A soldier from Texas took his own life just minutes after texting the Veterans Affairs crisis line to indicate he had tried out a suicide plan and was now in a place where he had the materials to carry out his idea.
According to a report from the VA’s Office of Inspector General, the crisis line responder failed to make direct phone contact with the veteran or attempt to notify emergency personnel of the possible suicide attempt before ending the conversation. The responder told the veteran to implement the safety plan they had discussed prior with a family member.
Before texting the line in 2021, the investigation revealed that the soldier had a history of suicidal conduct and PTSD. Although the veteran had been marked as a high suicide risk in the past, his marker had been removed the year prior.
At 10:14 p.m., the anonymous veteran texted the line to say he was in a location where he could obtain suicide supplies and that he had practiced his intended approach to the point where he could feel “everything fade.” A lack of a protocol on silent monitoring for quality control and the inability to save text messages were also identified as “systemic flaws” in the report about the veteran crisis line.
The VA OIG found that despite the VCL’s usage of text messaging for crisis management for over a decade, no formal process for archiving old messages was ever implemented.
According to the research, the crisis line responder who dealt with the suicidal veteran in 2021 had an “inadequate” response and failed to notice the veteran’s suicide risk while failing to follow up when the individual stopped texting. Not only did crisis line leaders wait too long to tell anybody about the suicide, but they also didn’t undertake the root cause investigation that was supposed to be done within 45 days.
Veterans Affairs suicide prevention director Matthew Miller assured legislators at a recent meeting that the hotline will be upgraded.
The VA was “saddened by the loss of this Veteran,” according to VA Press Secretary Terrence Hayes. They vowed to take lessons from the investigation and implement changes to prevent similar tragedies.