VA still working to install safety features after veteran suicides at VA hospitals

Photo credit VA

Since 2018, 49 veterans have died by suicide on the grounds of Department of Veterans Affairs medical facilities. Last year, multiple watchdog reports revealed VA failings may have contributed to some of those deaths. 

In West Palm Beach, Fla., investigators found that failures to follow VA’s own standards could have led to a patient’s death or risked the safety of other veterans. 

A veteran at the VA there died by suicide inside a locked mental health unit. Cameras at the hospital hadn’t worked for at least three years, safety alarms weren’t installed and patient safety rounds weren’t being conducted consistently by staff. Leadership deflected responsibility and disregarded safety risks, the report said. 

Efforts to fix those issues only began after the veteran’s death. 

In Minneapolis, Minn., at least three staff members at the VA hospital -- a nurse, a chaplain and a dietician -- heard a veteran express suicidal thoughts and didn’t do as they were trained, and tell doctors.

The veteran died by suicide at the hospital. 

Not only did VA staff fail to warn doctors that a veteran was suicidal, but documentation that he or she had suicidal thoughts also wasn’t heeded. Hospital leaders also didn’t tell the veteran’s family that an “adverse event occurred.” 

On Wednesday, in a House Veterans Affairs Committee oversight hearing, members of Congress wanted to hear from VA leaders what has been done since those incidents. 

“The worst thing we can have is these suicides happening in our facilities,” Rep. Mike Bost, R-Ill., said. 

"My prayers are with the loved ones of those two veterans and with the loved ones of each of the twenty of their brothers and sisters in arms who die by suicide every day," Ranking Member Rep. Phil Roe, R-Tenn., said.

From 2018 until Jan. 6, 2020 there were 49 suicide deaths at VA facilities, VA spokesman Mike Richman told Connecting Vets, out of 470 total attempts. VA was able to interrupt 421 of those attempts, Richman said. Ten happened during "active inpatient care." 

VA data shows about 20 veterans die by suicide daily, and lawmakers have made addressing veteran suicide a top priority. Funding for VA mental health and suicide prevention efforts pour in each year, but the number of deaths by suicide have not budged. 

VA spent about $64.7 billion on mental health services in the last decade, about $9 billion of which was spent last year alone, Chairman Rep. Mark Takano, D-Calif., said.

“VA has the opportunity to be one of the best systems in the country because the resources are there,” Roe said.

“I feel like we continue to pile on these initiatives, but we’re on a hamster wheel when it comes to accountability,” Rep. Susie Lee, D-Nev., said. 

VA leaders told lawmakers cameras are once again working in the West Palm Beach VA and door alarms are being installed. 

“Deterrent devices” have also been installed on the roofs of parking garages, VA Undersecretary for Health Operations Renee Oshinski said, where some veterans have attempted self-harm. 

When Takano asked why VA was not following its own policies for safety measures such as cameras and door alarms, Oshinski blamed new staff and a lack of training or failure to re-train staff. 

Of the 20 veterans who die by suicide daily, 14 either don’t qualify for VA health care or haven’t accessed it recently. The other six get their care from VA. 

“We need to make sure that the public is assured that the VA is a safe place … and know the standards everywhere are at the ideal level,” Takano said. "This crisis is not new, but our solutions and our behavior must be."

All VA healthcare facilities now provide same-day service for primary and mental health care, Richman said.

"Suicide prevention is VA’s highest clinical priority, and the department is taking significant steps to address the issue," he said, adding that the VA has reduced the number of in-hospital suicide deaths from 4.2 per 100,000 admitted patients to about .74 per 100,000 -- an 82.4 percent reduction. 

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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