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Review of Care Provided to a Patient Who Died by Suicide and the Subsequent Root Cause Analysis at the Robley Rex VA Medical Center in Louisville, Kentucky

This healthcare inspection was initiated to assess clinical and administrative concerns involving a patient who died by suicide. The OIG made eight recommendations.

Stethoscope

Review of Care Provided to a Patient Who Died by Suicide and the Subsequent Root Cause Analysis at the Robley Rex VA Medical Center in Louisville, Kentucky

June 9, 2026

This healthcare inspection was initiated to assess clinical and administrative concerns involving a patient who died by suicide. The OIG made eight recommendations.

Click to Read the Report

Review of the Peer Review Process at the VA Caribbean Healthcare System in San Juan, Puerto Rico

The VA OIG is committed to providing oversight for the welfare of veterans. This hotline inspection report focuses on the integrity of the peer review system at the VA Caribbean Healthcare System in San Juan, Puerto Rico.

Hospital bed

Review of the Peer Review Process at the VA Caribbean Healthcare System in San Juan, Puerto Rico
June 4, 2026

The VA OIG is committed to providing oversight for the welfare of veterans. This hotline inspection report focuses on the integrity of the peer review system at the VA Caribbean Healthcare System in San Juan, Puerto Rico.

Click to Read the Report

Review of Inpatient Mental Health Unit Processes at the West Palm Beach VA Healthcare System in Florida

This healthcare inspection was initiated following a patient death perpetrated by another patient in the inpatient mental health unit. The OIG made six recommendations.

Stethoscope

Review of Inpatient Mental Health Unit Processes at the West Palm Beach VA Healthcare System in Florida
June 4, 2026

This healthcare inspection was initiated following a patient death perpetrated by another patient in the inpatient mental health unit. The OIG made six recommendations.

Click to Read the Report

Overview of Veterans’ Experience, Environment of Care, and Staff Perspectives for Women Veterans in VHA Mental Health Residential Rehabilitation Treatment Programs

The VA OIG is committed to helping VA deliver high-quality health care. This national review of the Veterans Health Administration looked at the mental health residential rehab treatment programs and how they address the unique needs of women veterans.

Emergency room

Overview of Veterans’ Experience, Environment of Care, and Staff Perspectives for Women Veterans in VHA Mental Health Residential Rehabilitation Treatment Programs
June 2, 2026

The VA OIG is committed to helping VA deliver high-quality health care. This national review of the Veterans Health Administration looked at the mental health residential rehab treatment programs and how they address the unique needs of women veterans.

Click to Read the Report

Review of Emergency Dispatch and Facility Transport Processes at the Veterans Health Administration’s Veterans Crisis Line

The VA OIG is committed to providing oversight of VA processes and programs. This report evaluated dispatching emergency services and facility transport plans for VHA’s Veterans Crisis Line. The OIG made two recommendations.

Hospital bed

Review of Emergency Dispatch and Facility Transport Processes at the Veterans Health Administration’s Veterans Crisis Line
June 3, 2026

The VA OIG is committed to providing oversight of VA processes and programs. This report evaluated dispatching emergency services and facility transport plans for VHA’s Veterans Crisis Line. The OIG made two recommendations.

Click to Read the Report

Data Dashboard

Reports and Recommendations Published Within the Last 12 Months
149
Reports
743
Recommendations
$2.5B
Monetary Impact

The numbers totaled above are for published reports and recommendations only; the investigations and procurement-sensitive contract review totals can be found in the Semiannual Reports to Congress.

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