The South Bend Vet Center in Indiana in 2022. (Google Maps)
The family of an Indiana veteran who died by suicide after a Department of Veterans Affairs facility mismanaged his care will receive $1.7 million to settle a wrongful death claim, attorneys with the family said Wednesday.
Army veteran Jason Moon, 33, contacted the South Bend Vet Center for behavioral health care in 2020. But workers failed to conduct an appropriate suicide risk assessment or provide timely care, which lead to his death from a self-inflicted gunshot wound in his home Oct. 15, 2020, while his wife and three of his five children were there, according to a complaint filed with the family’s wrongful death claim in 2022.
“My husband was failed by a system that exists solely to support the men and women who have served our country,” Moon’s wife, LaShanda Moon, said in a statement. “I have spent nearly three and a half years reliving the worst night of my life hundreds of times while trying to be the voice for my husband and the other 22 veterans who end their lives every single day, as I have demanded the VA take accountability and pleaded with them to make policy changes.”
Since the veteran’s death, VA has completed all eight actions recommended by an inspector general review of the facility that included an evaluation of Moon’s care, said Terrence Hayes, a VA spokesman. It also installed new leadership at the veterans center, strengthened oversight and implementation of suicide risk assessment and follow-up processes in alignment with national policy at centers across the nation.
“Moving forward, we will continue to work to make sure that this does not happen again,” Hayes said. “There is nothing more important to VA than providing high-quality mental health care to veterans — especially veterans in crisis — whenever and wherever they need it. We are incredibly saddened and heartbroken by the loss of any veteran who dies by suicide, and we are doing everything in our power to prevent tragedies like this from happening in the future.”
Jason Moon left the Army in 2017 as a chief warrant officer after serving two tours as a medical evacuation crew member during Operation Iraqi Freedom, according to the complaint. At the time of his death, Moon was in the Army National Guard and working toward becoming a Black Hawk helicopter pilot.
He suffered from nightmares and anxiety, which led to alcohol abuse, according to the complaint. His behavior became violent and unpredictable. LaShanda Moon said he was suffering from post-traumatic stress disorder that had never been properly diagnosed.
Even with warning signs that he was likely going to harm himself, the veterans center placed Jason Moon in the care of an unlicensed intern, who was not properly supervised and only provided appointments by phone, according to the complaint. The intern failed to properly assess Moon and did not perform required suicide and lethality assessments. He also failed to collect records from an emergency room visit and admittance to an in-patient behavioral health facility, where Moon told staff that he felt hopeless and was thinking about suicide.
After the intern left the veterans center, a follow-up counselor did not return Moon’s messages and falsified records after his death to hide her own negligence and place the blame on the veteran, according to the complaint.
A VA inspector general report released in 2023 found the director of that center had informed his staff that categorizing a veteran’s risk of suicide as “intermediate” or “high” would negatively subject the veterans center to increased scrutiny from senior VA leaders. This led to staff rating the suicide risk as low for Moon, despite him reporting stressors that should have elevated it, according to the report.
“Money does not bring back a person. Nor does it replace a parent or spouse,” said Peter Bertling, attorney for the Moon family. “But it can provide support for their future and for their lives going forward. The case also exposed serious errors made by the South Bend Vet Center that we hope are rectified so no other veteran has to suffer like Mr. Moon did. He served his country in wartime and was owed so much better than the mental health care he received.”
