'Parking lot suicides' at VA hospitals prompt calls for better training, prevention efforts
ST. PAUL, Minn. - Alissa Harrington took an audible breath as she slid open a closet door deep in her home office. This is where she displays what's too painful, too raw to keep out in the open.
Framed photos of her younger brother, Justin Miller, a 33-year-old Marine Corps trumpet player and Iraq veteran. Blood-spattered safety glasses recovered from the snow-covered Nissan Frontier truck where his body was found. A phone filled with the last text messages from his father: "We love you. We miss you. Come home."
Miller was suffering from post-traumatic stress disorder and suicidal thoughts when he checked into the Minneapolis Department of Veterans Affairs hospital in February 2018. After spending four days in the mental-health unit, Miller walked to his truck in VA's parking lot and shot himself in the very place he went to find help.
"The fact that my brother, Justin, never left the VA parking lot - it's infuriating," said Harrington, 37. "He did the right thing; he went in for help. I just can't get my head around it."
A federal investigation into Miller's death found that the Minneapolis VA made multiple errors: not scheduling a follow-up appointment, failing to communicate with his family about the treatment plan and inadequately assessing his access to firearms. Several days after his death, Miller's parents received a package from the Department of Veterans Affairs - bottles of antidepressants and sleep aids prescribed to Miller.
His death is among 19 suicides that occurred on VA campuses from October 2017 to November 2018, seven of them in parking lots, according to the Department of Veterans Affairs. While studies show that every suicide is highly complex - influenced by genetics, financial uncertainty, relationship loss and other factors - mental-health experts worry that veterans taking their lives on VA property has become a desperate form of protest against a system that some veterans feel hasn't helped them.
The most recent parking lot suicide occurred weeks before Christmas in St. Petersburg, Florida. Marine Col. Jim Turner, 55, dressed in his uniform blues and medals, sat on top of his military and VA records and killed himself with a rifle outside the Bay Pines Department of Veterans Affairs.
"I bet if you look at the 22 suicides a day you will see VA screwed up in 90%," Turner wrote in a note investigators found near his body.
VA declined to comment on individual cases, citing privacy concerns. But relatives say Turner had told them that he was infuriated that he wasn't able to get a mental-health appointment that he wanted.
Veterans are 1.5 times as likely as civilians to die by suicide, after adjusting for age and gender. In 2016, the veteran suicide rate was 26.1 per 100,000, compared with 17.4 per 100,000 for non-veteran adults, according to a recent federal report. Before 2017, VA did not separately track on-campus suicides, said spokesman Curt Cashour.
The Trump administration has said that preventing suicide is its top clinical priority for veterans. In January 2018, President Donald Trump signed an executive order to allow all veterans - including those otherwise ineligible for VA care - to receive mental-health services during the first year after military service, a period marked by a high risk for suicide, VA officials say. And VA points out that it stopped 233 suicide attempts between October 2017 and November 2018, when staff intervened to help veterans harming themselves on hospital grounds.
Sixty-two percent of veterans, or 9 million people, depend on VA's vast hospital system, but accessing it can require navigating a frustrating bureaucracy. Veterans sometimes must prove that their injuries are connected to their service, which can require a lot of paperwork and appeals.
Veterans who take their own lives on VA grounds often intend to send a message, said Eric Caine, director of the Injury Control Research Center for Suicide Prevention at the University of Rochester.
"These suicides are sentinel events," Caine said. "It's very important for the VA to recognize that the place of a suicide can have great meaning. There is a real moral imperative and invitation here to take a close inspection of the quality of services at the facility level."
Keita Franklin, who became VA's executive director for suicide prevention in April, said the agency now trains parking lot attendants and patrols on suicide intervention. The agency also has launched a pilot program that expands its suicide prevention efforts, including peer mentoring, to civilian workplaces and state governments.
"We're shifting from a model that says, 'Let's sit in our hospitals and wait for people to come to us,' and take it to them," she said during a congressional staff briefing in January.
For some veterans, the problem is not only interventions but also the care and conditions inside some VA mental-health programs.
John Toombs, a 32-year-old former Army sergeant and Afghanistan veteran, hanged himself on the grounds of the Alvin C. York VA Medical Center in Murfreesboro, Tennessee, the morning before Thanksgiving 2016.
He had enrolled in an inpatient treatment program for PTSD, substance abuse, depression and anxiety, said his father, David Toombs.
"John went in pledging that this is where I change my life; this is where I get better," he said. But he was kicked out of the program for not following instructions, including being late to collect his medications, according to medical records.
A few hours before he took his life, Toombs wrote in a Facebook post from the Murfreesboro VA that he was "feeling empty," with a distressed emoji.
"I dared to dream again. Then you showed me the door faster than last night's garbage," he wrote. "To the streets, homeless, right before the holidays."
