OSC - Office of Special Counsel

12/07/2017 | Press release | Distributed by Public on 12/07/2017 08:58

VA Whistleblower, Office of Special Counsel Obtain VA Fixes to Provide Better Care to Suicidal Veterans Nationwide

U.S. Office of Special Counsel 1730 M Street, N.W., Suite 218 Washington, D.C. 20036‐4505

VA Whistleblower, Office of Special Counsel Obtain VA Fixes to

Provide Better Care to Suicidal Veterans Nationwide


CONTACT: Jill Gerber, (202) 804‐7065; [email protected]

WASHINGTON, D.C./Dec. 7, 2017 - The U.S. Office of Special Counsel has notified President Trump that it resolved a case of a VA whistleblower's allegations of unsatisfactory care for suicidal veterans at the Raymond G. Murphy VA Medical Center of Albuquerque, New Mexico. After a slow start, the U.S. Department of Veterans Affairs (VA) acknowledged shortcomings in flagging suicide risk in patient medical records and initiated agency‐wide corrective actions to help veterans across the country. The whistleblower helped the Office of Special Counsel uncover that the VA had no timeframe for flagging suicide risk in a veteran's medical record. Now, the agency plans to flag suicide risk within 24 hours or much less time.

"The agency initially appeared slow in recognizing the tragedy that suicide by veterans represents, seemingly implying that certain delays in care and a lack of adequate regulations governing the handling of suicidal veterans were tolerable," Special Counsel Henry J. Kerner wrote to President Trump. "Ultimately, following the receipt of the supplemental reports, I have determined that the reports contain all of the information required by statute and the findings appear reasonable."

The VA sent an initial report and a supplemental report to the Office of Special Counsel, investigating whistleblower allegations of failures by the suicide prevention coordinator in Albuquerque. These failures included flagging patient records as a high risk for suicide in a reasonable timeframe, as well as failing to respond to consults from the Veterans Crisis Line.

The special counsel's letter called the agency's initial report "disappointing," given that veteran suicide is a "national crisis," with more than 20 veterans committing suicide every day. The letter also took issue with the agency's initial contention that the Albuquerque suicide prevention coordinator was successfully fulfilling his or her duties when the agency simultaneously noted the individual had delayed responses to multiple calls from suicidal veterans. "In the context of responding to a suicidal veteran's call to the Crisis Line, a delayed response can be as harmful as no response," Kerner wrote.

After the initial lag in acknowledging the magnitude of the problems, the VA recognized the need for a standard timeframe for placing a flag on a veteran's medical record once the veteran is identified as a high risk for suicide. The agency said a standard timeframe for placing such a flag should be required and drafted provisions to establish that standard. The agency also outlined proactive steps taken to clarify rules and regulations surrounding the handling of suicidal veterans and implement new standard operating procedures and employee training. The steps included improving communication between VA facilities when a veteran changes facilities, a problem identified through the investigation.

The agency said it reviewed the suicide prevention team workload, another concern identified through the investigation, and changed employee approval powers to make the workload moremanageable. The agency noted that the suicide prevention team is currently successfully meeting the demands and requirements of the program.

The special counsel sent a copy of his letter, the unredacted agency reports, and the whistleblower comments to the chairmen and ranking members of the Senate and House Committees on Veterans Affairs. He also filed copies of the letter,the redacted agency reports (available here and here), and the whistleblower comments in OSC's public file, available atwww.osc.gov.


The U.S. Office of Special Counsel (OSC) is an independent federal investigative and prosecutorial agency. Our basic authorities come from four federal statutes: the Civil Service Reform Act, the Whistleblower Protection Act, the Hatch Act, and the Uniformed Services Employment & Reemployment Rights Act (USERRA). OSC's primary mission is to safeguard the merit system by protecting federal employees and applicants from prohibited personnel practices, especially reprisal for whistleblowing, and to serve as a safe channel for allegations of wrongdoing. For more information, please visit our website at www.osc.gov.