Vet Centers provide community-based counseling for veterans, service members, and eligible family members coping with combat trauma, military sexual trauma, bereavement, readjustment problems, and other service-related challenges. Their work includes identifying clients at elevated risk for suicide and coordinating care when a veteran needs additional clinical support.

In testimony before the U.S. Senate Committee on Veterans’ Affairs, the Department of Veterans Affairs Office of Inspector General said its first nine Vet Center Inspection Program reports covered all five Readjustment Counseling Service districts and found frequent noncompliance with required processes, particularly suicide-risk assessment and documentation. The OIG also identified weak internal oversight and unclear or inconsistent policies as recurring problems.

Recent Inspections Found Delayed Suicide Reviews

Those concerns have continued in later inspections. In August 2026, the VA Office of Inspector General reported that North Atlantic District 1 leaders did not complete all required morbidity and mortality reviews within 120 days after client suicides. WV News reported that three of five reviews involving active clients who died by suicide missed the deadline. District leaders also failed to report those delays as required, some reviews lacked required components, and lessons from the reviews were not distributed nationally.

Morbidity and mortality reviews examine the circumstances surrounding a death, the clinical services provided, possible opportunities for improvement, and practices that could help prevent similar outcomes.

The pattern is not limited to one region. A 2025 VA Office of Inspector General inspection of Midwest District 3 found that three suicide reviews were completed on time, but the review panels lacked required members and one report omitted a required component. Inspectors also found that all three zones failed to meet the requirement to document high-risk client contacts and outcomes in RCSNet within five business days.

High Risk Suicide Tracking Has Repeatedly Raised Concerns

The High Risk Suicide Flag system is designed to help Vet Center staff identify clients who need follow-up based on clinical concerns. In its 2024 Senate testimony, the OIG said staff had reported difficulty using the SharePoint system, confusion about its purpose and requirements, and inaccurate data.

Later district inspections found similar weaknesses. In Pacific District 5, the VA Office of Inspector General did not conduct its planned review of the high-risk flag system because of data-accuracy concerns. The same inspection found untimely morbidity and mortality reviews and failures to complete or provide safety plans to some clients at intermediate or high suicide risk.

In Southeast District 2, inspectors found delayed suicide reviews, untimely documentation of high-risk contacts, concerns about the accuracy and use of the flag system, and failures involving consultation and safety plans.

The 2026 North Atlantic inspection found noncompliance with high-risk documentation requirements and concerns with the system’s accuracy and functionality. WV News reported that the platform became inaccessible in June 2025, forcing staff to use a manual spreadsheet process.

National Oversight Can Connect Lessons Across Vet Centers

The findings span multiple districts, years, and parts of the suicide-prevention process. A national petition calls on Veterans Health Administration and Readjustment Counseling Service leaders to enforce timely and complete mortality reviews, distribute lessons learned across the Vet Center system, and ensure high-risk suicide tracking tools work accurately and reliably.

Sign the petition to call for consistent suicide-prevention safeguards at every VA Vet Center.

Click below to make a difference.