VA removed a young veteran's high-risk label. Then they died by suicide.

Abbie Bennett
August 27, 2019 - 1:13 pm


The Department of Veterans Affairs removed a red flag indicating a veteran patient was at high risk of suicide, despite a long, detailed history of mental health concerns and suicidal thoughts. 

The veteran was later found dead. He or she died by suicide.

A VA Inspector General report released this month showed multiple failings on the part of San Diego VA staff. The veteran's gender and branch were not included in the report, but he or she was younger than 30 at the time of death. 

VA staff repeatedly reached out to the veteran, who struggled with substance abuse, "chronic" suicidal thoughts and often missed appointments. But it wasn't enough. 

The San Diego State Medical Examiner ruled the veteran's death a suicide in July 2018. 

The Inspector General investigation and subsequent report were precipitated by an anonymous call that alleged the veteran was "turned away" by VA. But when investigators tried to contact the caller to follow up, they couldn't be reached. So the IG couldn't substantiate the accusation. 

The investigation found multiple "deficits" at the San Diego Medical Center but did not say the hospital contributed to the veteran's death. 

Among those was the choice to deactivate a flag on the veteran's medical records identifying the patient as a high suicide risk. A hospital suicide prevention coordinator removed the high-risk label "without contacting the patient" or "consulting the patient's treatment team," the report said. 

The veteran stayed off the list, even after they missed multiple mental health appointments over two months. 

VA Secretary Robert Wilkie has repeatedly said veteran suicide is his agency's top priority. VA data shows about 20 veterans die by suicide daily, and of those, about 14 do not receive care at VA. 

The San Diego IG report was followed more recently by a report about the West Palm Beach VA, where failures to maintain safety cameras, complete safety checks on high-risk patients and multiple other issues led to another veteran's death by suicide earlier this year. 

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The high-risk label is intended to help VA staff track veterans most at risk and make additional efforts to bring them in for care, according to VA guidelines. But VA "does not have clear" requirements for deactivating the high-risk flag, the report said.

The veteran's high-risk label was removed in spring 2018, the report said, and in summer 2018, the veteran showed up in a VA emergency room with suicidal thoughts. The veteran was discharged from the hospital, but attempts by the VA to follow-up went unanswered, including multiple calls and a letter. 

The veteran took his or her life two days after the letter was sent, the report said. 

For more information on potential warning signs of suicide, click here.

If you or someone you know needs help, contact the Veteran Crisis Line 24/7 at 1-800-273-8255 (select option 1 for a VA staff member). Veterans, service members or their families also can text 838255 or go to

Reach Abbie Bennett: or @AbbieRBennett

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