It seems as though every year there is a crisis at the Veterans Administration. As a healthcare ethics keynote speaker, healthcare ethics consultant and ethics book author, I wonder if anyone is in charge and how the massive bureaucracy maintains quality control?
Could the tragedy have been averted?
The Veteran’s Administration is again in the news and this time for an “incident” that appears to have gone unreported since 2021.
Allegedly, it has taken the Veteran Administration’s Office of Inspector General to come forward with an incident in which the VA crisis line people did not return a text exchange from a veteran who was seriously committing suicide. They did not try to call the veteran or alert first responders who might have been dispatched.
Allegedly, a family member had requested a “safety plan” of some type but the VA crisis line operator never verified with the family member nor did they get a text back from the suicidal veteran.
According to Michael Lee (Fox News, September 24, 2023):
“The veteran committed suicide 11 minutes after a text exchange with the crisis line was terminated. [In fact, the veteran] saying he had tested a plan for suicide and was in a location with access to the materials to carry it out, according to a report from Military.com.”
Psychologists tell us that when a suicidal person, especially a veteran who was shown to have PTSD and suicidal behavior, says they are serious about committing suicide, they must be believed. As a healthcare ethics keynote speaker, healthcare ethics consultant and ethics book author, I begin to wonder why the crisis people did not see this red flag?
“The veteran had also previously been flagged as a high risk for suicide, but the report found that flag had been removed the year before, something that could have helped the responder’s response.”
Who removed the flag?
Someone in the VA suicide prevention hierarchy allegedly removed the flag that indicated the veteran was suicidal. Though the crisis line eventually contacted the family member, it was too late. The veteran was not bluffing. He could no longer cope and committed suicide.
Naturally, the bipartisan veteran’s affairs committee has duly noted its outrage. Said Senator. Bill Cassidy, R-La.:
“This is an incredibly damning OIG report, incredibly damning. I’m struck that the executive director who apparently interfered with the OIG report was not fired. She’s reassigned, I presume, still receiving a paycheck.”
Someone else in the VA hierarchy (it always seems to be “someone else”), allegedly held up the report of the investigation. By policy, this investigation should have been concluded in 45-days. It took two-years to get it uncovered.
In addition to this alleged story of the failure of the system to intercede, the full OIG report found organizationally wide issues with the crisis-line program. It is rather ridiculous to me as a healthcare ethics speaker that the crisis line program cannot save text messages from veterans seeking help! They have had 10-years in which to address this issue and have essentially done nothing. We are in a new era of Artificial Intelligence and data storage, can there be no mechanism for coordinating text messaging claiming suicidal depression and the system flagging the risks and actions?
Naturally, the Executive Director of the Suicide Prevention center, Matthew Miller has promised to make improvements:
“It’s our earnest desire and pledge to apply the wisdom gained through this review to strengthen processes as we continue to serve veterans who are the center of all we do, even at this very minute as we answer calls.”
Well after the fact, everyone is pledging to do a better job in the future. It helps no one in the veteran’s family and it’s my guess that other cases of suicides and near suicides will come to light in the future.
The VA system is massive and the amount of money spent on veterans is massive and yet the flaws in the system keep appearing in the form of lives lost. Where is ethics in all of this business?
The VA sat on the OIG report for more than two-years beyond the requirement to respond. It was an unethical decision pure and simple. Unless the VA adheres to their ethical responsibilities to help the most vulnerable, what is the point to the crisis prevention program?
I think it is time to demand ethical answers to the obvious unethical practices. Who is in charge here and why are they still retained?
