Suicide hotline botched veteran’s cry for help
A veteran, having a history of depression and PTSD, contacted the suicide hotline via text in early 2021. The responder noted that the veteran planned to commit suicide and that he was in a shed with a belt around a hook. During the text exchange, the veteran claimed that he was not being completely honest. The responder recorded a safety plan that involved the veteran texting a family member for help. The veteran would then go to bed and wait for someone to follow up the next day. However, the veteran died via suicide 38 minutes after sending the last text message.
From USA Today:
In the San Antonio incident, a crisis responder inadequately assessed the 31-year-old veteran’s history of post-traumatic stress disorder and suicidal behavior, missing the signs of an impending attempt during the text conversation one night in 2021, the inspector general found. The staffer also failed to note the veteran’s alcohol use and did not establish an effective safety plan or confirm access to lethal weapons or other means to die by suicide.
The veteran had a history of depression and PTSD and had been flagged as being at high risk for suicide but the flag was removed in early 2020. When the vet contacted the hotline by text at 10:14 pm in early 2021, the responder made a note that the veteran planned to die by suicide and was in a “shed with a belt around a hook that hangs from the rafters of the shed,” and “reached out tonight in order to stop from taking action to end (the patient’s) life,” according to the inspector general’s report.
At the same time, during the text conversation, the patient, who was not identified by name in the report, said they weren’t being “entirely honest.” The responder documented a “safety plan” that said the veteran would text a family member for help, go to bed, and wait for someone to call and follow up the next day.
But the veteran never went into the house and didn’t go to bed. The vet died by suicide at 11:40 p.m. — 38 minutes after sending a last message to the crisis line.
The responder reported in notes that the veteran “stayed online until the call ended normally” and with an “agreement to enact a plan of safety,” despite not hearing anything from the veteran after 11:02 p.m. even as the responder messaged the patient for half an hour with no response, according to the report.
Investigators concluded the responder underestimated the patient’s suicide risk and failed to follow up when they stopped texting, according to the report. In addition, they found the hotline hadn’t established adequate procedures since 2011 for keeping text messages on file, limiting the ability of VA personnel or investigators to ensure the hotline is providing quality service to the thousands of veterans who now depend on it.
USA Today provides additional information here.
Category: Veterans in the news
Watch, they’ll automate it with ChatGPT in response– problem solved! /sarc
This initiative is already being floated. Seriously.
Jeez. 🙁 That’s like the all-purpose condolence letter in Catch 22.
Sounds like too little info to judge. And if you think a determined suicide will always be stopped by a sympathetic text – I suspect your rose-colored glasses are getting between you and reality.
Agreed.
I still support 988 for mental health crisis intervention … but …
text is a bad option – minimally arguable as better than nothing.
It appears in this case all it provided was a last contact for someone who had made the decision.
My condolences to the family. Hopefully the 988 worker is a terrible person who didn’t care. Otherwise, my condolences to them as well.
Sad situation obviously, but as others have mentioned there isn’t quite enough to go on.
Was the staff member negligent? Lazy? Or maybe just overwhelmed and overworked?
Texting can be useful for many conversations, and it is always better than nothing, but a text doesn’t open the same window into another person’s soul the way a conversation can.
May everyone involved in this situation find peace.
Damn shame, whether it is incompetence or a lack of training. Or both.
“Suicide Prevention Hotline can you hold please.” (elevator music) “Your call is very important, please stay on the line until a representative is available to take your call.” (elevator music) “Please stay on the line, you can expect your call to be taken in….minutes.” (elevator music)
Hopefully the caller isn’t a jumper and the wait Muzak, ‘ I believe I can fly ‘
Yeah, even Homer Simpson did a better job putting someone on hold:
https://youtu.be/rhXrqfCpigM?si=HJKADH8-DywlMvYN
Texting just seems too impersonal for this type of thing. Maybe it’s generational, but I would rather hear a voice, you know.
At least it’s not a phone tree: “If you’re thinking of shooting yourself, Press 1.”
WTF? 30 minutes of non-response?
Just out of an abundance of caution how about call the cops to do a welfare check?
And yeah texting, impossible to ‘hear’ the hurt or pain in the voice. Texting makes it more like a video game.
Agreed – texting is supposed to be, in theory, just the start and an opening to a phone conversation. But, this is generational as well.
In many areas 988 operations are outsourced to for-profit companies. If 988 sends 911 for a welfare check that turns out to be unnecessary, 988 is charged an exorbitant fee. Hence, 988 lines have pretty strict guidelines for calling for welfare checks. If a particular situation doesn’t check all the boxes …
Like others have said there really isn’t enough info in this article. The veteran previously had a flag, did the operator know that? The veteran said they weren’t being completely honest, was that in response to questions of substance abuse, suicidal ideation history, trauma history, where they were, what actions they planned or their agreement to the safety plan actions? We simply don’t have enough info to judge.
Still, ONLY the last is a clear (according to crisis guidelines) enough flag to call for a welfare check. 30 minutes of nonresponse to follow up could be the caller/texter was doing what they said – contacting a family member and going to bed. Did the 988 operator get another person to confirm the closing of the case? If so, the “failure” is on the company and system as a whole, in part for presuming any intervention will stop a person who is determined and their decision is made.
FWIW – I worked very, very briefly on a 988 line. For most, it is a critical and useful tool. The exceptions are heartbreaking, for lots of reasons. Again, I hope the 988 operator is a terrible person but honestly, those I know who do or have done this role are very, very good and caring.
As if breaking up by text wasn’t lame enough…
RUOK? YOLO!