Marine Sgt. Tom Bagosy stepped out of his black GMC Sierra pickup and onto the gray, speckled pavement of McHugh Boulevard, a busy thoroughfare in the heart of Camp Lejeune, N.C. He held a pistol in his right hand.
The military police car that had pulled him over idled on the shoulder a safe distance behind him. The midday traffic stopped. Bagosy stood for a moment on the warm pavement under a cloudless May sky. Then he raised the pistol, pointed it to the right side of his throat just below his jaw, and pulled the trigger.
The bullet sliced through his jugular vein, traveled through his skull and exited near the top left side of his head. He crumpled down in the road. Even if the bullet had failed to rip through his brain, shooting through the jugular was solid insurance. He would have bled out in minutes anyway.
Bagosy, 25, who had served in Iraq and Afghanistan, had become another statistic in the war-fatigued military and its steadily escalating suicide rate. Last year, 52 Marines committed suicide. The suicide rate among Marines has doubled since 2005, and the Corps has the highest suicide rate in the military. The circumstances of Bagosy's death, however, provide a particularly poignant case study in what many critics say is the military's inadequate response to that suicide crisis.
Bagosy's story shows how the military's ineptitude in the face of crisis affected a single family -- in this case, a Marine in the last hours of his life, and his two young children and his wife, who waited in vain that day for him to come back to his home just outside Camp Lejeune.
These circumstances are particularly troubling because Bagosy died a year after a former Camp Lejeune psychiatrist risked his reputation and career to warn Navy officials that unless Camp Lejeune dramatically improved mental health services -- and in particular, develop precise, rigorous protocols for handling Marines who might kill themselves or others -- there would be deadly consequences.
That psychiatrist, Dr. Kernan Manion, repeatedly warned Camp Lejeune and Navy officials in writing starting in the spring of 2009 about the risk of more Marine suicides, murder and "immediate concerns of physical safety" if Camp Lejeune did not improve. Frustrated by what he saw as a lack of action by officials at Camp Lejeune, Manion took his concerns to a series of military inspectors general in late August. He was fired four days later. The Defense Department inspector general is investigating that case.
The lessons from Bagosy's suicide are especially provocative because minutes before his death, Bagosy was inside the Camp Lejeune Deployment Health Center, the place where doctors are supposed to help Marines like Bagosy. Healthcare workers there knew he had problems. They knew he had already been diagnosed with both a brain injury and post-traumatic stress disorder, the signature injuries of the current wars. He'd been seeing a doctor there and a therapist. He'd talked with his therapist about thoughts of suicide. Officials at the clinic the day he died also knew Bagosy was acutely suicidal that very morning and that he was armed, because his wife, Katie, had called to warn them about all of it. They had decided he needed to be hospitalized.
Yet he managed to get away from the clinic, and minutes later Bagosy would lay covered by a bloody sheet on one of Camp Lejeune's main thoroughfares.
Bagosy first started seeing doctors at Camp Lejeune in the summer of 2007 after a tour in Iraq. He was soon diagnosed with a brain injury and PTSD. His wife described the change in her husband after that first tour in Iraq this way: "The man I married died in Iraq and I didn't know the man who came back." Then Bagosy went to Afghanistan, with Marine Corps Forces Special Operations Command. A close friend died in an explosion there. He returned in November 2009. Bagosy struggled with typical symptoms for his continuing problems: depression, anxiety, alcohol abuse and bouts of sudden, intense suicidal and homicidal thoughts. At work at Camp Lejeune in February of this year, Bagosy threatened to "shoot up the place" according to his medical records, a threat his superiors took so seriously they temporarily confiscated Bagosy's weapons from his home. (He later signed them out again, claiming he wanted to practice at a nearby shooting range.)
He was seeing a counselor and a psychiatrist at Camp Lejeune, but Bagosy didn't think it was helping much. Mostly he felt overmedicated. His condition worsened. In April, Katie wrote a letter to her husband's psychiatrist, worried about poor treatment, and suggesting he switch doctors. "I can no longer stand by and watch my husband lose control and watch as his life slips away," she warned.
In March, Tom and Katie argued in the kitchen. He pulled a handgun from the top of the refrigerator and put it to his head. "Do you want me to kill myself?" he screamed at Katie.
The day before Easter they fought again. Tom went for the gun. "He was sitting at the computer," Katie recalled later, huddling on her sofa in her home just outside Camp Lejeune. "He stood up and started to walk toward the kitchen. I knew where he was headed and I tried to get there first." They struggled over the weapon. "It was like a movie. We were hand-in-hand fighting over that gun. Obviously, he is stronger than I am," she said. "He pushed me off and got in his car and drove off."
Katie called the police, who could not find him. Tom later told his mental health counselor at Camp Lejeune about the incident. The counselor asked him if he'd been drinking at the time. Bagosy admitted that he had. The counselor informed his commanders, who referred him to a later appointment at the substance abuse program that was also located inside the Deployment Health Center.
Tom got worse. The day before he went to that substance abuse appointment, May 9, Mother’s Day, Tom was despondent. "I spent the whole day trying to convince him not to kill himself," Katie recalled. He took a handful of anti-anxiety pills. It didn't kill him.
That night, Katie recalled, "He had the gun and he was waving it around," and said to her, "Don't worry. I'm not going to kill you."
"I'm not worried about that. I'm worried about you killing yourself," Katie replied. "There is no way I can keep you from doing this, is there?"
"No," Tom said. Katie quotes him as saying: "I went from being so angry that I want to take someone with me, to I just want it to end."
She convinced him to go to his appointment at the Deployment Health Center the next morning. She thought she might be able to save him, if she could just get him in the door.
