Why some veterans suddenly die after leaving Murfreesboro VA hospital

Taylor Hoffmann was hoping one day to criss-cross the country in a sort of pilgrimage on a bus.

Instead, she overdosed on keyboard air duster a week after Thanksgiving and just four days after leaving rehab.

Hoffmann, a 29-year-old Navy veteran, was originally destined for Room at the Inn, a Nashville homeless shelter where she hoped to get on her feet after completing a 28-day inpatient rehab program at Lincoln Trail Behavioral Health System in Radcliff, Kentucky. 

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It was her second rehab stint in about two months, paid for through the the Department of Veterans Affairs' Veterans Choice program, according to her father. 

But Hoffmann changed her mind about where to stay, her father said, after the VA said it would give her back-disability pay and $2,900 a month for the two dozen symptoms that developed after she was sexually assaulted by another woman when she was aboard the USS Teddy Roosevelt, her medical records show. 

Hoffmann is one of at least four veterans from Tennessee who died soon after their release from rehab programs and who had multiple stays at the Alvin C. York VA hospital in Murfreesboro, the USA TODAY Network-Tennessee has found based on interviews and medical records.

The veterans' families — and others who have spent time at the Murfreesboro VA hospital — paint a bleak picture about how some are treated, leveling accusations that patients are force-fed medications, treated like jail inmates and given dozens of prescriptions when discharged. 

“When I came, I was hopeless. I was lost. When I left I was homicidal and suicidal,” said Daniel Stott, an Iraq war veteran who stayed in Murfreesboro’s inpatient treatment wing, where he said he felt more like a prisoner than someone who spent 19 straight months in a war zone.

The surviving family members say their loved ones were not the same when they left treatment, overly medicated and with the underlying conditions they developed serving the country in combat the same or worse.

In multiple cases reviewed by the USA TODAY NETWORK - Tennessee, they relapsed and were found dead within days or weeks after their release, each by self-inflicted means. 

"They’re considered slow suicides. They know the demon that’s gonna get them, and they just give into it," said David Toombs, who has become an advocate for reforms and veterans issues since his son, John Toombs, hanged himself in a building on the large hospital campus in November 2016.

The cases raise questions about how the VA handles veterans battling intense depression, post-traumatic stress and addiction, and if the VA is discharging veterans too soon with medications that could contribute to their deaths.

"The VA is not latching on to the veterans. (The VA is) trying to get them out the door as fast and as cheaply as possible," said Kenny Yates, an Army veteran who also has been an inpatient at the Murfreesboro hospital. 

The VA made changes to its Residential Recovery Treatment Program, or RRTP, a program for veterans with PTSD, substance abuse and other issues, in the wake of Toombs' death. Veterans said the changes were visible, but have made little progress in treatment. 

The VA says its focus is on the immediate safety of veterans, and checks in once a week with veterans after they are discharged for the first month, and longer if the veteran agrees.

The Murfreesboro VA says its Residential Recovery Treatment Program and psych ward have treated nearly 6,000 veterans since 2011, and most survey responses are positive.

It has shown recent evidence that it has had success reducing dependency and prescription of opioids, including at Murfreesboro, an issue itself that has reached epidemic levels. 

According to VA's data, the opioid prescription rate in the Tennessee Valley Healthcare System, which includes Murfreesboro, dropped from 24 percent to 15 percent from 2012 to 2017.

The agency also uses a rubric-like checklist that scores veterans on a variety of conditions like substance abuse, depression and other mental health conditions. Doctors are also required to check a database to make sure they don't overprescribe.

"The safety of our veterans is always our primary concern, but our acute inpatient psychiatric units have highly-trained staff engaging with veterans to ensure safety," the VA said.

More:VA publicly releases opiate prescribing rates for all its hospitals for the first time

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'Gibberish, unconnected thoughts'

Douglas Beaver, 38, died in February 2017 after what an autopsy suggests was complications from inhaling freon-based propellant, similar to Hoffmann. It caused his heart to stop. 

Brian Barr, 46, died March 1, 2017, after his stay at the hospital ended Jan. 3. Barr drank himself to death, his mother, Nola McCormick, said, a condition he had been treated for 17 times in and out of VA facilities since he left the Army after Desert Storm.

The amount of alcohol in Barr's blood was more than five times the legal limit to drive a car, his autopsy states.

When McCormick cleaned out her son's personal belongings, she found more than 60 bottles of prescription medications given to Barr in just two months, she said, which she believes was a contributing factor to his death.

Among them were Effexor and Vistraril, both of which come with warnings to avoid alcohol and closely monitor reactions for increased suicidal behaviors.

Paul Hoffmann, Taylor Hoffmann's father, said he found more than 200 bottles of medications given to his daughter. It filled a moving box to the top, he said.

She left treatment in Kentucky with a half-dozen medications, including trazadone, buspirone and Zoloft.

With those pumping in her system, and knowing where she was headed, her father questions the decisions to release her from the rehab program, and if the VA could have done more to help her.

“That’s someone you dump on a bus and say best of luck?” Hoffmann questioned.

