Department of Veterans Affairs leaders have said repeatedly that veteran suicide prevention is a top priority for the agency, but VA does not have accurate information on how many veterans have died by suicide at its own hospitals, parking decks and cemeteries, a new watchdog report found.
Dozens of veterans have died by suicide on VA property but the department doesn't keep accurate or complete records of those deaths, according to a Government Accountability Office (GAO) report released Wednesday. The report shows that VA's process for identifying "on-campus" suicides doesn't include checking for accuracy in those reports -- so VA's numbers are inaccurate.
VA first started tracking veteran suicide deaths on its properties in October 2017 and uses the results to keep VA leaders and Congress informed, according to the report. "Weaknesses" in VA's processes have led to inaccurate reporting, even though it's been three years since the department began tracking the deaths.
When investigators reviewed VA's data, it found errors in the 55 reported deaths on VA property from October 2017 to September 2019, including 10 deaths that should never have been included and four that should have been.
One of those that should not have been included was a veteran who was still alive, according to the report.
Suicide was the 10th leading cause of death in the United States in 2018. In 2017, veterans accounted for 13.5% of all suicide deaths among U.S. adults, though they make up less than 8% of the population, according to data released by VA in 2019. Suicide data for VA typically lags behind by about two years.
About 17 veterans die by suicide daily, according to the most recently available VA data, along with 3 service members, for a total of roughly 20 per day. Only about 6 (35%) of the veterans who die by suicide daily are recent users of VA health care. In response to those figures, which have stagnated or worsened in recent years, VA and Veterans Affairs lawmakers in Congress made veteran suicide prevention a top priority.
Accuracy in reporting suicides on VA property is important, investigators wrote in the report, because it's not always clear that a death was a suicide, an accident or natural. It could require a coroner or medical examiner's review to accurately determine an official cause of death.
VA has taken some steps to address on-campus veteran suicides, including upping staff training, creating new policies and making physical improvements (such as door alarms and higher barriers on raised walkways or parking decks). But it's unclear how effective some of those efforts have been since VA's analysis of them is lacking, GAO investigators found.
VA requires staff to look into the root causes of a veteran's suicide on campus to try to find ways to prevent future incidents, but it doesn't require that analysis for all veteran suicide deaths that happen on department property.
Of the cases GAO investigators reviewed, only about 25% included an analysis of the "root causes."
VA also doesn't use all the information it collects about these deaths, the report found, "such as clinical and demographic data collected through other VA suicide prevention efforts." Veterans Health Administration officials told investigators they couldn't connect the different sources of information the department might have, but investigators found that some hospitals and clinics could.
"Without accurate information on the number of suicides and comprehensive analyses of the underlying causes, VA does not have a full understanding of the prevalence and nature of on-campus suicides, hindering its ability to address them," the report reads. "Without a robust process that accurately identifies all on-campus veteran deaths by suicide, VHA risks continuing to report incorrect information about these incidents to the public and Congress, as well as preventing VA from understanding the extent of the issue."
GAO recommended VA improve its process to more accurately record on-campus veteran suicide deaths and "conduct more comprehensive analyses" of the incidents.
VA Acting Chief of Staff Brooks Tucker said they planned to create a committee to evaluate the issues GAO revealed in its report and said the committee's review would be complete by July 2021.