The Veterans Crisis Line failed to prevent a veteran's suicide within an hour of the individual's distress call.
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The US Department of Veterans Affairs Inspector General report reveals mismanagement and lack of protocols in handling the case.
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Crisis line staff neglected to establish a plan to prevent suicide and failed to document communication properly.
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The report highlights a ten-year failure to save veterans' text messages for follow-up.
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The VA Undersecretary expressed deep condolences for the veteran's loss and the family's grief.
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This incident sheds light on ongoing concerns about the effectiveness of the Veterans Crisis Line.
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Crisis line responder inadequately assessed the veteran's history of PTSD and suicidal behavior.
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The veteran, flagged as high-risk for suicide, reached out for help via text but didn't receive adequate support.
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Procedural problems at the crisis line jeopardize its role as a safety net for millions of veterans.
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The VA commits to strengthening suicide prevention efforts and ensuring staff receive proper training and reviews.
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