Editor’s note: If you or someone you know is having suicidal thoughts, you can reach the national crisis hotline by dialing 988.
Jordan Hunkin joined the Marines right out of high school. Eager to serve, he skipped his graduation at Clearwater's Calvary Christian in 2004 to enlist. He completed multiple tours in Iraq and Afghanistan from 2005 to 2012.
In 2023, his struggles with depression and service-related post-traumatic stress disorder reached a nadir.
Early that year, he ended up at the Malcom Randall Veterans Affairs Medical Center in Gainesville seeking a voluntary stay for mental health treatment. Instead, according to an Aug. 28 report from the VA Office of Inspector General, he was involuntarily held under Florida’s Baker Act.
He died by suicide six months later.
James Hobby, a fellow Marine and friend, said he filed multiple complaints with the White House VA complaint hotline when he learned what had happened. He said VA hospital staff closed his complaints within hours of him submitting them, so he filed a complaint with the Office of Inspector General, which opened an investigation.
“People need to be fired. People need to be arrested,” Hobby said. “That’s the only way I’ll get retribution for my friend.”
Hunkin’s name was not included in the OIG report for health privacy reasons, but Hobby confirmed it was about his friend.
The report found that the emergency physician in charge of evaluating Hunkin was concerned he would leave before receiving treatment and incorrectly filled out the Baker Act paperwork to hold him in the hospital. This included marking that Hunkin refused voluntary examination and was unable to determine for himself that the examination was necessary, citing the word “depression” as supporting evidence.
Susan Tostenrude, a director within the VA Office of Inspector General, said these observations were different from a psychiatrist’s findings of Hunkin’s behavior.
“Consistently, we hear from clinicians and see in the medical record that the patient (Hunkin) is calm and is cooperative and logical,” she said. “But the patient is expressing, and it's documented numerous times in the chart, that the patient is very upset about being involuntarily admitted to the unit.”
North Florida/South Georgia VA chief of communications William-Joseph Mojica said in a statement that the VA is “undertaking significant steps” to make sure staff follow proper procedures in response to the report.
Michael Mclelland also served in the Marines and was friends with Hunkin. He fell out of contact with Hunkin after they left the Marines, but Hobby reconnected them in 2023.
“That first phone call that we all had together, it was pretty clear to me that he was just not OK,” Mclelland said.
Mclelland said mental health is often stigmatized in the veteran community because it’s an invisible struggle.
“The grand mantra of the armed services is to operate while under duress,” he said. “No one's ever told when you have to stop operating in that mode.”
The OIG report also found that mental health staff members were not receiving the state-mandated Baker Act training, and the hospital wasn’t tracking the training. Hunkin also did not receive his rights in written form while being involuntarily held, as Florida law requires.
Hobby said that in his experience veterans only go to the VA when they have no other choice. He expressed frustration with the way the VA staff treats veterans in crisis.
“It’s when these guys have to go to the VA that they start feeling hopeless,” Hobby said. “It’s the VA that’s pushing them over the edge.”
Tostenrude also said there was a misunderstanding of when VA police were able to intervene, with many medical providers and members of the VA police thinking a Baker Act form was required to prevent someone from leaving the hospital.
“This misunderstanding is not unique to Gainesville," she said. "This is an issue that the VA struggles with at other facilities as well."
The report also conducted a random sample of 100 patients admitted to the facility’s inpatient mental health unit from October 2022 to September 2023. Sixty-one of those were admitted for involuntary examination. Of those, 15% had inaccuracies in the paperwork and inconsistent documentation of the physician’s rationale for involuntary examination. For 28% of them, staff failed to take appropriate action within 72 hours.
According to Tostenrude, it’s “unusual” for the VA to follow state law instead of federal regulations. But involuntary mental health treatment is one of the few times the VA does have to follow state laws such as Florida’s Baker Act.
Hunkin told providers he would no longer be seeking mental health treatment from the VA because of his experience at Malcom Randall. Six months later, the VA learned from a family member of Hunkin's suicide.
The OIG ended the report with 12 recommendations for the North Florida/South Georgia Veterans Health System, which includes Malcom Randall. These included clarifying the process by which patients are given written rights and ensuring all licensed mental health staff members receive annual training that is tracked.
Tostenrude said the OIG will closely monitor the recommendations in the coming months until it finds “sufficient evidence” that the changes have been made.
In the statement, Mojica said, “preventing Veteran suicide is our highest priority, and we take this responsibility with the utmost seriousness.”
According to Mojica, the VA will implement flow charts for voluntary and involuntary Baker Act admission, mandating Baker Act training for all emergency medical and mental health staff and clearly displaying written information on patients’ rights in mental health evaluation rooms.
Mojica said the hope is to fully implement the OIG’s recommendations by November.
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