Miller was recruited as a high school trumpet player into the prestigious 2nd Marine Aircraft Wing Band based in Cherry Point, North Carolina. In Iraq, he was posted at the final checkpoint before U.S. troops entered the safe zone at al-Asad Air Base.
Hour after hour, day after day, his gun was aimed at each driver's head. He carefully watched the bomb-sniffing dogs for signs that they had found something nefarious.
After he came home, Miller's family noticed right away that he was different: incredibly tense, easily agitated and overreacting to criticism. He eventually told his sister that he suffered from severe PTSD after being ordered to shoot dead a man who was approaching the base and was believed to have a bomb.
Miller called the Veterans Crisis Line last February to report suicidal thoughts, according to the VA inspector general's investigation. The responder told him to arrange for someone to keep his guns and to go to the VA emergency department. Miller stayed at the hospital for four days.
In the discharge note, a nurse wrote that Miller asked to be released and that the "patient does not currently meet dangerousness criteria for a 72-hour hold." He was designated as "intermediate/moderate risk" for suicide.
Although Miller had told the crisis hotline responder that he had access to firearms, several clinicians recorded that he did not have guns or that it was unknown whether he had guns. There was no documentation of clinicians discussing with Miller or his family how to secure weapons, according to the inspector general's report, a fact that baffles his father.
"My son served his country well," said Greg Miller, his voice breaking. "But they didn't serve him well. He had a gun in his truck the whole time."
Franklin, head of VA's suicide prevention program, called the suicide rate "beyond frustrating and heartbreaking," adding that it's essential that "local facilities develop a good relationship with the veteran, ask to bring their families into the fold - during the process and discharge - and make sure we know if they have access to firearms."
She said VA is looking at ways to create a buddy system during the discharge process, pairing veterans who can support each other's recoveries.
During the week of Miller's birthday in December, his family joined his high school band leader to donate Miller's trumpet to a local low-income high school.
"He was a blue-chip, solid kid," said Richard Hahn, his high school band leader. "He does this honorable thing and goes into the Marines. Then we have this tragic ending."
He sat with Miller's mother, Drinda, as she closed her eyes in grief, rocking gently. Hahn and Harrington recalled their memories of Justin, playing the trumpet at Harrington's wedding and taps at his grandfather's funeral.
After the investigation into Miller's suicide, VA's mistakes were the subject of a September hearing in front of the House Veterans' Affairs Committee, but it was overshadowed by Brett Kavanaugh's testimony during his Supreme Court confirmation hearing.
Listening to the conversation about her son, Drinda broke down and left the room. She sat in the lobby, shaky and crying. Her daughter knelt in her skirt to hold her mother's hand.
A Rand Corp. study published in April showed that, while VA mental-health care is generally as good or better than care delivered by private health plans, there is high variation across facilities.
"There are some VAs that are out of date. They are depressing," said Craig Bryan, a former Air Force psychologist and a University of Utah professor who studies veteran suicides, referring to problems with short staffing and resources. "Others are stunning and new, and if you walk into one that's awe-inspiring, it gives you hope."
The Murfreesboro VA hospital, where Toombs took his life, was ranked among the worst in the nation for mental health, according to the agency's 2016 internal ratings. It has since improved to two out of a possible five stars.
The program, "while nurturing in some ways, also has strict rules for picking up medications on time and attending group therapy," said Rosalinde Burch, a nurse who worked closely with Toombs in the VA program. She believes she was transferred and later fired from the program for being outspoken that "his death was totally preventable."
Toombs was 20 minutes late to pick up medications the day he was kicked out, Burch said. He had been late several other times and occasionally left group sessions early, because he was suffering from anxiety.
"But those shouldn't have been reasons for kicking him out," she said. "He was making real progress."
Toombs' substance abuse screenings were clear, and he was starting to counsel other veterans, she said. Burch wrote an email to the hospital's program director, saying, "We all have the blood of this veteran on our hands."
Since Toombs' death, the program has a new leadership team, including a new program chief and nurse manager, the hospital spokeswoman said. Burch has filed a complaint with the Office of Special Counsel, an independent federal agency that investigates whistleblower claims, to get her job back.
For Miller's family, their son's death has motivated them to speak out about how VA can improve.
"The VA didn't cause his suicide," Harrington said. "But they could have done more to prevent that, and that's just so maddening."
On the snowy burial grounds behind St. Joseph of the Lakes Catholic Church in a quiet suburb of the Twin Cities, she huddled with her parents around his grave. Nearby stood the special in-ground trumpet stand that his father designed.
The family sipped from a tiny bottle of Grand Marnier, a drink that Miller liked. His mother shook her head in despair as she recalled the sounds of her son's music.
"Justin used to play his trumpet for all of the funerals," his father said. "But he wasn't here to play for his own."
This article was written by Emily Wax-Thibodeaux, a reporter for The Washington Post.
The Washington Post's Julie Tate contributed to this report.