Another veteran, Stephen DeMoss, 31, spent a decade battling alcoholism and intense post-traumatic stress after his tour in Iraq that earned him two Bronze Stars.

DeMoss also spent time in both privately managed rehab facilities and the VA in Murfreesboro. He died Nov. 13 after spending five days in the Murfreesboro facility in October.

He died in his sleep from a lethal combination of alcohol and nordiazepam, his autopsy states. Three-and-a-half empty bottles of vodka were found, and his roommate told authorities he had been on a three-week bender after leaving the VA program, and it wasn't the first time he had relapsed.

“The drugs (VA doctors) gave him made him crazy those remaining days. He called us and was talking total gibberish, unconnected thoughts,” his father, also named Stephen, said.

A medical examiner’s report indicated his cause of death was accidental.

The VA says it treats veterans who come to the inpatient psychiatric ward in ways that focus on safety first, but can hold veterans for up to 72 hours for various reasons, including doctor's orders and by law enforcement.

"Anyone held beyond that would require a judge’s order," said Chris Vadnais, a VA spokesman for the Murfreesboro hospital. "If safety is not stabilized, a judge would hold a hearing and make a decision to either discharge the veteran or continue treatment."

What the VA is doing

The VA has grappled with ways to reduce the prevalence of suicide among veterans. The VA points to centers it has established to field crisis calls, and the specialized service it offers to its patients.

It developed an Opioid Safety Initiative and the Psychotropic Drug Safety Initiative, both aimed at reducing the dependency on opioid medication and other drugs linked to addiction.

VA Secretary David Shulkin has repeatedly called veteran suicide his "number one clinical priority." 

President Donald Trump recently signed an executive order aimed at expanding suicide prevention services to veterans not connected to the VA. It adds to another measure put in place last year that allowed veterans with "other than honorable" discharges to get care from the VA.

Suicide spurred changes

Murfreesboro remains among the most poorly rated veterans hospitals in the country, and is facing new criticism that it treats veterans like criminals, especially those dealing with post-traumatic stress and substance abuse problems.

John Toombs posted a video on YouTube before he hanged himself, alleging he was booted from the treatment program for "trivial" reasons to set an example by the VA.

Barr, a close friend of Toombs, was put on suicide watch after Toombs' death. He told McCormick the hospital had installed more cameras, added security locks and changed personnel, she said.

The VA discharged Barr on Jan. 3, 2017.

McCormick believes the VA never should have released her son.

"There should be something, some way — a place they can live in a structured environment for situations like his," she said. 

After his release, McCormick described six weeks of "pure joy" where she and Barr shared a home, memories and church. She called them "the best six weeks a mother could ask for." 

But then he moved out, relapsed, and was dead within two weeks.

► More:Nashville, Murfreesboro VA hospitals among worst for mental health

Yates and Stott believe the VA should base their treatment for the most afflicted veterans with support and compassion, not an atmosphere that resembles a prison.

“That’s the only way they acknowledge you is when you make an ass of yourself,” Stott said, recounting a recent visit where he and Yates raised their voices to get the immediate psychiatric triage that Stott said he needed.

'Isolation'

The depictions of what happens inside the facility from veterans who stayed there paint a picture of jail-like intake.

Veterans say they’re strip searched when they enter the facility known as "7A," which is intended for veterans needing intense inpatient psychological therapy. Doors are locked behind them, and veterans who become too much to handle are sedated, Yates said. 

“It’s the whole deal,” said Yates, who has stayed there himself and gone with others, like Stott, to advocate on the behalf of veterans.

There is one full-time patient advocate at Murfreesboro, and six in Nashville, according to the VA. Nearly 6,000 veterans have been through RRTP or 7A since 2011, the hospital said.

The average stay in those programs is just over seven days, the VA said, and most veterans have positive reviews based on the VA's own data.

Nearly a third of those 6,000 have stayed in either program more than once. 

Yates and Stott said there’s little oversight and attention from nurses and doctors, and veterans experiencing intense withdrawals are placed among others in overwhelming states of paranoia or rage and others put in padded rooms. 

“The whole thing is about isolation,” Stott said.

Stott and Yates are considering creating a nonprofit to provide advocacy to veterans.

Demoss’ parents said their son's stays were never long enough, and said he was discharged far too soon, sending him back down the spiral that put him there to begin with.

'Live to live'

Just days before her death, Hoffmann had written in discharge papers from Lincoln Trail that she had a plan to avoid relapsing. She wanted to "live to live."

She and a close friend, Gwen Yeager, 21, had discussed a journey across the country — perhaps beyond — in a bus she hoped to buy with the disability back pay. Yeager said Hoffmann had hope, and things seemed to be turning in the right direction.

"It’s a shame she passed away before she could go on her big adventure," Yeager said.

Hoffmann was found in cardiac arrest. She was never revived.

Paul Hoffmann said when he picked up his daughter's remains in Nashville in early January that he's lost his faith in the Murfreesboro VA and the agency itself, and carries "tremendous guilt" for not sending her elsewhere.

"We might have saved Taylor for the rest of her life, but they could have saved her that day with just a phone call," he said. 

Reach Jake Lowary at jlowary@tennessean.com or on Twitter at @JakeLowary.