passion than ever,” he wrote in the note he addressed to his wife. “Please know that there is no such thing as a ‘right choice’ or ‘wrong choice,’ anything you decide was meant to be.”
On May 12, Luis Mariscal Munoz was buried with military honors at the National Memorial Cemetery of Phoenix.
A few days earlier, Lisa Mariscal had written him a note on Facebook.
“I miss you so much. You were not only the love of my life but my best friend and I am not sure how to move on without you. You were all that I knew, my rock, my motivation to keep on bettering myself. Our future looked so bright and I just wish you had given me more time to show you that. I will cherish all of the memories we had, both the good and bad. You will always be ‘mi amor.’ Thank you for the best 9 years of my life. I’ll always love you. RIP Luis and we will see each other again.”
New Times requested the incident report about Luis’ death from the Maricopa County Sheriff’s Office. The office declined the request pending issuance of the county medical examiner’s report.
Looking back, Lisa believes that Luis concealed his mental struggle from her because he was trying to protect her.
“He hid it pretty well from me,” she says. “I don’t know why he did what he did. To me, nothing was bad enough to do what he did. Even with the records — I see where he was unhappy with himself, but I still don’t see why.”
Lisa hopes the VA will change how its psychiatrists handle suicidal veterans.
“I’m not embarrassed by what he did. I want people to know,” she says. “The only thing I can do now is try and help others. That’s my motivation now.”
If the Phoenix VA does change, it might be under the watch of its new director, Deborah Amdur, who was appointed this past November. At a town-hall meeting with vets in January, Amdur pledged that the VA would be more responsive to its constituents.
But Amdur has a steep hill to climb.
In early April, the VA Office of the Inspector General issued a report regarding the VA medical center in White River Junction, Vermont, where Amdur had served as director before coming to Phoenix. The findings — long wait times, manipulating data to conceal shortcomings — were reminiscent of those that sparked the scandal at the Phoenix VA. (In fact, one of the Vermont employees whose complaints led to the investigation claimed to have been emboldened to speak up after the Phoenix story broke nationwide.)
The report prompted a finger-wagging response from U.S. Senator John McCain, who wrote Amdur an open letter demanding answers.
In a story about the report, Dennis Wagner of the Arizona Republic quoted a written statement from Amdur in response to the OIG’s findings. “While I was director at the White River Junction VA, we were working on reorganizing our scheduling processes to centralize all appointment scheduling activities when internal questions from staff were raised about our scheduling practices,” Amdur reportedly said. “I immediately asked the VA’s inspector general to come in and investigate. ... I’ve always believed that taking immediate action is the right thing to do, and that helped us immensely when I was at WRJ. I carry that same belief with me at the Phoenix VA and encourage staff to come forward to leadership when they find things they think might not be correct.”
But just last month, the OIG issued another report, this one finding fault with Phoenix following an investigation in response to complaints about delays, unsanitary conditions, and patient confidentiality. The results of the investigation substantiated most of the complaints. When it came to issues of cleanliness, the OIG cited understaffing as a contributing factor.
McCain and his fellow U.S. senator from Arizona, Jeff Flake, released a statement regarding the ongoing problems.
“I am deeply disturbed and disappointed in the conditions at the Phoenix VA. … Cleanliness, timeliness, and confidentiality are not lofty goals but bare minimums,” Flake said in the statement. “The failures of the Phoenix VA are worrisome.”
Added McCain: “We have a long way to go to change the culture that led to this scandal in care at the Phoenix VA that failed our state and nation’s veterans.”
Asked to comment about the Phoenix VA’s current approach to suicide prevention, chief media officer Paul Coupaud responded with a 500-word written statement that included quotes from Deborah Amdur.
“We have ensured that there is strong coverage for Veterans who present with mental health issues — putting in place 24/7 Social Work coverage and adding Mental Health Nurse Practitioners,” Coupaud writes. “We are also recruiting to have a psychiatrist on station 24/7. … We have tightened our protocols and provided all ED [Emergency Department] staff with training on assessment for suicide risk. We have seen a significant drop in the wait times in the ED as a result of these focused improvements.”
Coupaud quotes Amdur as saying she is confident that her staff is focused on its mission, and that creating a workplace where employees feel comfortable coming forward with concerns “without fear of reprisal” has been a top priority.
Amdur concludes by saying, “We still face challenges with staffing, improving employee morale, and the overall perception of care from our Veterans and the community. But by focusing each day on where we were and where we are now, Veterans, employees, and our stakeholders will begin to have confidence and re-establish trust in our organization here in Phoenix.”
Dr. Sam Foote says Amdur “inherited a huge mess of employees who were wronged and abused.”
He believes the VA’s troubles, then and now, can largely be traced to insufficient resources.
“Systemwide, they have a mismatch between supply and demand,” Foote says. “They have more demand for services than they [can fill].”
Paula Pedene sees it somewhat differently.
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“I don’t think lack of resources is the issue,” she says. “I think it’s management of resources.
“The culture wasn’t right. The culture still isn’t fixed, although I know they keep trying,” Pedene continues. “It takes a long time for a culture to go bad, and it takes a long time to heal once it has gone bad.”
Adds Pedene: “This is about morals and this is about ethics and it’s about one thing: Did we do the right thing for our veterans today?”
Veterans experiencing suicidal thoughts can seek care through any form of communication with VA staff or by calling the Veterans Crisis Line at 800-273-8255, extension 1.