Editor’s Note: An earlier version of this story incorrectly identified the current director of mental health for the Department of Veterans Affairs. David Carroll is the mental health division’s executive director.
In the wake of a scathing report about failures in the Department of Veterans Affairs’ suicide hotline, U.S. Sen. Mark Kirk sent a letter Sunday to the Secretary of Veterans Affairs demanding the resignation of Dr. Mary Schohn, the VA’s director of mental health.
Late Monday, CNN confirmed Schohn retired from the Department of Veterans Affairs in April of 2014.
A spokeswoman for Senator Kirk’s office apologized for the error but released a statement confirming the Illinois Republican’s resolve to hold people responsible for failures at the VA.
“The culture of corruption at the VA means consistently protecting those responsible for failing our vets and the taxpayers,” the statement said. “Every person who oversaw the hotline for the past nine years should be fired because the GAO and VA OIG (Office of Inspector General) have repeatedly noted the crisis line’s failure.”
In his letter to VA Secretary Bob McDonald, Kirk cited his position as chairman of the Appropriations Subcommittee that oversees funding for the VA in calling for the firing of the department’s mental health director.
Kirk’s office now admits it was working with bad information concerning the status of the now-retired director.
CNN was also unaware of Schohn’s retirement. A spokeswoman for the VA whom CNN contacted Sunday night failed to mention Schohn’s retirement, apparently because she was also not aware Schohn was no longer working for the VA.
As CNN reported last week, the inspector general’s report found suicide hotline calls being placed on hold or sent to backup call centers, and some calls were even forwarded to a voicemail system.
Kirk’s letter says the recent OIG report is one of several warnings in recent years highlighting failure in mental health treatment for veterans.
Kirk’s letter urges McDonald to take immediate action, concluding, “There can be no higher order within the VA than taking seriously the suicide rates of our service men and women when they return from the battlefield.”
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 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.”