NYT: Troubled Veterans and Early Deaths

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U.S.

Troubled Veterans and Early Deaths After Iraq



Adithya Sambamurthy/The Bay Citizen

Hamilton's mother, Dianne Hamilton, set up a memorial in her Modesto

home.

1 more image

By AARON GLANTZ

Published: May 29, 2011

This month, the Department of Veterans Affairs informed the parents of

Hamilton, an Iraq war veteran, that it was not responsible for his death.

Mr. 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 Mr. 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.

Mr. 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 Mr. 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.

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, " Mr.

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 Sullivan, executive director of Veterans

for Common Sense, a nonprofit advocacy group.

The agency, Mr. 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 Mr. Hamilton's

case and others reveal the suffering of many veterans.

Mr. 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.

Mr. Hamilton's family traces his deteriorating condition to an episode in Mosul,

a city in northern Iraq. In 2005, Mr. Hamilton was guarding a rooftop when his

best friend, Pusateri, was shot to death by insurgents. When Mr.

Hamilton returned home, he was racked by guilt, said his mother, Dianne

Hamilton, a Modesto teacher.

Her son started abusing methamphetamines and cocaine, Ms. 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 Mr. Hamilton continued to deteriorate.

On May 13, 2010, Mr. Hamilton became so disturbed that his father called the

Calaveras County Sheriff's Department. At 2 p.m., deputies rushed Mr. Hamilton

to nearby Mark Twain St. ph's Hospital. Hospital staff members reported that

Mr. 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, " , a Calaveras County crisis worker,

wrote.

Health records show that the hospital staff tried to transfer Mr. Hamilton to

three V.A. hospitals, including the one in Palo Alto, but " they do not start

transfers this late in the day, " Ms. wrote at 3:45 p.m.

At 4:39 p.m., a V.A. social worker, Symmonds, wrote that Ms. 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 Mr. Hamilton's being denied care. Dr.

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 Air Force Base in Fairfield admitted Mr.

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, Mr. Symmonds called Mr. Hamilton's brother Chase to apologize for

the transfer problems. Chase Hamilton interrupted him: " There won't be any need

for that. Thank you, " he said, according to Mr. Symmonds's notes.

Mr. Hamilton was dead.

aglantz@...

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[Guest guest]

http://mobile.nytimes.com/2011/05/29/us/29bcveterans.xml

U.S.

Troubled Veterans and Early Deaths After Iraq



Adithya Sambamurthy/The Bay Citizen

Hamilton's mother, Dianne Hamilton, set up a memorial in her Modesto

home.

1 more image

By AARON GLANTZ

Published: May 29, 2011

This month, the Department of Veterans Affairs informed the parents of

Hamilton, an Iraq war veteran, that it was not responsible for his death.

Mr. 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 Mr. 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.

Mr. 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 Mr. 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.

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, " Mr.

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 Sullivan, executive director of Veterans

for Common Sense, a nonprofit advocacy group.

The agency, Mr. 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 Mr. Hamilton's

case and others reveal the suffering of many veterans.

Mr. 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.

Mr. Hamilton's family traces his deteriorating condition to an episode in Mosul,

a city in northern Iraq. In 2005, Mr. Hamilton was guarding a rooftop when his

best friend, Pusateri, was shot to death by insurgents. When Mr.

Hamilton returned home, he was racked by guilt, said his mother, Dianne

Hamilton, a Modesto teacher.

Her son started abusing methamphetamines and cocaine, Ms. 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 Mr. Hamilton continued to deteriorate.

On May 13, 2010, Mr. Hamilton became so disturbed that his father called the

Calaveras County Sheriff's Department. At 2 p.m., deputies rushed Mr. Hamilton

to nearby Mark Twain St. ph's Hospital. Hospital staff members reported that

Mr. 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, " , a Calaveras County crisis worker,

wrote.

Health records show that the hospital staff tried to transfer Mr. Hamilton to

three V.A. hospitals, including the one in Palo Alto, but " they do not start

transfers this late in the day, " Ms. wrote at 3:45 p.m.

At 4:39 p.m., a V.A. social worker, Symmonds, wrote that Ms. 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 Mr. Hamilton's being denied care. Dr.

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 Air Force Base in Fairfield admitted Mr.

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, Mr. Symmonds called Mr. Hamilton's brother Chase to apologize for

the transfer problems. Chase Hamilton interrupted him: " There won't be any need

for that. Thank you, " he said, according to Mr. Symmonds's notes.

Mr. Hamilton was dead.

aglantz@...

Sent via BlackBerry by AT & T

[Guest guest]

http://mobile.nytimes.com/2011/05/29/us/29bcveterans.xml

U.S.

