Hon soon called for an investigation, and the Department of Veterans Affairs Office of the Inspector General has now released its thoughts on what happened.

"The first time I read it, I was so angry," said Hon.

Combing through 25 pages, Hon found the government agreed with what she says went wrong. Inspectors could not find evidence that the provider sufficiently explored Ron's suicidal thoughts, or inquired about the location of the patient's gun. The report says staff did not provide the patient with a mental health consult within the required time frame, or facilitate further assessment of his mental health.

"It surprised me that they admitted it, and I'm glad that they did," Hon said.

Still, the report says inspectors cannot conclude these deficiencies impacted Ron's death.

"When you read it, they contradict themselves," she said.

Hon says she hoped for vindication and consequences but her frustration continues. So to does her hope for veterans needing help.

"When they see a mental health care provider, they need to stick with that mental health care provider, (not be) pushed from one to another. They're with this one provider," she said.

The report made recommendations for VA medical centers, including documenting discussions about weapon possession, making sure mental health patients are seen a timely manner, and that staff plan for future mental health checkups. The Office of the Inspector General says it will follow up to make sure those recommendations become reality.