Gregg Zoroya

USA TODAY Opinion

A VA suicide hotline movingly portrayed in an Oscar-winning documentary has allowed crisis calls to go into voicemail and has struggled with adequate staff training, according to an inspector general investigation.

Inspectors found problems occurred when calls were routed to backup crisis centers after staff at the Department of Veterans Affairs suicide hotline center in Canandaigua, N.Y., (800-273-8255) were taking all the calls they could handle.

"We substantiated allegations that some calls routed to backup crisis centers were answered by voicemail, and callers did not always receive immediate assistance," said the VA Inspector General report made public late last week.

The VA, which has highlighted veteran suicides as a crucial area of concern, said that since the hotline was created in 2007, about 2 million calls have been answered and emergency efforts made to intervene and save lives in more than 53,000 cases.

An HBO documentary highlighting the life-and-death drama of the VA suicide hotline efforts won an Oscar last year.

Filmmakers put veterans and suicide in spotlight

The Inspector General report did not document how many calls are going to voicemail. But it said the number of calls going to backup crisis centers increased dramatically in recent years, from 36,261 in 2013 to 76,887 in 2014. About every sixth call goes to a backup center, the report said.

Investigators found 20 calls going to voicemail at one backup crisis center in 2014 where staff were apparently unaware there was a voicemail system, the report said.

In response to the findings, the VA concurred with all recommendations for taking steps to ensure calls no longer go to voicemail and that staff training be improved. Steps to increase staffing at the Canandaigua center were announced by the VA almost a year ago, said Victoria Dillon, department spokesperson.

A comprehensive training initiative is underway, and a quality assurance surveillance plan to monitor backup centers is being developed, she said.

"Systems are being reviewed and action plans have been developed to resolve the issues and address the OIG (Officer of Inspector General) recommendations," she said, adding that all improvements will be in place by September.

When the Canandaigua staff are busy taking calls, new phone calls are routed to one of six call-receiving crisis centers that are part of the federal Substance Abuse and Mental Health Services Association. The Inspector General found that staffers at these centers may not have the same level of training as the VA workers in Canandaigua.

Calls routed to the backup centers can be placed in a queue where they hear music for several minutes while they wait, the report said. The VA had no process for learning how long these people wait or how many of them finally hang up, the report said.

The 2014 documentary on the VA crisis hotline, "Crisis Hotline: Veterans Press 1" won the Oscar for best documentary, short subject.