ATLANTIC CITY, N.J. (AP) — A government investigation has found serious problems with a New Jersey veterans clinic where a Gulf War veteran set himself on fire and later died.
The Veterans Affairs Department’s inspector general found Charles Ingram III went nearly a year without seeing a counselor or taking medications for his mental health problems before his death in March 2016.
He requested an appointment to see his psychologist at the Northfield clinic and was given an appointment date more than three months later.
He had lost his job and was on the verge of a divorce.
The report found the clinic did not provide appropriate supervision and oversight in the 11 months before his death.
The clinic has since hired more staff, and the VA says better procedures will be implemented next year