The suicide of Marine Corps veteran Justin Miller earlier this year prompted a federal review of the Minneapolis VA system. The final report released last week criticizes a communications breakdown at the VA. Meanwhile, Miller's family is still wondering what happened to him, and why he didn't get the help he needed.
Miller had his first piano lesson at 3 years old. He took to it so fast, pretty soon he outpaced his big sister, Alissa Harrington.
"The joke is that I'm the musical slouch of the family because I only play four instruments," she said.
By high school, Harrington said, her brother was leading the school marching band with his trumpet. At 17, the Marines recruited him to play in the military band.
He was proud when he knew that he was going to be a Marine, and was going to play music.
Harrington said the family wasn't all that nervous about Miller becoming a Marine. He was in the band. It was a guaranteed assignment.
They wanted to believe all he had to do was look sharp and blow those pretty high notes.
But the U.S. government doesn't train Marines just to play music. And in summer 2005, the Marines sent him to the Middle East.
"He was deployed to Iraq," said Harrington. "So he was in Iraq with his trumpet and a gun."
Miller was assigned guard duty, standing watch over the gates of an air base.
Something happened there that changed her brother, Harrington said. She's still piecing together the details.
"He would tell one of us that he had to shoot camels," she said. "He'd tell another one of us that sometimes those camels had riders."
And to the people he knew really well, he said sometimes the camels were wired with explosives. They blew up when he shot them.
"He was a soldier, but he was a musician. That type of trauma was not something he was expecting to have to process," Harrington said.
Miller finished his deployment and came home. He trained to become an electrician, like his dad. He played his trumpet for the Coon Rapids American Legion. He started playing piano again, as he'd done as a kid.
Then, in February of this year, he called a veterans crisis hotline, and checked himself into the mental health unit of the Minneapolis VA. He was having suicidal thoughts and needed help.
After four days of treatment, Miller was released. He walked to his car, climbed in and took his own life with a gun. He was 33.
Those last four days of Miller's life have become the subject of a federal review.
An exhaustive report released last week by the Office of the VA Inspector General shows a breakdown of communication across the Minneapolis VA system.
The facility employs suicide prevention coordinators who work with high-risk patients.
But Miller was never flagged as a high-level suicide risk, so he never got that help.
Miller told several nurses that he had easy access to guns, but denied that fact to others. No one noticed the inconsistency.
When his parents called the VA, looking for updates, some departments didn't even know Miller had been discharged.
It was only after that phone call when VA staff searched their parking lot and found Miller's body.
Harrington had none of this information until the Inspector General's report was released.
"And it was a lot of the same raw guttural emotions all over again. The same way when we found out that he had died in the first place," she said.
She doesn't blame the doctors or nurses for what happened. She says a lack resources and funding stopped them from helping her brother.
She hopes that telling his story will change things at the VA.
Correction (Oct. 2, 2018): Alissa Harrington's name was misspelled in an earlier version of this story. The article has been updated.
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