Two weeks ago, 51 year old veteran, Charles R. Ingram, III, stood outside a Veterans Affairs clinic in New Jersey and set himself on fire.

He did not leave a note or reason for his actions, which has prompted many to ask what, if any, kind of counseling he was receiving.

The Wilmington VA Medical Center issued a statement:

“…saddened to learn about the tragic incident that took place outside of the Atlantic County Community Based Outpatient Clinic … Our thoughts and prayers are with the victim’s family, friends and neighbors.

Due to the open investigation and patient privacy concerns, we will not be commenting further at this time.”

While the details of Mr. Ingram’s case are still unknown, the situation, although alarming, is not uncommon.

On March 3rd, the Daily Caller reported on the case of Thomas Young, a 30 year old veteran who committed suicide by laying on train tracks a day after calling the VA’s Crisis Hotline and being sent to voicemail.

Young had returned from his second tour of Iraq in 2004 with severe PTSD. He tried to go to the Hines VA hospital in Illinois for help with a drinking problem, but they turned him away, saying they didn’t have any space available since he wasn’t suicidal.

His brother said he believes Young called the VA hotline on July 22nd or 23rd. He laid down in front of a train on July 23rd, leaving behind a wife and two daughters. He had previously tried to kill himself by passing out on train tracks, but someone always carried him off the tracks before he was hit. He tried to go back to Hines, but was put on a waitlist.

The hotline in question is a part of a department that the VA set up in 2007 in order to meet the needs of distraught servicemen and women who were wrestling with substance abuse, PTSD, depression, and were contemplating suicide.

Alarmingly, the cases of Young and Ingram are not isolated instances. In fact, the VA has disclosed that 22 veterans commit suicide each day. That is one suicide every 65 minutes.

This staggering statistic highlights the VA’s inability to deal with such an epidemic. VA officials say the hotline program is understaffed and underfunded. Other detractors say that it’s the predictable outcome of government-run health services.

The VA states that they have backup call centers for times all available lines are busy. The idea is that the call will roll over to the external centers quickly, so as not to have long wait times when a veteran is in immediate need. It’s a system that sounds good in theory, but many veterans are saying that the system isn’t even close to that efficient.

Combat Veteran, William Fuzi, spoke with WCPO 9 On Your Side. He recounted a call he had with the hotline where he reached out in need and was on hold for more than 36 minutes.

“…terrified because I was afraid for myself…at first,” Fuzi said.

Stories like Fuzi’s are what led the CVO (Coalition of Veterans Organizations) to file a complaint with the VA over the “life-threatening shortcomings of the Crisis Hot Line,” which in turn prompted the Veterans Affairs Inspector General to investigate the claims.

In early February of this year, the Office of the Inspector General released a report on their findings.

The report, which can be read here, makes some startling discoveries. One grievance the Inspector General investigated was that many calls were being forwarded to backup centers, then sent to voicemail, and in many instances those voicemails weren’t listened to or simply didn’t prompt a response.

“Our review identified over 20 calls that were routed to voicemail at one of the backup centers. When VCL management investigated these complaints, they discovered that the backup center staff were not aware the voicemail system existed; thus, they did not return these calls.”

Another complaint was that forwarded calls were not being answered quickly, or that callers were being put on hold for extended periods of time. In some instances, the caller was told to contact another organization altogether. The report states that part of the problem is that the backup centers were only meant to deal with 10 percent of all calls to the hotline, but the amount has almost doubled.

“VCL management stated that in the past, though they hired more responders to answer the increasing number of calls, they did not use a business management model for collecting and analyzing data to map and project staffing needs.”

Further troubling were the substantiated claims that many Social Services specialists (SSA) had not received adequate training before handling live calls.

“During interviews, SSA staff reported that orientation consisted mostly of sitting with another SSA, who may or may not have been experienced and had access to a handbook that did not instruct them on specific SSA procedures or processes. Some SSAs stated that they did not feel they had adequate training and had received erroneous or inadequate information from other SSAs, including information regarding rescue procedures and consult resources.”

The staggering inadequacies of the VA have been a focal point of lawmakers for some time now, however, veterans are still feeling left out in the cold. And while the conversation seems to be narrowly confined to how to fix hotlines and “telemedicine,” many veterans are complaining that telemedicine itself is not an adequate solution to a severe mental health crisis within the veterans’ community.

One thing is certain, our veterans deserve far better than they have received at the hands of the VA.

One veteran summed up the collective frustration in a comment he posted to the site DisabledVeterans.org:

“He deserve better. We gave freely of ourselves personally… please return the favor. Technology is awesome for some things, but not to help a vet deal with the thoughts that riddle our dreams and waking hours.”