Report Summary

Title: Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died
Report Number: 19-08542-11 Download
Issue Date: 11/17/2020
City/State: Canandaigua, NY
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate an allegation regarding Veterans Crisis Line (VCL) staff’s management of a veteran caller who died the same day as contacting the VCL.

The OIG substantiated that VCL staff did not initiate an emergency dispatch for the caller who reported use of alcohol and over the counter medications that cause drowsiness. VCL policies did not address management of intoxicated callers or assessment of risk for accidental overdose. The VCL did not have policies related to safety planning with intoxicated callers or risk assessment of accidental overdose of illicit or over-the-counter drugs.

VCL leaders implemented criteria for aggregated data reviews and supervisor follow-up related to silent monitoring to oversee the quality of responders’ telephone calls. However, the supervisory intervention only applied to consecutive calls rather than call trends, which may have contributed to inadequate performance improvement and quality assurance initiatives.

The caller’s lethality risk should have been considered high, and VCL staff should have initiated other actions including submission of an urgent or emergent suicide prevention coordinator consult.

The OIG made one recommendation to the Office of Mental Health and Suicide Prevention Executive Director related to the development of suicide prevention strategies for weekend and holiday callers. The OIG made seven recommendations to the VCL Director related to a review of the caller’s contacts, evaluation of lethal means training, written guidance on responders’ documentation of supervisory oversight and consideration of independent supervisory documentation, policy and training of callers’ substance use and overdose risk, use of a standardized safety plan template and completion of safety planning per VCL standards, criteria for supervisor follow-up including silent monitoring criteria, and a system to identify caller contacts that warrant internal reviews and track the review process.