Now the Office of Special Counsel, the same federal agency that investigated the scheduling scandal last year is looking into claims there is not enough training and staff to properly treat and keep suicidal patients at the VA safe.
"No suicidal veteran should leave the VA without talking to somebody, that shouldn't be allowed to happen," said Brandon Coleman.
Coleman is an addiction specialist at the Phoenix VA and now a whistleblower who says some suicidal vets are not getting the proper help when they show up at the emergency room on the brink of taking their own lives.
A well-known problem that was brought during a VA staff meeting that was recorded by an employee.
In the recording, the Chief of social work and an Emergency Room worker discuss recent incidents of suicidal veterans being able to leave the ER when they should have been admitted.
Voice of David Jacobson, Chief of social work: "We've had a couple incidences in the past week or two, where veterans here that were at risk for suicide just bolted out the door and weren't prevented from that happening... We've been really lucky that nothing bad has happened in these specific incidences that just happened it, was sheer luck that nothing happened."
Voice of the ER department worker: "It has actually been a high number just since I've been down there's been five in the last week."
Every suicidal vet in the ER is supposed to be watched by a so-called sitter, a person assigned to watch the vet and make sure they don't leave or hurt themselves before they are helped, but VA workers say there's not enough sitters and some are not trained in suicide prevention.
Voice of ER department worker: "The problem is you should have someone one to one with a sitter, they're providing one sitter for up to 4 patients, and the sitter is not trained, sitters will walk away sometimes. There are 2 exits out the ED so if someone just gets up and walks out, there doesn't seem to be a sense of urgency sometimes to make sure that doesn't happen, because there's not the appropriate staff ratio."
Thursday night David Jacobson, the Chief of Social Work at the VA couldn't say whether the staff to ratio concern had been addressed.
"That is our policy for one on one; we should have the staff to do what. Whether have enough staff to do that or not is part of this fact-finding that we'll see," said David Jacobson.
He couldn't say if the sitters did receive suicide prevention training.
"I can't speak to their training at this time," he said.
Nor could he account for all of the five suicidal veterans said to have walked out of the emergency department.
"We haven't actually confirmed that... the two that I know of, both those veterans are safe and not harmed," said Jacobson.
"More should be done, there should be more frontline staff, there should be paid VA employees that have a vested interest in order to sit with the veterans," said Coleman.
The Office of Special Counsel is investigating several of Coleman's claims, including the lack of training for those who deal directly with suicidal patients, and the failure to monitor and provide suitable accommodations for suicidal veterans.