A Suicidal Veteran Texted the VA Crisis Line. A Responder Didn’t Send Help, and Minutes Later the Veteran Was Dead.

by Braxton Taylor

A Veterans Affairs Office of Inspector General report highly critical of the Veterans Crisis Line’s handling of a suicidal veteran sparked outrage this week from U.S. senators responsible for oversight of the VA.

The OIG report, released last week, detailed the failure of the Veterans Crisis Line, or VCL, to help the veteran, who died by suicide minutes after cutting off contact. The veteran reached out to the hotline by text, telling a responder they had tested out their planned means of suicide and were in a location where they had access to those materials.

The crisis line responder did not contact the veteran directly by phone or alert first responders, but instead directed the individual to enact a safety plan formulated with a nearby family member. The responder terminated the text thread without verifying that the plan had been enacted when the veteran did not respond.

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“This is an incredibly damning OIG report, incredibly damning,” Sen. Bill Cassidy, R-La., said in a Senate Veterans Affairs Committee hearing Wednesday on suicide prevention at the VA. “I’m struck that the executive director who apparently interfered with the OIG report was not fired. She’s reassigned, I presume, still receiving a paycheck.”

The report also appeared to outrage the committee chairman, Sen. Jon Tester, D-Mont.

“We’ve had so damn many hearings on mental health, and it doesn’t seem like anything has changed,” Tester said. “We just got to do better. … It’s ruining lives, it’s ruining families.”

In addition to the failure of the responder to help the veteran, the inspector general’s investigation found systemic issues at the VCL, such as lack of a policy on silent monitoring, which is supposed to be conducted for quality control, and an inability to save texts other than cutting and pasting.

“The OIG determined that the leaders failed to establish a text message retention process in over 10 years of the VCL’s use of text messaging for crisis management,” wrote Dr. John Daigh, the VA’s assistant inspector general for health care inspections.

With an estimated 17 veterans dying each day by suicide, the VA has made suicide prevention a top priority. Matthew Miller, executive director for suicide prevention at the Veterans Health Administration, told senators that the VA hired 900 crisis line workers in the last 18 months.

Since adopting the 988, Press 1 emergency number, Miller added, the VA’s crisis line has fielded more than 1 million calls, texts and chats.

In 2016, the VCL came under fire for failing to answer all calls. More than one-third of the calls to the line were rolled over to contractors who had less training than the VA employees who manned the call center.

The number of veterans who died by suicide in 2021 is expected to be released by the VA this month. In 2020, the most recent year for which data is available, 6,146 veterans died by suicide, down nearly 10% from 2018.

The inspector general report said the San Antonio-area veteran, who suffered from post-traumatic stress and had a history of suicidal behavior, texted the crisis line in 2021 asking for help. The veteran previously had been flagged as being a high risk for suicide, but that flag had been removed the year before, eliminating a marker that would have warned the Veterans Crisis Line responder of the veteran’s mental health history.

The veteran, who was not named in the report, contacted the line at 10:14 p.m. and said they were in a place with access to means. The veteran said they had tested the method to a point, “feeling everything fade.”

The veteran then said they had a safety plan with a family member and had texted a hint that the safety plan needed to be enacted. That text, at 11:02 p.m., was the last from the veteran. The responder continued to try to text the veteran but did not receive a response. The responder terminated the call at 11:29 p.m.

According to the report, the veteran died by suicide at 11:40 p.m.

The IG concluded that the crisis line worker’s response was inadequate, failing to recognize the veteran’s suicide risk and not following up when they stopped texting. The responder never reached out to the veteran by phone and did not send emergency personnel to the scene, despite the veteran saying on the text thread that they had attempted suicide.

Later, crisis line leaders delayed disclosure of the death and did not conduct a root cause analysis of the suicide — an investigation that is required to be done within 45 days.

Furthermore, leaders failed to update the veteran’s status in the electronic health record and elsewhere, exposing the family to calls from providers about appointments and medical care and “caring communication” notices from the VA after the veteran’s death.

“Why does it take an inspector general’s investigation for this to be addressed? What’s not taking place at VA to get this solved before this particular veteran committed suicide?” asked Sen. Jerry Moran of Kansas, the committee’s ranking Republican.

In testimony to the committee, Miller acknowledged the veteran’s death by suicide immediately following contact with the Veterans Crisis Line.

“We, I, as a veteran grieve the loss of a veteran,” Miller said.

The inspector general recommended that the crisis line review all communications between staff and veterans and improve risk assessment guidelines for responders. The VA has plans to update the text messaging service of the crisis line next year, according to the report.

During the hearing, Miller pledged improvements at the crisis line and throughout the VA to prevent suicides.

“It’s our earnest desire and pledge to apply the wisdom gained through this review to strengthen processes as we continue to serve veterans who are the center of all we do, even at this very minute as we answer calls,” Miller said.

If you are a service member or veteran who needs help, it is available 24/7 at the Veterans and Military Crisis Line, call, 988 Press 1, text 988 or use the online chat function at www.veteranscrisisline.net.

— Patricia Kime can be reached at Patricia.Kime@Military.com.

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