At least 23 veterans, troops or family members who called the Veterans Crisis Line in fiscal 2014 were transferred to a voicemail system and their calls never returned, according to a Veterans Affairs Department Inspector General report.

The VA watchdog's investigation into the hotline's performance launched last year also found that the centers responsible for the voicemail errors, who were contractors hired to provide backup services when the VA-run Crisis Line is operating at peak, may not have trained their counselors adequately to answer calls from those experiencing a mental health crisis.

But because the VA does not train the backup center employees or monitor the centers' training requirements, the department has no way of knowing whether their training is sufficient, the report noted.

The Veterans Crisis Line was established in 2007 to address the growing problem of suicide among veterans and service members. It has fielded more than 2 million calls and is credited with saving more than 50,000 lives. An HBO documentary highlighting the life-and-death drama of the VA suicide hotline efforts won an Oscar last year.

But as demand has risen for its services, so have the number of calls routed to the hotline's backup facilities: According the inspector general, the number of calls rose by 112 percent from 2013 to 2014.

The VA OIG launched an investigation into the Veterans Crisis Line in early 2015 after receiving complaints from callers that they were placed on hold, didn't receive immediate help or their calls went to voicemail.

Sen. Bill Nelson, D-Florida., also asked for a report on the service after a Florida veteran told the Tampa television station WFTS he was put on hold repeatedly for up to 10 minutes at a time, while he was suicidal.

John Daigh, VA assistant inspector general for health care inspections, said his office could not substantiate that veterans were placed on hold because neither the Veterans Crisis Line staff nor the backup center managers monitor information on how long calls stayed in backup center queues.

But Daigh did find that some veterans who reached a backup center were transferred to a voicemail system. And according to the VA OIG, staff members at that backup center were unaware they had a voicemail system, and the calls weren't returned.

The VA OIG staff made a number of recommendations to ensure that veterans receive better service from the Veterans Crisis Line. They include:

  • Resolving all problems related to calls routed to the backup centers.
  • Improved tracking of calls at the backup centers.
  • Establishing a quality assurance process for both the Veterans Crisis Line and the backup centers.
  • Ensuring that contracts with the backup centers set expectations.

VA officials said they agreed with the recommendations and would implement all changes no later than Sept. 30.

A VA spokeswoman also said a number of changes already were underway at the Veterans Crisis Line, to include that callers are never placed on hold while waiting for services or to be assessed for risk.

The department also has hired additional staff to work peak hours and is upgrading its telephone and technology systems and renovating space to ensure it can accommodate larger peak-time staff.

"These improvements are already beginning to show that we are increasing our capacity to speak with the veterans who need us," VA Secretary Robert McDonald said during a visit to the New York facility in September.

The Veterans Crisis Hotline is staffed 24 hours a day, seven days a week, at 800-273-8255, press 1. Services also are available online at or by text, 838255.

Patricia Kime covers military and veterans' health care and medicine for Military Times. She can be reached at

Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.

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