PHOENIX — The family of a Valley veteran has filed an administrative claim, or "notice to sue" the Phoenix Veterans Administration Hospital. This is the second notice filed against the VA in the last two weeks.
In the claim, the family of Iraq war hero Edward Hager say the VA staff failed to provide proper care to Hager when he went to them for help in a time of need.
Two weeks ago ABC15 first told you about the legal notice of claim filed by the family of war veteran Joshua Kinnard. Kinnard was shot and killed by Gilbert police after suffering a psychotic episode days after being released from the Phoenix VA hospital.
Kinnard's fiancée Maggie Jones told ABC15 she begged VA staff not to release Kinnard early, because he was supposed to be on a 72-hour watch. Jones said staff ignored her concerns.
This time, the family of Edward Hager says VA staff failed to provide proper care to Hager when he walked into a VA clinic in the summer of 2019, asking for help. "He wore his uniform with honor," said Hager's mother Donna Fett.
Hager, known as "Scrappy" was not only a hero to his family, but also to "veterans with demons from the battlefield" according to the administrative claim.
His family says Hager created a Facebook group named "Them Grunts" and counseled other suicidal veterans to help them deal with the "demons" they brought home from the war. He took their calls at all hours of the day and night, until his own demons got the better of him and he was unable to help.
Richard Lyons, an attorney representing the family says Hager had been declared 80% disabled from post-traumatic stress disorder before his death. Hager suffered traumatic brain injuries from four separate improvised explosive devices during the Iraq invasion. He suffered depression, anxiety, sleep deprivation, and frequent nightmares, according to his family.
Lyons says all of that was known to the VA when he walked into the clinic on June 24, 2019 asking for help. Documents state Hager told the provider at the VA "I am feeling anxious and need some counseling. My wife and children are gone for two weeks and I don't know what to do with myself."
Lyons said he got the information from medical records he had obtained. The claim states "Ed told the provider his that 'I have hardly slept in days. I hate being alone and in my own head.'" He told the VA provider his thoughts were "getting too dark [and] bringing up past memories." Hager reported he had "too much time on [his] hands and is thinking too much."
Lyons said instead of providing help, the provider simply told Hager to go home, give his guns to family members for safekeeping, and to come back and start counseling in 30 days. "He went home that night and shot himself in the head. So clearly those signs were missed," said Lyons.
He called it another tragic story of a veteran who came home after serving his country with great honors, decked with awards and medals, but like so many veterans, Hager had internal scars that were not visible. Audio and visual hallucinations and voices in his head telling him to do the unthinkable, said his wife Sarah.
"He had a suicide letter already written out," she added.
Hager's mother Donna said she had checked up on Hager when his wife and children left to visit her family in Florida. She said she thought things may be improving when he told her he was heading to the VA to get help, and she noted that he had cleaned the house, done the dishes and folded the laundry, something that was not typical.
When they did not hear from Hager the next morning, Fett rushed to his home and went in using a spare key, but it was too late. Hager was gone.
His family believes Hager's death could have been prevented.
"One hundred percent. They should have kept him there. They should have called me. I am his wife," she added, noting that she had actually gone to a few sessions with him when he was undergoing counseling at the VA.
"They did not even try to reach out to me or hold him there. They just let him go. Like a number. I am disgusted, truly disgusted over that," said Sarah.
Months after his death, on Thanksgiving week, a small crowd gathered at the Arizona National cemetery to give Hager a proper military burial.
His family says they are hoping to see the VA stepping up their game by addressing the families of those who have fallen through the cracks. They want to see the VA making major policy changes on how someone who has a history of PTSD is treated when they walk into the VA for help. They are asking for better training for all VA staff members, especially the intake staff who first see the veteran. They also want to see the VA involving family members in mental healthcare treatment and decisions.
Lyons said if the VA provider who had spoken to Hager on the day that he walked into the clinic had bothered to check his medical records, he would have noted Hager was a high risk patient with debilitating PTSD.
Now his family can only wonder if this case would have been handled differently if someone with better training had handled this interaction with a veteran crying out for help.
"They did not try, they really did not try," said Fett. "My son should still be here. They let him down. He served his country and they let him down," she cried.
ABC15 reached out to the VA for a comment. Cynthia Dorfner, the Chief of Communications for the Phoenix VA healthcare system sent us this statement: “Our deepest condolences go out to the loved ones affected by these deaths. Due to privacy concerns, we will not be discussing the specifics of these cases."
Suicide prevention is VA’s highest clinical priority, and the department is taking significant steps to address the issue.
As the Joint Commission explains: “The US Department of Veterans Affairs (VA) has been able to reduce the number of in-hospital suicides from 4.2 per 100,000 admissions to 0.74 per 100,000 admissions on mental health units, an 82.4% reduction, suggesting that well-designed quality improvement initiatives can lead to a reduction in the occurrence of these tragic events.”
The Los Angeles Times recently reported that, when it comes to reducing suicides among certain inpatients, VA “offers some clues as to what might work” for other health care systems.
All VA health care facilities, including the Phoenix VA Health Care system, now provide same-day services in primary and mental health for Veterans who need them.
We encourage any veteran, family member or friend concerned about a Veteran’s mental health to contact the Veterans Crisis Line at 1-800-273-8255 and press 1 or text 838255.
Trained professionals are also available to chat here. The lines are available 24 hours a day, 7 days a week.
Just as there is no single cause of suicide, no single organization can end Veteran suicide alone.
That’s why the President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS) executive order aims to bring together stakeholders across all levels of government and in the private sector to work side by side to provide our Veterans with the mental health and suicide prevention services they need.
The EO builds on VA’s public-health approach to suicide prevention, which focuses on equipping communities to help Veterans get the right care, whenever and wherever they need it.
Earlier this year, VA released its 2019 national Veteran suicide prevention report, see here.
Secretary Wilkie discussed suicide prevention at length an op-ed posted on Inside Sources.