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Nov 19, 2020

Tester Demands VA Action Following Damning Watchdog Report on Veterans Crisis Line Responder Missteps

Ranking Member: “We must ensure no veteran who reaches out for life-saving assistance falls through the cracks”

Senate Veterans’ Affairs Committee Ranking Member Jon Tester is demanding action from the Department of Veterans Affairs (VA) following a damning report from the Office of Inspector General (OIG) outlining responder missteps in the Veterans Crisis Line (VCL) which may have contributed to a veteran’s death. The VCL provides an important service for responding to veterans in crisis and preventing veteran suicide.

The OIG report highlighted VCL staff’s failure to request an emergency dispatch and adequately respond to a veteran in crisis, as well as underlying staff training and policy issues within the VCL and VA. Less than 12 hours after first contacting the VCL in July 2018, the veteran caller was found dead from an overdose.

“This report is particularly disturbing because the veteran spoke to two different VCL responders and reported suicidal ideation, a past suicide attempt, access to lethal means, and intoxication from alcohol and drugs,” Tester wrote to VA Secretary Robert Wilkie. “Despite these red flags, neither VCL responder requested an emergency dispatch to check on the veteran and provide any necessary, immediate intervention. Instead, VCL staff conducted safety planning with the veteran and submitted a routine consult to the veteran’s local VA suicide prevention coordinator for follow-up.”

In its review, the OIG found both VCL responders failed to adequately clarify the veteran’s access to lethal means and therefore did not appropriately utilize the VCL protocol to reduce the veteran’s access to a gun. Responders also failed to include key safety plan elements. In the letter, Tester stressed the urgent need for VA to evaluate its policies, training, and quality review mechanisms for determining veteran callers’ suicide risk.

Tester continued, “It is vital that VA ensure call responders are fully trained on how to properly assess suicide risk, and that VA leadership has strong quality assurance mechanisms in place to monitor staff’s ability to respond to veterans in crisis. This OIG report should serve as a call to action for the Department and the VCL…We must ensure no veteran who reaches out for life-saving assistance falls through the cracks.”

Read Tester’s full letter to Secretary Wilkie HERE.

The Veterans Crisis Line offers free, confidential support, 24 hours a day, 7 days a week, 365 days a year. If you are a veteran in crisis, or concerned about a veteran in crises, please call 1-800-273-8255 and Press 1, chat online at, or text 838255.

Office Contact Information

Senator Tester's Montana staff serves the state from offices in Billings, Bozeman, Butte, Great Falls, Helena, Kalispell, and Missoula. Please bring your concerns with federal agencies, academy nominations, and other situations to one of these Montana offices.


Judge Jameson Federal Building
2900 4th Ave N, Suite 201
Billings, MT 59101
Phone: (406) 252-0550
Fax: (406) 252-7768


Avant Courier Building
1 E Main Street, Suite 202
Bozeman, MT 59715
Phone: (406) 586-4450
Fax: (406) 586-7647


Silver Bow Center
125 W Granite, Suite 200
Butte, MT 59701
Phone: (406) 723-3277
Fax: (406) 782-4717

Great Falls

119 1st Avenue N, Suite 102
Great Falls, MT 59401
Phone: (406) 452-9585
Fax: (406) 452-9586


208 North Montana Avenue
Suite 104
Helena, MT 59601
Phone: (406) 449-5401
Fax: (406) 449-5462


8 Third Street E
Kalispell, MT 59901
Phone: (406) 257-3360
Fax: (406) 257-3974


130 W Front St.
Missoula, MT 59802
Phone: (406) 728-3003
Fax: (406) 728-2193

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