Report says Fayetteville VA failed vets at high risk of suicide

A 2009 public service poster designed to raise awareness about stress-related causes of suicide amongst U.S. servicemembers. The Veterans Crisis line can be reached at 1-800-273-8255.


By DREW BROOKS | The Fayetteville Observer, N.C. | Published: February 3, 2013

A recent government audit of the Fayetteville Veterans Affairs Medical Center shows that the VA failed to properly check on veterans considered high suicide risks after releasing them from the hospital.

The audit precedes a report released Friday that says the vast majority of veterans seeking help from the VA who attempt suicide do so within a month of a hospital visit.

The report, billed as the first comprehensive review of veteran suicides, found that an average of 22 veterans a day committed suicide in 2010.

The audit of the Fayetteville VA was prepared by the Department of Veterans Affairs Office of Inspector General and released Dec. 10.

It found the VA noncompliant in two areas dealing with mental health - workers failed to property follow up with patients in accordance with Veterans Health Administration policy and did not document attempts to contact patients who failed to appear for scheduled appointments.

According to the audit, nine of 10 patients who were on the high risk for suicide list did not receive sufficient follow-ups.

The VA is required to check on such patients weekly for the first month following their release, according to the review, but Fayetteville officials failed to check on the patients for the last two weeks of that period. The report released Friday by the Department of Veterans Affairs revealed that 80 percent of all suicide attempts among VA patients occur within that one-month span.

Elizabeth Goolsby, director of the Fayetteville VA, did not respond to email requests for an interview.

According to the audit, mental health managers at the Fayetteville VA told officials that its suicide prevention coordinator position had been vacant, and that other staff members shared that responsibility.

The position is now filled, but Fayetteville VA officials did not provide information on how long the position had been vacant, despite repeated requests.

They did provide statistics showing that seven Fayetteville VA patients have committed suicide since 2009, including two in 2012.

Pete Hegseth, chief executive of Concerned Veterans for America, said the issues within the Fayetteville VA are more than a local problem.

"It's a national issue," Hegseth said, adding that he's seen similar complaints in Minnesota. "What I see, statistically and anecdotally, is that patients are discharged too quickly without proper follow up or medication."

Hegseth criticized the VA for being too big of a bureaucracy. He said it needs to be able to adapt more nimbly to individual patients.

In addition to the mental health concerns, the report on the Fayetteville VA noted a significant increase in veterans seeking care and found that some areas of the hospital were not sufficiently cleaned. It also found that medications prescribed did not always match those listed on patient discharge forms.

VA officials and the military have each been battling a record number of suicides in recent years.

Last year, as many as 349 service members committed suicide, according to the Department of Defense. It was the highest number since the Pentagon began keeping count in 2001.

The Army released its suicide statistics Friday.

In 2012, there were 182 suspected suicides among active-duty troops, up from 165 confirmed cases in 2011.

Another 143 suspected suicides took place among Army National Guard and Army Reserve soldiers, up from 118 confirmed suicides in 2011.

Lt. Gen. Howard Bromberg, Army deputy chief of staff for manpower and personnel, said the 2012 numbers were the highest on record and reaffirmed the service's commitment to suicide prevention.

On Jan. 15, The Fayetteville Observer asked Fort Bragg for the number of its soldiers who committed suicide in 2012. The post responded that the Pentagon would provide those figures by the end of the month. That didn't happen.

The VA study on suicides looked at the demographics and rates of suicides and suicide attempts among veterans from 1999 to 2012 by combining VA data with information from state records and the Veterans Crisis Line.

The collaborative effort to collect data took two years to complete, according to the report, but does not include every state.

Only 21 states, including North Carolina, provided complete data for the report.

Officials said they hoped to use the study, which will be updated as more data becomes available, to increase understanding of suicides among veterans.

Officials said the overall number of veteran suicides has increased in recent years but now make up a lower percentage total of U.S. suicides, revealing that the problem extends beyond the military.

The average veteran committing suicide was in his 50s, according to the study, suggesting that recent combat is not the driving force behind most suicides.

"The mental health and well-being of our courageous men and women who have served the nation is the highest priority for VA, and even one suicide is one too many," said Secretary Eric K. Shinseki in a statement. "We have more work to do and we will use this data to continue to strengthen our suicide prevention efforts and ensure all veterans receive the care they have earned and deserve."

Nationally, VA officials say they are engaged in an aggressive hiring campaign to expand access to mental health services, with 1,600 new clinical staff and 300 new administrators. It is is in the process of hiring and training 800 peer-to-peer specialists.

Officials said additional staff members have been hired and trained in an attempt to increase capacity of the Veterans Crisis Line, a nationwide hotline for veterans.

The crisis line has made about 26,000 rescues of actively suicidal veterans, officials said.

VA officials have also started a year-long public awareness campaign, "Stand By Them," to educate family and friends on how to seek help for veterans.

Staff writer Greg Barnes contributed to this report.

Staff writer Drew Brooks can be reached at brooksd@fayobserver.com.


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