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This month, the Department of Veterans Affairs informed the parents of William Hamilton, an Iraq war veteran, that it was not responsible for his death.
Hamilton had been admitted nine times to a V.A. psychiatric ward in Palo Alto. He saw demon women and talked to a man he had killed in Iraq. His parents allege that the V.A. illegally turned away Hamilton — three days before he stepped in front of train on May 16, 2010, at the age of 26.
The agency denied the wrongful-death claim in a one-page letter: “The VA did not breach a legal duty,” wrote Suzanne C. Will, the agency’s regional counsel in San Francisco.
Hamilton’s death was recorded in an obscure government database called the Beneficiary Identification Records Locator Subsystem death file, which contains records for all veterans receiving benefits since 1973. The file provides a detailed portrait of the mental and physical wounds of veterans of the wars in Iraq and Afghanistan, and the high rate of suicides and risky, sometimes-fatal behaviors.
Records from that database, provided to The Bay Citizen under the Freedom of Information Act, show that the V.A. is aware of 4,194 Iraq and Afghanistan veterans who died after leaving the military. More than half died within two years of discharge. Nearly 1,200 were receiving disability compensation for a mental health condition, the most common of which was post-traumatic stress disorder.
“There are failures and people falling through the cracks who need care,” said Representative Jerry McNerney, an East Bay Democrat and member of the House Veterans Affairs Committee who is investigating Hamilton’s death.
The new data comes amid growing criticism of the V.A. for its handling of veterans returning from Iraq and Afghanistan. On May 10, the United States Court of Appeals for the Ninth Circuit, in San Francisco, cited the V.A. for “unchecked incompetence” and ordered an overhaul of how it provided health care and disability benefits.
The decision grew out of a 2007 lawsuit in which two veterans groups accused the V.A. of failing to provide proper care for hundreds of thousands of Iraq and Afghanistan veterans with post-traumatic stress.
The V.A. has refused to comment on the ruling. The Justice Department, which is representing the agency, has asked the court for more time to evaluate the decision before deciding whether to appeal.
David Bayard, a V.A. spokesman, said the agency was working hard to treat veterans with mental health issues. “V.A. has some pretty fine programs,” Bayard said, “but unfortunately we aren’t always successful.”
In October, The Bay Citizen, using public health records, reported that 1,000 California veterans under 35 died from 2005 to 2008 — three times the number killed in Iraq and Afghanistan during the same period. At the time, the V.A. said it did not keep track of the number of Iraq and Afghanistan veterans who died after leaving the military.
The V.A. database does not include veterans who never applied for benefits or who were not receiving benefits at the time of their death, according to the agency. The V.A. said it also did not
keep track of the cause of death.
Senator Patty Murray, Democrat of Washington and chairwoman of the Senate Veterans’ Affairs Committee, said the lack of an accurate accounting by the V.A. prompted her to work with state health departments to “ensure they report data on suicides among our veterans who never access the care and benefits they have earned.”
Veterans groups said they believed that the methodology would reveal a higher number of deaths.
“V.A. still doesn’t get it,” said Paul Sullivan, executive director of Veterans for Common Sense, a nonprofit advocacy group.
The agency, Sullivan said, is “intentionally and outrageously ignorant about what’s happening to our veterans.”
The V.A. redacted the names and hometowns of the veterans who died, saying disclosure of such information was prohibited. But details about Hamilton’s case and others reveal the suffering of many veterans.
Hamilton died when he stepped in front of a train on the Union Pacific track alongside Highway 99 in Modesto. There were three other recorded deaths involving Iraq and Afghanistan veterans that day: one man drank himself to death in his car in Pennsylvania; another, who had traumatic brain injury, died in an Illinois hospital. The third was a Navy veteran who could not be identified.
Hamilton’s family traces his deteriorating condition to an episode in Mosul, a city in northern Iraq. In 2005, Hamilton was guarding a rooftop when his best friend, Christopher Pusateri, was shot to death by insurgents. When Hamilton returned home, he was racked by guilt, said his mother, Dianne Hamilton, a Modesto teacher.
Her son started abusing methamphetamines and cocaine, Hamilton said. He moved in with her, spending most of the day alone in his room.
“He would sit there and talk with a man he killed in Iraq for 45 minutes,” she said. “He would have an entire conversation; just talk, talk, talk.”
In September 2009, his father, Cecil Hamilton, a former aircraft mechanic, moved his son to Sonora in the Sierra foothills, hoping the clean air and open space would help him. But Hamilton continued to deteriorate.
On May 13, 2010, Hamilton became so disturbed that his father called the Calaveras County Sheriff’s Department. At 2 p.m., deputies rushed Hamilton to nearby Mark Twain St. Joseph’s Hospital. Hospital staff members reported that Hamilton was delusional.
“Speaking of demon women and bright flashes of light, he is not able to respond to where or who he is — was wandering around naked, refusing to eat/take meds/engage in treatment,” Megan Harris, a Calaveras County crisis worker, wrote.
Health records show that the hospital staff tried to transfer Hamilton to three V.A. hospitals, including the one in Palo Alto, but “they do not start transfers this late in the day,” Harris wrote at 3:45 p.m.
At 4:39 p.m., a V.A. social worker, Paul Symmonds, wrote that Harris had contacted the Palo Alto hospital but “was told they would not accept a transfer for admittance of veteran this late in the day.”
V.A. officials said they had no record of Hamilton’s being denied care. Dr. Stephen Ezeji-Okoye, deputy chief of staff at the Palo Alto V.A. hospital, said the inpatient psychiatric ward operated continuously and was not at capacity that day.
“We have gone through and talked with our staff to try to determine if there was anyone who had received any contact from Calaveras County,” Dr. Ezeji-Okoye said. “We feel confident that indeed our policy was being followed.”
That night, a hospital on Travis Air Force Base in Fairfield admitted Hamilton. Two days later, he asked to leave and was discharged.
Mrs. Hamilton picked up her son on May 16. She said she cried the entire drive home to Modesto, fearing that he would not survive.
The next day, Symmonds called Hamilton’s brother Chase to apologize for the transfer proble Chase Hamilton interrupted him: “There won’t be any need for that. Thank you,” he said, according to Symmonds’s notes.
Hamilton was dead.
This article also appears in the Bay Area edition of The New York Times.