Marine veteran loved to fix things — but the VA offered no plan for him to help himself
By NIKKI WENTLING | STARS AND STRIPES Published: September 28, 2018
WASHINGTON – Justin Miller was a fixer. At least, that’s how his older sister, Alissa Harrington, would describe him.
He worked as an electrician and was always tinkering with things to figure out how they worked, she said.
When he was a toddler, Miller managed to undo all of the child-proof locks on the family’s kitchen cabinets. Decades later, when Harrington and her husband were having trouble installing a fan in their attic, Miller used his rock-climbing gear to scale their steep-pitched roof and devised a pulley system to lift the supplies.
He was a Marine Corps veteran, an excellent marksman, a talented trumpet player and sometimes a “glorious pain in the ass,” Harrington said. But above all, a fixer.
When he went to the emergency department at the Minneapolis Department of Veterans Affairs hospital in February, Miller was trying to fix himself.
He sought help from the VA while struggling with suicidal thoughts – feelings of helplessness, frustration and anxiety. After spending four days at an inpatient mental health unit, he left the hospital, went to his car and shot himself. Police found his body the following day, his phone full of voicemails and texts from his father, Greg Miller, with one message sent over and over again: “I love you. We love you. Come home.”
His treatment at the Minneapolis VA Health Care System was the subject of a report released this week by the VA Office of Inspector General.
For the first two days of his stay at the facility, nurses marked in his medical record that Miller, 33, repeatedly asked about a treatment plan. According to investigators, he would never get a sufficient one. The inspector general’s office found VA staff made several mistakes in Miller’s case, including not providing him with an adequate plan when he was discharged.
When Miller left, he was marked at “moderate risk” for suicide. He left without a follow-up appointment for his newly prescribed antidepressants. Staff wasn’t sure whether he had access to firearms, and there was no documentation that they reached out to his family to try to engage them in his treatment.
“He went there for help. He took that step, did the right thing,” Harrington, 36, said. “He was there because he wanted to get better. He had made it clear he wanted to get better and didn’t know how. And they gave him no plan. He walked out those doors with no plan in place.”
Trauma in Iraq
The last time Harrington saw her brother was on Christmas last year, when the family got together and sang along to Robert Goulet’s holiday album. In that moment, Miller was happy, she said. When he was happy, he sang.
Miller was a standout musician in a family of musicians, she said. When he was a junior in high school, he applied – and was accepted into – the Marine Corps band.
Like his dad, Miller was a trumpet player. He was inspired to join the military by his grandfathers, both of whom served in World War II – one in the Pacific theater and one in Europe.
“We were both raised to be very respectful and proud of our country,” Harrington said. “We wanted to serve our country, one way or another.”
After high school, Miller went through basic training and was assigned to the 2nd Marine Aircraft Wing Band out of Cherry Point, N.C. He deployed in 2005 to Iraq, where he served as military police.
During his deployment, he struggled with night terrors, Harrington said. When he returned home, his family immediately noticed a difference in his behavior. He was impulsive, stressed and angry.
He began counseling last fall, but he never confided much in friends and family, Harrington said. The night after his suicide, she and others talked about what Miller had shared regarding his service in Iraq. Together, they assembled the whole picture.
“One of the most heartbreaking things was realizing he had shared bits and pieces of what happened in Iraq with each of us, but it wasn’t until that night that we put it all together,” Harrington said. “We didn’t really understand how traumatic it had been.”
Just before his suicide in February, Miller had been asked to leave the home he had shared with his girlfriend for two years. He had recently been in a car accident and was off work for about seven months, which Harrington said was “hard on him.”
He called the Veterans Crisis Line and told a crisis responder that he was suicidal and had immediate access to firearms. On the crisis worker’s advice, he sought help from the Minneapolis VA.
The hardest thing – something Harrington said she would never wish upon anybody – was getting the phone call that her brother had committed suicide. The second worst came this week, when she learned her brother’s last days were detailed in a public government report.
Harrington and the rest of Miller’s family didn’t know the VA Office of Inspector General report was coming. Rep. Tim Walz, D-Minn., the ranking Democrat on the House Committee on Veterans’ Affairs, had requested the investigation.
Miller’s suicide was one of several that have occurred on VA property in recent years – a trend acknowledged by former VA Secretary David Shulkin last summer, who said veterans “tend to come to the VA and actually commit suicide on our property.” In part, Shulkin thought veterans did so because they didn’t want their families to discover them.
A 62-year-old veteran shot himself this spring in the VA emergency department in St. Louis. In 2016, a 76-year-old shot himself in the parking lot of a VA hospital in New York, and a 32-year-old veteran of the Afghanistan War hanged himself at a VA facility in Tennessee. In July this year, a 58-year-old Air Force veteran died after he set himself on fire near the Georgia State Capitol in Atlanta to protest the VA system.
