Special counsel investigation leads to change in VA policy about suicidal vets

A Defense Department illustration depicts the hazards of suicidal thoughts, as it aims to boost awareness of mental health prevention programs available to servicemembers.


By NIKKI WENTLING | STARS AND STRIPES Published: December 14, 2017

WASHINGTON — The Department of Veterans Affairs is implementing a new agency-wide policy to flag medical records of patients at high risk of suicide within 24 hours — a decision made following whistleblower allegations last year that a VA suicide-prevention team in Albuquerque, N.M. was being neglectful of suicidal veterans.

According to the Office of Special Counsel, the VA is also in the process of clarifying rules to follow when handling suicidal veterans, and it’s establishing new employee training and improving communication between VA facilities about veterans at risk for suicide.

The Office of Special Counsel initiated an investigation last year following complaints from an unidentified employee at the Raymond G. Murphy VA Medical Center in Albuquerque. The special counsel discovered the VA facility was failing to flag medical records for veterans at risk of suicide.

In a letter to President Donald Trump, Special Counsel Harry Kerner announced the case closed Nov. 30 and the original whistleblower complaints, as well as correspondence between the special counsel and the VA, were publicly released.

Kerner wrote to Trump that the VA was initially slow to take action.

The investigation started in April 2016. Among other findings, it uncovered that providers weren’t updating the VA’s “High Risk for Suicide” list or flagging patient medical records in a timely manner. The flagging system is intended to inform VA doctors nationwide when a patient might be at risk for suicide.

It was also discovered the hospital’s suicide-prevention coordinator didn’t perform evaluations every 90 days for some veterans who were flagged for suicide risk, as the VA requires. In some cases, the Veterans Crisis Line referred veterans to the hospital’s suicide-prevention team and their responses were delayed. In one instance, it took eight business days for the coordinator to contact a veteran referred from the hotline.


The VA’s initial response to the findings were “disappointing,” Kerner wrote to Trump. The VA responded it didn’t have policy in place to flag patient records for suicide risk within a certain timeframe and it didn’t substantiate many of the whistleblower claims.

“The agency initially appeared slow in recognizing the tragedy that suicide by veterans represents, seemingly implying that certain delays in care and a lack of adequate regulations governing the handling of suicidal veterans were tolerable,” he wrote. “As seen from the agency reports, a lack of requirements leads to delays and delays lead to veteran deaths.”

After going back-and-forth with the VA since February, Kerner determined the agency’s response was now “reasonable.”

Besides implementing the 24-hour rule, the agency is adding staff to the suicide-prevention team in Albuquerque, the Albuquerque Journal reported. The newspaper reported the suicide-prevention coordinator criticized by the unnamed whistleblower kept her position.

“Ultimately… I have determined that the reports contain all of the information required by statute, and the findings appear reasonable,” Kerner wrote to Trump. “This matter is now closed.”

Twitter: @nikkiwentling