August 23, 2019

Chairman Takano Calls For VA-Wide Stand-down to Address Veteran Suicide

WASHINGTON, DC – Today, House Committee on Veterans’ Affairs Chairman Mark Takano (D-Calif.) issued the following statement after the VA Office of Inspector General (IG) released a report on the tragic veteran suicide at the West Palm Beach VA Medical Center in March 2019.  

“After 3 suicides on VA property in 5 days in April, I directed this Committee to address the national crisis of veteran suicide and made it this Committee’s top priority. We took immediate steps, held hearings, and passed 5 bills to address this crisis. With each suicide, it becomes more clear our country is not doing enough. And yesterday, the VA Office of Inspector General released a report revealing failures that led to the death by suicide of a veteran on VA’s watch. 

“Repeatedly, Congress has aimed to bolster VA’s veteran suicide prevention efforts through increased funding, accountability, and oversight. Yet, it is clear VA must do more. We need new solutions. That’s why I am calling on VA to institute an immediate nation-wide stand-down to address this crisis.

“By VA’s own definition, inpatient suicide is considered a “never event”-- one that is preventable and should never happen. Although the facility had instituted 15-minute checks to ensure patient safety, chronic understaffing prevented nursing assistants from completing these life-saving safety checks on time. The facility installed security cameras 3 years ago to keep veterans safe, but never turned them on. Over-the-door alarms used to prevent veteran suicide were never installed -- despite a VA-wide recommendation. In fact, the IG report noted roughly 50 percent of VA facilities still don’t have them. And perhaps worst of all, only one third of the employees at the facility who were responsible for maintaining a safe mental health environment for patients were even assigned the required suicide prevention training.

“Who is responsible for the failures that occurred? Why were steps not taken after previous incidents identified gaps in policies or procedures? What will VA do to ensure that veteran suicide does not happen on VA’s watch? 

“In order for veterans to have confidence in VA’s ability to care for them in a crisis, they must have confidence in the administration’s leadership. Currently, VA does not have a permanent leader to coordinate suicide prevention.

“That’s why I’m calling for VA to hold a nation-wide suicide stand-down within the next 15 days so every leadership executive, administrator, nurse, doctor, and employee across VA understands how to identify veterans in crisis and get them the help they need. VA must conduct a top-to-bottom review of its hospitals and clinics to ensure that all of its facilities offer a safe environment of care for veterans in crisis.

“We cannot keep delaying action. Americans must know that key policies to keep veterans safe are in place, that VA will enforce them, and trust that senior VA leadership will be held accountable.”

Background: The incident at the West Palm Beach VA was the second of 10 veteran suicides completed at VA facilities this year. After this tragic event, Chairman Takano requested a report from the Office of Inspector General to investigate this particular incident. The Committee has hosted a bipartisan roundtable, a staff-level briefing, a full-committee hearing, and a joint subcommittee hearing with the House Armed Services Committee. Additionally, HVAC members have introduced and passed five pieces of legislation, and Chairman Takano has requested a GAO study on veteran suicide at VA hospitals to ensure we have the information we need to better care for our veterans in crisis.

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