In some cases, the VA Office of Inspector General investigates the deaths. They did in 2012, when a veteran committed suicide after being treated at the same hospital where Miller died. At the time, inspectors found the hospital was “deficient” in how it handled the situation. Four of the recommendations the IG made after that suicide apply now, the IG wrote in its latest report.
Like with Miller, the suicide prevention coordinator didn’t take a proactive role in assessing whether the veteran was at high risk for suicide.
In a statement this week, Walz said the fact the hospital made some of the same mistakes in Miller’s case as it did in 2012 “should outrage us all.”
To Harrington, the findings were devastating. Reading through the report, she felt the same raw emotion she did in February, when she learned of Miller’s suicide.
“It’s absolutely maddening to see on paper the exact places where the system failed,” she said, her voice breaking. “Because it’s not just the loss of my brother – the tragic, out-of-place loss of my brother – it’s now about whether or not his loss could’ve been prevented.”
Though the VA failed in several areas, inspectors said they couldn’t determine whether the mistakes directly led to Miller’s suicide.
Harrington said she doesn’t believe anything the VA did caused her brother’s suicide, but they could’ve done more to prevent it.
One particularly gut-wrenching revelation, she said, was that the VA staff didn’t find out with certainty whether Miller had access to firearms. A chart included in the IG report shows that three VA staff members wrote in Miller’s medical record that he had access to guns. Three said he didn’t, and three wrote they were uncertain about his access to guns or they didn’t ask.
Harrington said Miller had a license to carry.
“This was not difficult information to discover,” she said.
The IG provided the Minneapolis VA with seven recommendations. Ralph Heussner, a spokesman for the health care system, said they were on track to implement the recommendations by January 2019. He said the IG investigation was “an opportunity for the [Minneapolis VA] to review and implement lasting improvements.”
Hoping for change
Harrington hopes that her brother’s story and experience can affect change.
“What I really hope is there are veterans out there who hear his story and know they have brothers and sisters and parents and friends who love them and who don’t see them as a burden,” Harrington said. “If telling his story means that one veteran doesn’t have to die, it’s worth any type of pain that it might cause us to talk about it.”
On Wednesday, one day following the release of the IG report, the VA released the new National Suicide Data Report – a breakdown of veteran suicides in 2016.
Overall, veterans accounted for 14 percent of all suicides in the United States in 2016, yet veterans make up only 8 percent of the population, the VA found. Keita Franklin, executive director of the VA’s suicide prevention program, said that there are still about 20 suicides each day among veterans, servicemembers and non-activated National Guard and Reserve members – a statistic the VA first reported in 2016. Of those 20, six have received VA health care in the two years before their suicide.
The most glaring finding was that suicide among younger veterans increased substantially. For every 100,000 veterans age 18 to 34, 45 committed suicide in 2016 – up from 40.4 for every 100,000 in 2015.
Miller, at 33, was part of that group.
“My brother had one tour of duty and it was a short one,” she said. “We have veterans coming home with 10, 12, 15 deployments. I can’t imagine it’s going to get better without some serious effort.”
At a hearing Thursday of the House Committee on Veterans’ Affairs, lawmakers took a critical look at the country’s suicide prevention programs for veterans. Franklin, who has been on the job since April, said suicide prevention would require a “whole of nation approach,” including community efforts, peer support and hotlines, such as the Veterans Crisis Line.
“I’m beyond frustrated about the numbers and the data. Having worked in this field as long as I have, it’s frustrating,” Franklin said. “When I try to think about what we’re missing … we tend to do a lot of one thing at a time and do it very well, full throttle. Preventing suicide takes a bundle of 10 to 12 things done at full throttle, all the time.”
The committee chairman, Rep. Phil Roe, R-Tenn., said Thursday that he wanted to follow up the hearing with a roundtable of lawmakers, VA officials and veterans groups. Rep. Brian Mast, R-Fla., asked for a joint hearing between the House Committee on Veterans’ Affairs and the House Armed Services Committee to talk about servicemembers’ struggles transitioning out of the military.
After reading through the IG report about her brother’s death, Harrington read the VA suicide report. It gave her more resolve to put a face and personality to a statistic.
Telling her brother’s story, she said Miller was never without what he described as his “urban survival kit,” which included a knife, dental floss and tactical spork. He enjoyed riding his motorcycle, and he was active with his local American Legion chapter. He played taps and the national anthem at military funerals and events.
Harrington remembered the time she was a “wreck” after her first midterm in law school, and Miller, dressed as a pirate, took her to a pirate bar to calm her nerves. She remembered the hat made of reindeer hide her husband got Miller for his birthday, and Miller being so excited about it that he wore it for an entire day.
She remembered him as a fixer.
“He was brilliant and funny and caring and loving,” Harrington said. “If he could fix something, he would.”
Justin Miller with his older sister, Alissa Harrington, at her wedding Jan. 27, 2007. Following Miller's suicide in February, Harrington is speaking out, trying to spur improvements to veteran suicide prevention.