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Workers at the national Veterans Crisis Line mismanaged communication with a veteran who died by suicide within an hour of texting the hotline and failed for 10 years to establish protocols to save veterans' text messages for future follow-up, according to a report by the US Department of Veterans Affairs Office of the Inspector General.  

The independent watchdog's report issued Thursday details the events leading up to the death in San Antonio, Texas, in 2021 and "problematic" actions taken by leaders at the crisis line afterward. The investigation found crisis line staff failed to ensure a plan was in place to try and prevent the suicide and to adequately document communication with the veteran. The staff also didn't tell local VA staff in Texas about the death.

"Suicide prevention is the #1 clinical priority for VA, and the VCL is an important part of VAs suicide prevention efforts," VA Inspector General Michael Missal told USA TODAY. "Unfortunately in this situation, the VCL failed to help a veteran in need."

The inspector general's investigation revealed procedural problems at the crisis line relied on by millions of veterans across the country as a critical safety net, including with the silent monitoring of calls and the issues with saving text messages with veterans.

The VA Undersecretary for Health Dr. Shereef Elnahal said in response to the findings that the Veterans Health Administration is "incredibly saddened by the loss of this Veteran and our thoughts are with the Veteran’s family."

It's not the first time the hotline has drawn the attention of investigators. Ten years after it launched in 2007, the hotline, created to connect veterans with specially trained responders, was sending about a third of its calls to backup call centers or voicemail. Other concerns identified by the inspector general at the time included long hold times and inadequate training, guidelines, and quality assurance.

The Veterans Crisis Line has fielded a record number of cries for help in recent years. Since July 2022, the hotline received more than 750,000 calls, a 12.5% increase from a year earlier, and 250,000 other contacts including texts and chats, VA stats show.

ONE YEAR LATER:What’s working and what’s not with the 988 Suicide & Crisis Lifeline

Crisis line responder missed signs

In the San Antonio incident, a crisis responder inadequately assessed the 31-year-old veteran's history of PTSD and suicidal behavior, missing the signs of an impending attempt during the text conversation one night in 2021, the inspector general found. The staffer also failed to note the veteran’s alcohol use and did not establish an effective safety plan or confirm access to lethal weapons or other means to die by suicide.

The veteran had a history of depression and PTSD and had been flagged as being at high risk for suicide but the flag was removed in early 2020. When he contacted the hotline by text at 10:14 pm in early 2021, the responder made a note that the veteran planned to die by suicide and was in a "shed with a belt around a hook that hangs from the rafters of the shed," and "reached out tonight in order to stop from taking action to end the patient's life," according to the inspector general's report.

At the same time, during the text conversation, the patient, who was not identified by name in the report, said they weren't being "entirely honest." The responder documented a "safety plan" that said the veteran would text a family member for help, go to bed, and wait for someone to call and follow up with him the next day.

But the veteran never went into the house and didn't go to bed. The vet died by suicide at 11:40 p.m. – 38 minutes after sending a last message to the crisis line.

The responder reported in notes that the veteran "stayed online until the call ended normally" and with an "agreement to enact a plan of safety," despite not hearing anything from the veteran after 11:02 p.m. even as the responders messaged the patient for half an hour with no response, according to the report.

Investigators concluded the responder underestimated the patient’s suicide risk and failed to follow up when they stopped texting, according to the report. In addition, they found the hotline hadn't established adequate procedures since 2011 for keeping text messages on file, limiting the ability of VA personnel or investigators to ensure the hotline is providing quality service to the thousands of veterans who now depend on it.

'Don't volunteer anything extra'

Investigators from the inspector general's office said crisis line leadership also delayed and inadequately disclosed notice of the patient’s death. The national hotline did not conduct a "root cause" analysis of the incident, which is required within 45 days, until the inspector general became involved about 11 months after, according to the report. 

The investigation further revealed that the hotline’s director of quality and training may have coached the responder after the incident, potentially compromising the staffer’s "candidness" during reviews of what happened, officials said. In an instant message to the responder ahead of an inspector general interview, the director said the "main points are to only answer the question asked – don’t volunteer anything extra."

Staff at the VA hospital in San Antonio were notified four days after the death but didn't note it in the veterans' medical records for months. In the meantime, VA staff continued calling and sending mail as if the veteran were still alive, exacerbating the family's grief.

VA vows to strengthen suicide prevention

The inspector general’s latest recommendations include that the crisis line review staff correspondence with all patients and make clear suicide risk assessment guidelines for responders. The text messaging platform is expected to be updated with the latest guidelines for suicide risk response and documentation in 2024, according to the report. 

"VHA is committed to performing at the highest standards and finding ways to improve our response to Veterans in crisis," Elnahal wrote. "Any Veteran suicide is one too many and VHA remains steadfast in our mission to support those in suicide crisis. We are utilizing this review to strengthen processes for improved suicide prevention."

Missal, the VA inspector general, told USA TODAY: "It’s critical that VCL leaders ensure that staff are properly trained and incidents are adequately reviewed."

The Senate Veterans Affairs Committee is scheduled to convene a hearing on Wednesday to evaluate the VA's mental health and suicide prevention measures.

If you or someone you know is experiencing a mental health crisis, call the 988 Suicide and Crisis Lifeline which provides confidential 24/7 support by dialing 988, or visit 988lifeline.org.

Crisis Text Line also provides free, 24/7, confidential support via text message to people in crisis when they dial 741741.