Troubled Veterans and Early Deaths After Iraq



Adithya Sambamurthy/The Bay Citizen

Hamilton's mother, Dianne Hamilton, set up a memorial in her Modesto

home.

1 more image

By AARON GLANTZ

Published: May 29, 2011

This month, the Department of Veterans Affairs informed the parents of

Hamilton, an Iraq war veteran, that it was not responsible for his death.

Mr. 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 Mr. 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.

Mr. 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 Mr. 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.

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, " Mr.

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 Sullivan, executive director of Veterans

for Common Sense, a nonprofit advocacy group.

The agency, Mr. 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 Mr. Hamilton's

case and others reveal the suffering of many veterans.

Mr. 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.

Mr. Hamilton's family traces his deteriorating condition to an episode in Mosul,

a city in northern Iraq. In 2005, Mr. Hamilton was guarding a rooftop when his

best friend, Pusateri, was shot to death by insurgents. When Mr.

Hamilton returned home, he was racked by guilt, said his mother, Dianne

Hamilton, a Modesto teacher.

Her son started abusing methamphetamines and cocaine, Ms. 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 Mr. Hamilton continued to deteriorate.

On May 13, 2010, Mr. Hamilton became so disturbed that his father called the

Calaveras County Sheriff's Department. At 2 p.m., deputies rushed Mr. Hamilton

to nearby Mark Twain St. ph's Hospital. Hospital staff members reported that

Mr. 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, " , a Calaveras County crisis worker,

wrote.

Health records show that the hospital staff tried to transfer Mr. Hamilton to

three V.A. hospitals, including the one in Palo Alto, but " they do not start

transfers this late in the day, " Ms. wrote at 3:45 p.m.

At 4:39 p.m., a V.A. social worker, Symmonds, wrote that Ms. 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 Mr. Hamilton's being denied care. Dr.

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 Air Force Base in Fairfield admitted Mr.

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, Mr. Symmonds called Mr. Hamilton's brother Chase to apologize for

the transfer problems. Chase Hamilton interrupted him: " There won't be any need

for that. Thank you, " he said, according to Mr. Symmonds's notes.

Mr. Hamilton was dead.

aglantz@...

Sent via BlackBerry by AT & T

[Guest guest]

http://mobile.nytimes.com/2011/05/29/us/29bcveterans.xml

U.S.

Troubled Veterans and Early Deaths After Iraq



Adithya Sambamurthy/The Bay Citizen

Hamilton's mother, Dianne Hamilton, set up a memorial in her Modesto

home.

1 more image

By AARON GLANTZ

Published: May 29, 2011

This month, the Department of Veterans Affairs informed the parents of

Hamilton, an Iraq war veteran, that it was not responsible for his death.

Mr. 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 Mr. 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.

Mr. 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 Mr. 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.

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, " Mr.

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 Sullivan, executive director of Veterans

for Common Sense, a nonprofit advocacy group.

The agency, Mr. 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 Mr. Hamilton's

case and others reveal the suffering of many veterans.

Mr. 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.

Mr. Hamilton's family traces his deteriorating condition to an episode in Mosul,

a city in northern Iraq. In 2005, Mr. Hamilton was guarding a rooftop when his

best friend, Pusateri, was shot to death by insurgents. When Mr.

Hamilton returned home, he was racked by guilt, said his mother, Dianne

Hamilton, a Modesto teacher.

Her son started abusing methamphetamines and cocaine, Ms. 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 Mr. Hamilton continued to deteriorate.

On May 13, 2010, Mr. Hamilton became so disturbed that his father called the

Calaveras County Sheriff's Department. At 2 p.m., deputies rushed Mr. Hamilton

to nearby Mark Twain St. ph's Hospital. Hospital staff members reported that

Mr. 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, " , a Calaveras County crisis worker,

wrote.

Health records show that the hospital staff tried to transfer Mr. Hamilton to

three V.A. hospitals, including the one in Palo Alto, but " they do not start

transfers this late in the day, " Ms. wrote at 3:45 p.m.

At 4:39 p.m., a V.A. social worker, Symmonds, wrote that Ms. 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 Mr. Hamilton's being denied care. Dr.

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 Air Force Base in Fairfield admitted Mr.

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, Mr. Symmonds called Mr. Hamilton's brother Chase to apologize for

the transfer problems. Chase Hamilton interrupted him: " There won't be any need

for that. Thank you, " he said, according to Mr. Symmonds's notes.

Mr. Hamilton was dead.

aglantz@...

Sent via BlackBerry by AT & T