(CNN)A VA suicide hotline designed to help distressed vets, at times instead sent their calls to a voicemail message, provided no immediate assistance, and did not even return some calls, according to a new report.
VA crisis line left vets in limbo, says report
The hotline at the center of the disturbing new report is the Veterans Crisis Line, or VCL, based in Canandaigua, New York. The crisis center was recently the focus of a HBO documentary praising the workers' tireless efforts to help vets. The film, "Crisis Hotline: Veterans Press 1," even won an Oscar last year. (HBO and CNN have the same parent company, Time Warner.)
But it turns out the suicide hotline itself was in trouble, and not helping some veterans in their worst time of need, according to the report.
The VA Office of Inspector General of Healthcare Inspections began investigating the crisis call center last year after complaints by veterans that they were placed on hold, or transferred to voicemail, or not given appropriate help when most in need.
The Office of Special Counsel also received complaints, prompting the IG to further investigate.
Investigators determined that during busy times at the center, veterans would get redirected to a backup center, or sent to voicemail and sometimes never got a return call, the report said.
The report also raised concerns about staff training.
"We also substantiated that VCL management did not provide social service assistants with adequate orientation and ongoing training," the report states.
And for workers in the backup center, where phone calls sometimes landed during busy times, the report also said "we did find evidence that raised concerns regarding backup center training adequacy."
Ironically, the call center was part of an overall VA plan to address the staggering problem of veteran suicides. According to the report 20% of those who kill themselves are veterans. From October 1, 2008, through the end of 2010, "VHA suicide prevention coordinators reported approximately 5 suicide deaths per day and nearly 950 veteran suicide attempts per month among veterans receiving care," the report states.
The hotline began running in July of 2007 and runs 24/7. Numbers show demand for the services is high. Staff at the center field hundreds of thousands of calls a year. The report shows that from fiscal year 2013-2014 the center saw a 30% uptick in calls from 287,070 in 2013 to 374,053 in 2014. During that same period, the backup center staff saw an increase of 112% in call volume.
The IG office also said it had identified "gaps" in a "quality assurance process" at the crisis call center.
"These gaps included an insufficient number of required staff supervision reviews, inconsistent tracking and resolution of VCL quality assurance issues, and a lack of collection and analysis of backup center data, including incomplete caller outcome or disposition information from backup center staff."
Rep. Jeff Miller, Chairman of the House Committee on Veterans Affairs, said the report "leaves many of the most important questions unanswered, namely what happened to all of the veterans who were sent to voicemail or just gave up without leaving a message?"
"No veteran in crisis should ever have to wait for service or be transferred without a positive handoff, told to call another organization, or -- worst of all -- have their call terminated without receiving any assistance," said Rep. Miller.
"The larger issue is that this situation shows that the VA employees in charge of running the crisis line were asleep at the switch -- utterly unfamiliar with the day-to-day operations of the program."
Officials at the U.S. Department of Veterans said Thursday they were well aware of the report and its findings, and said that efforts have been underway for a year to make improvements.
"It is important for veterans and our key stakeholders to know that the VA undertook actions to strengthen Veterans Crisis Line operations long before publication of the inspector general report. The goal is to make the Veterans Crisis Line nothing short of a world-class crisis response center," said VA Deputy Secretary Sloane Gibson.
Gibson said that, since last year, the VCL has hired a director with a better background, a deputy director with call center management experience, four dedicated staff trainers and six dedicated quality managers. He also said there is now improved data that provides "the most responders at the times when veterans are most in crisis," and he said staff training has been "strengthened."
"Since the crisis line began operations in 2007, our crisis line responders have saved 53,000 Veterans," he said "Getting this right is a top priority."