Tracking of Veteran Suicides at VA Facilities in Disarray, GAO Finds

A sculpture portrays a wounded soldier being helped on the grounds of the Minneapolis VA Hospital
In this June 9, 2014, file photo is a sculpture portraying a wounded soldier being helped on the grounds of the Minneapolis VA Hospital. (AP Photo/Jim Mone)

The Department of Veterans Affairs' efforts to track so-called "parking lot suicides" have been so riddled with errors that a living veteran was counted as dead, according to a Government Accountability Office report.

In its review of suicides on the grounds of VA facilities, the GAO report issued Wednesday found "four missing cases that should've been counted and 10 cases that shouldn't have been, including a veteran who was alive."

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The live veteran had attempted suicide but survived, as later confirmed by officials at the unnamed VA medical facility where the attempt was made, the GAO report states.

The report concluded, "The VA isn't fully using data it already has to analyze these suicides," recommending that the department "improve how it tracks and analyzes this data to better address and prevent on-campus veteran suicides."

The VA has made preventing veteran suicides its No. 1 clinical priority. But according to the GAO report, "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."

The VA began tracking "on campus" suicides at its medical facilities and clinics, parking lots and cemeteries in 2017 and found that there were 55 in fiscal 2018 and 2019.

However, the GAO report found that 10 of the 55 cases were the result of overcounts based on faulty information, as well as four undercounts that should have been included on the suicide list.

The overcounts included the live veteran; one veteran whose death was later ruled to be from natural causes; two whose deaths were from accidental overdoses; and one case of a decedent who was not a veteran.

The undercounts included the case of a veteran who died in the parking lot of an outpatient clinic; two who died in buildings that provide support for the homeless; and one case of a veteran who died at the front gate of a cemetery, the GAO report states.

The 33-page report, titled "VA Needs Accurate Data and Comprehensive Analyses to Better Understand On-Campus Suicides," states plainly that the department's system "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."

The VA concurred with the GAO's recommendation to improve its system for identifying on-campus suicide deaths by "ensuring that it uses updated information and corroborates information with VA facility officials."

In a later statement on the GAO report, the VA did not dispute the findings while defending the department's overall record in addressing veteran suicides.

"Suicide prevention is VA's highest clinical priority, and the department's practices for tracking veteran suicide data are continually improving, as underscored by the fact that the Trump administration is the first administration in history to track on-campus suicides," according to the statement.

-- Richard Sisk can be reached at

Related: VA Ramps Up Mental Health Funding After Rash of Parking Lot Suicides

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