published : 2023-09-24

VA Crisis Line Under Fire After Failing to Send Help for Suicidal Veteran

Department of Veterans Affairs faces criticism as a Texas veteran commits suicide minutes after contacting crisis line

A photo of a veteran speaking on the phone with the VA crisis line, capturing the urgency and importance of effective communication in times of crisis. (Taken with a Nikon D850)

The Veterans Affairs crisis line is facing scrutiny after a report revealed that it failed to provide assistance to a veteran who tragically took his own life.

According to the report from, a Texas veteran reached out to the crisis line via text message, expressing his intent to commit suicide and stating that he had a plan and access to the necessary materials.

However, the crisis line responder did not directly contact the veteran or alert first responders. Instead, the responder directed the veteran to enact a safety plan prepared with a family member and subsequently terminated the conversation without verifying if the plan had been put into action or receiving any further response from the veteran.

Tragically, the veteran died by suicide just 11 minutes after the text exchange was terminated.

The incident was uncovered in a VA Office of Inspector General report, which also highlighted the veteran's history of suicidal behavior and post-traumatic stress disorder.

Furthermore, the report revealed that the veteran had been previously flagged as a high risk for suicide, but the flag had been removed, potentially impacting the response from the crisis line.

An image of a compassionate counselor providing support to a veteran suffering from post-traumatic stress disorder, illustrating the need for mental health assistance. (Taken with a Canon EOS R5)

Lawmakers expressed bipartisan outrage during a Senate Veterans Affairs Committee hearing on suicide prevention at the VA.

Senator Bill Cassidy criticized the failures of the VA's executive director, who was not fired but reassigned.

Senator Jon Tester emphasized the need for better mental health support, stating that the current situation is ruining lives and families.

The report also identified other systemic issues with the veteran crisis line, such as the lack of a policy for quality control monitoring and the inability to save text messages.

Dr. John Daigh, the VA's assistant inspector general for health care inspections, highlighted the failure to establish a text message retention process over the past decade.

The crisis line responder responsible for the 2021 exchange with the veteran received criticism for an inadequate response and a failure to recognize the veteran's suicide risk.

A picture of Senator Bill Cassidy passionately addressing the failures of the VA's executive director during a hearing on suicide prevention, highlighting the importance of accountability. (Taken with a Sony A7 III)

Additionally, there was a delay in disclosing the veteran's death, and a required root cause analysis was not conducted within the specified timeframe.

During the hearing, Senator Jerry Moran questioned why it took an inspector general's investigation for action to be taken, calling for improved protocols within the VA.

Matthew Miller, the executive director for suicide prevention at the VA, pledged to make improvements to the crisis line.

The VA expressed deep sadness over the loss of the veteran and promised to learn from the review to prevent similar tragedies in the future.

The Audie L. Murphy Memorial Veterans Hospital (ALMMVH) also stated that it has implemented measures in response to the report, including a standardized procedure for death notifications, improved tracking of veteran suicides, and a behavioral health autopsy program.

The VA and the hospital are committed to providing world-class, life-saving care for veterans in need.