In a recent development, the Veterans Affairs Office of Inspector General (OIG) has released a deeply concerning report shedding light on the shortcomings in the prevention of veteran suicides. The report is centered around a tragic incident in 2021 when a suicidal veteran reached out to the Veterans Crisis Line, only to take their own life minutes after the interaction. This incident has sparked a nationwide call for reform within the system.
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The Veterans Crisis Line, available 24/7 through telephone, text messages, and online chat, played a pivotal role in this tragic event. The distressed individual engaged in a 75-minute text conversation with a crisis line staff member, culminating in their devastating decision to end their life merely 10 minutes after the last message was exchanged.
During a Senate Veterans Affairs Committee hearing, Louisiana Senator Bill Cassidy expressed his deep concern about the OIG report, deeming it “incredibly damning.” The report also highlighted issues in the aftermath of the veteran’s suicide, including allegations of potential interference with the OIG’s investigative work.
Matthew Miller, the Executive Director for Suicide Prevention at the Veterans Health Administration, addressed lawmakers during the hearing, emphasizing the significant progress made on eight out of the 11 recommendations outlined in the OIG report. Miller stressed the urgent need for improvement, stating, “We’re better than what was depicted in that report, and we have to do better.”
The veteran at the center of this tragedy, aged in their 30s, had a history of post-traumatic stress disorder, depression, alcohol use disorder, and suicidal behavior. On that fateful night, they reached out to the crisis line in a desperate attempt to prevent self-harm, revealing that they had both the means and the location to commit suicide. They even hinted at the possibility of becoming intoxicated enough to carry out their plan.
Despite these known risk factors, the OIG report revealed that the crisis line worker failed to escalate the situation by transitioning the text conversation to a phone call, contacting third-party rescue personnel, or confirming the intervention of a family member in the patient’s efforts to prevent suicide. Tragically, the patient’s last outgoing text message to the crisis line was sent at 11:02 p.m., while the last response from the staffer was around 11:29 p.m., with the note that the patient had remained on the line until the call ended normally. The patient took their life at 11:40 p.m.
The following day, the suicide prevention program case manager contacted the sheriff’s department to request a welfare check, only then discovering the patient’s tragic death by suicide.
This incident underscores the persistent and alarming issue of veteran suicides. According to the latest VA figures, there were approximately 17 veteran suicides per day in 2020, a rate significantly higher than that of the general U.S. adult population. This gap has varied over the years, from 12% to as wide as 66% higher over the last couple of decades. In 2020, veterans committed suicide at a staggering 57% higher rate than nonveteran adults.
Cole Lyle, a former Marine and advocate for veterans with Mission Roll Call, points out systemic issues within the VA’s approach to suicide prevention. He argues that the system is too reactionary, advocating for increased outreach and funding for local organizations to address veterans’ crises at an earlier stage.
Lyle acknowledges that the Veterans Crisis Line has had success stories but insists that improvements are urgently needed. He states, “This is an unacceptable example of a lack of empathy and accountability, and we certainly need to do better.”
In light of this heart-wrenching incident and the broader context of veteran suicide, it is clear that a comprehensive reform of suicide prevention strategies is essential. It is a collective responsibility to ensure that our veterans receive the support and care they need during their most vulnerable moments.