The next morning when Tom went out to his GMC Sierra, he had a handgun in the middle console of the truck between the two front seats.
The details of what happened on May 10 are not in dispute. Tom arrived as scheduled. He filled out some paperwork to begin treatment at the substance abuse center. Tom's written responses about his depression alarmed one counselor there so much he immediately escorted Tom into a doctor's office.
At the same time, Katie called her husband's mental health counselor who was sitting upstairs inside the same building. She told the counselor that Tom was there and that he wanted to kill himself. Katie said he needed to be hospitalized, but would probably resist efforts to do so. "He has a tattoo that says, ‘Death Before Dishonor'" Katie explained later. "To him, this was dishonor." That wasn't all. "I told them he had a gun," she remembered.
The counselor called downstairs and relayed all of this information to workers there. The counselor informed them that Tom should not even be allowed out of the building to smoke a cigarette. He needed to go to the hospital.
The counselor and the healthcare officials in the substance abuse center all agreed that Tom needed hospitalization immediately, but they were unsure on just how to transport him there. Ultimately, the staff called Tom's commanders at the Marine Corps Forces Special Operations Command to arrange an escort. Tom seemed calm and cooperative throughout this process. He also agreed to wait for his escort.
Despite his cooperative demeanor, the officials at the clinic were still worried that Tom might flee before his escort arrived, though, again, they were evidently unclear on just what to do about that as well. A substance abuse counselor agreed to keep an eye on Tom, who sat on a sofa in the counselor's office.
When the counselor turned to his computer to work, however, Tom stood up and struck up a conversation with a civilian in the hall. Then he simply walked quickly down the hall, out of the clinic, and broke into a run as he headed toward his truck. This was a prospect that the clinic staff had no protocol or tools at their disposal to prevent; there was not even a military police officer on hand to watch the door.
The substance abuse counselor panicked, chased Tom outside and asked some nearby Marines in the parking lot -- patients themselves -- to tackle Tom. There was a struggle at Tom's truck. Tom produced the gun from the console. The counselor and the Marines backed off. Tom got in the truck and drove away.
Clinic workers had already called the M.P.s. Tom had barely made it a block when an officer passed him driving in the opposite direction. The officer noticed that Tom was talking on a cellphone while driving.
"He called me and was crying hysterically," Katie remembered. "He said, 'I love you and I don't think I'm going to ever see you again.'"
Tom hung up. The police car had turned around and pulled Tom over on the shoulder of McHugh Boulevard.
The commander of the Naval Hospital at Camp Lejeune, Capt. Gerard Cox, says staff at the Deployment Health Center followed established protocol in their efforts to hospitalize Bagosy. "We practice by the exact same standards as the civilian world," Cox explained. "There is a risk assessment that is conducted by that medical professional, and then it is a matter of judgment as to whether the person needs to be taken right now" to the hospital, he said. "One extreme would be taken under armed guard and another extreme would be they take themselves." In this case, Cox said, calling Bagosy's command to come to the clinic to escort him to the hospital seemed sufficient.
Those judgment calls are that much more difficult when a patient appears to cooperate, Cox argued. "He was not overtly agitated, violent, threatening, or stating any intent for violence against himself or for anybody else," Cox explained.
Indeed, by civilian standards, officials at the clinic handled Tom appropriately. "They did not blow it," said Lanny Berman, a psychologist and executive director of the American Association of Suicidology. "The physician needs to make arrangements to have the patient escorted," Berman explained.
The very fact that Bagosy died following the ad hoc nature of the clinic's effort to arrange for his hospitalization, however, suggests that civilian protocol might not suffice for a clinic treating combat-hardened troops with acute, explosive conditions. "This is exactly the sort of event I was trying to help them prevent when I repeatedly urged them to implement a comprehensive and truly fail-safe violence response protocol," Manion said.
Indeed, the account of the treatment gaps that preceded Bagosy's suicide track closely to what Manion complained about. The psychiatrist told his supervisors that the various doctors treating Marines should compare notes and coordinate care. He wanted specially trained M.P.s on hand at all times at the clinic and ready to intercede if any cases got out of hand, as Bagosy's did.
Manion was adamant because he insisted these were no ordinary patients. They are traumatized, volatile, armed and trained to kill, requiring extra precautions, top-shelf care and the exercise of rigorous safety protocols. "This service population is one of high risk, high intensity and frequent crisis," Manion desperately wrote his superiors in an April 24, 2009, memo seeking improvements in the way Camp Lejeune handled Marines in crisis.
"Tom's suicide, as sad as it is, also makes me furious because it was entirely preventable," Manion said recently. "His death highlights Lejeune's grossly inadequate understanding of the specific needs of these psychiatrically high-risk troops."
Cox said Camp Lejeune officials continue to investigate why things went so wrong. "It is an interesting question that you ask, that since the population is different, whether our services and capabilities should be different," he said. "I think they are."
Manion disagrees, and says the Navy should know better, particularly after nearly 10 years of war. "To me, their persistent lack of preparation -- repeatedly refusing to heed the explicit warnings they've received from me and others -- exemplifies not only willful ignorance, but a defiant arrogance," he said.
Bagosy was buried at Arlington National Cemetery earlier this month. Casualties of the wars in Iraq and Afghanistan are buried in one revered section there, called Section 60. Bagosy is buried in Section 59, since he is not considered a casualty of those wars. Katie is furious, and sees his burial in Section 59 as a marginalization of her husband’s psychological wounds. It is well known that the military struggles with the stigma of mental trauma. "They are even stigmatized in death," she said.