Veteran Suicide: VA Needs Accurate Data and Comprehensive Analyses to Better Understand On-Campus Suicides

GAO-20-664 Published: Sep 09, 2020. Publicly Released: Sep 09, 2020.
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Fast Facts

Preventing veteran suicide is the Department of Veterans Affairs' highest clinical priority. The VA started tracking suicide deaths on VA campuses—medical facilities, parking areas, and cemeteries—in October 2017 and identified 55 on-campus veteran suicides through September 2019.

We reviewed the VA's data and found errors: 4 missing cases that should've been counted and 10 cases that shouldn't have been—including a veteran who was alive. Also, the VA isn't fully using data it already has to analyze these suicides.

We recommended that the VA improve how it tracks and analyzes this data to better address and prevent on-campus veteran suicides.

Heightened barriers at a VA medical facility parking garage to prevent efforts to jump off of the structure

garage with fencing

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What GAO Found

The Department of Veterans Affairs' (VA) process for identifying on-campus suicides does not include a step for ensuring the accuracy of the number of suicides identified. As a result, its numbers are inaccurate. VA's Veterans Health Administration (VHA) first started tracking on-campus veteran suicides in October 2017, and uses the results to inform VA leadership and Congress. GAO reviewed the data and found errors in the 55 on-campus veteran suicides VHA identified for fiscal years 2018 and 2019, including 10 overcounts (deaths that should not have been reported but were) and four undercounts (deaths that should have been reported but were not).


Examples of Errors on the Department of Veterans Affairs' (VA) List of 55 On-Campus Veteran Suicides for Fiscal Years 2018 and 2019 (as of September 2019)

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VA has taken some steps to address on-campus veteran suicides, such as issuing guidance and staff training. However, GAO found that the analyses informing these efforts are limited. Specifically, VHA

  • requires root cause analyses—processes to determine what can be done to prevent recurrences of incidents—for some but not all on-campus veteran suicides. According to VHA officials, only 25 percent of on-campus suicides from October 2017 to April 2019 met the criteria for a root cause analysis.
  • does not make use of all relevant information VA collects about these deaths, such as clinical and demographic data collected through other VA suicide prevention efforts. VHA officials said they could not link the different sources of information, but GAO found that selected medical facilities could do so.

Without accurate information on the number of suicides and comprehensive analyses of the underlying causes, VA does not have a full understanding of the prevalence and nature of on-campus suicides, hindering its ability to address them.

Why GAO Did This Study

VA established suicide prevention as its highest clinical priority. In recent years, there have been reports of veterans dying by suicide on VA campuses—in locations such as inpatient settings, parking lots, and on the grounds of cemeteries.

GAO was asked to review veteran deaths by suicide on VA campuses. This report examines (1) VA's process to track the number of veterans that died by suicide on VA campuses, and (2) steps VA has taken to address these types of suicides.

GAO reviewed the sources of information VHA uses to identify and analyze on-campus veteran suicides, VA and VHA strategic plans and policies related to suicide prevention and reporting, and federal internal control standards. GAO also interviewed VA and VHA central office officials, and officials from three medical facilities that GAO selected because they reportedly had on-campus veteran suicides between fiscal years 2018 and 2019.

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GAO is making three recommendations, including that VA improve its process to accurately identify all on-campus veteran suicides and conduct more comprehensive analyses of these occurrences. VA did not concur with one of GAO's recommendations related to conducting root cause analyses. GAO continues to believe that this recommendation is valid, as discussed in the report.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Under Secretary for Health should, in collaboration with relevant VBA and NCA officials, improve its process to accurately identify all on-campus veteran deaths by suicide by ensuring that it uses updated information and corroborates information with VA facility officials. (Recommendation 1)
VHA concurred with this recommendation and stated that they established a standing committee that includes representatives from VHA, VBA, NCA, and the Office of Operations, Security, and Preparedness. In January 2022, VHA told us that the committee drafted changes to VA Directive 0321 to require notification of all veteran suicide deaths on VA property to the Office of Mental Health and Suicide Prevention (OMHSP), to include procedures for email notification, reconciliation, and corroboration from local officials. VHA told us that the directive is under revision and will include these changes. We will continue to monitor implementation of the recommendation.
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Under Secretary for Health should expand the policy requirement for a root cause analysis to include all cases of on-campus veteran death by suicide, regardless of whether the veterans involved were enrolled in VHA health care services at the time of their death. (Recommendation 2)
VA disagreed with our recommendation and stated that a root cause analysis was not the appropriate tool for conducting suicide surveillance for all cases of veteran death by suicide. In January 2022, VA stated that VHA requires issue briefs for all suicide attempts and deaths that occur at medical centers, and that the VA committee consisting of VHA, VBA, NCA, and the Office of Operations, Security, and Preparedness, will identify opportunities to expand issue brief reporting and further develop reporting methods. VA added that the committee will also identify methods for enhancing approaches to extract core and optional data surveillance elements for trend analysis and ongoing process improvement. As of January 2022, VA did not update their process. We continue to believe that VA should perform a root cause analysis because it is an existing process that requires no new development in order to implement.
Department of Veterans Affairs The Under Secretary for Health should direct the Office of Mental Health and Suicide Prevention to expand its analyses of on-campus veteran deaths by suicide to include all relevant information VA collects for these incidents, such as data from root causes analyses and information collected through the Behavioral Health Autopsy Program. (Recommendation 3)
VHA concurred with this recommendation. In August 2020, VHA stated that the Office of Mental Health and Suicide Prevention (OMHSP) would formalize processes for timely analysis of on-campus veteran deaths by suicide to include information from the Behavioral Health Autopsy Program data, root causes analyses, police reports, incident reports, and information from facilities. In September 2021, VHA stated that they have instituted a monthly reconciliation meeting to review data on veteran suicide deaths on VHA property from patient safety reporting, root cause analyses, and issue briefs. In January 2022, VHA stated that OMHSP will complete further analyses of these data sources and then provide a report from these analyses by June 2022. We will continue to monitor implementation of this recommendation.

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