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Suicide at Walter Reed Went Unnoticed For Two Days
ABC News
April 23, 2007

April 23, 2007 — - On July 4, 2003, Carol and Richard Coons had planned to welcome home their son Master Sgt. James Coons, a career soldier who had seen action in Iraq in 2003 and during the first Gulf War. Instead, they found out James was dead.

He had committed suicide in his room at Walter Reed Army Medical Center and was found hanging from a bed sheet just inside his room in an outpatient hotel. Walter Reed staff did not find him until at least two days after his death, and only then at the insistence of his family, who were desperate to locate their son.

In their first network television interview since their son's death, Carol and Richard Coons sat down with me to talk about their family's anger and quest for answers. "They didn't take care of my son. They just didn't take care of him," Carol said.

Watch "World News With Charles Gibson" tonight for Bob Woodruff's full interview.

Just a few days earlier, Coons, 35, had been evacuated from a base in Kuwait because he had overdosed on sleeping pills. An Army doctor at a combat hospital labeled the action a "suicidal gesture," according to Coons' medical records.

Coons told medical personnel that he had visited a morgue on the base to pay his respects to the fallen soldiers and had been haunted by one of the faces -- that of a Navy corpsman who had been badly burned and disfigured by an IED.

His parents knew from talking to him on the phone that he was troubled -- they say his voice began to sound different, and they could tell that he was under a lot of strain. "He said, 'The things that I've seen are really bothering me,'" said Carol. "He would see demons and he was trying to control his demons," added Richard.

Devoted Father, Husband, Soldier

The noncommissioned officer in charge of the Army's 385th Signal Company, Coons was awarded a Bronze Star for his service in the March 2003 invasion of Iraq. He had served in the military for more than 16 years, and family and friends have said the Army was his life.

A father of two, he was also a devoted family man. "He loved his wife and girls, and that's what he wanted, to get home to his girls," said Richard.

At the time of his overdose, his tour in Operation Iraqi Freedom was nearly at an end, and Coons had already trained his replacement.

After the overdose, Coons told doctors he was unsure if he had been trying to commit suicide, but that he had taken the pills because he couldn't shake the image of the dead corpsman, and he "just wanted to make it stop."

The Army kept him under close watch in Kuwait for four days and diagnosed him with anxiety, depression and acute stress disorder. He was then evacuated to the military hospital in Landstuhl, Germany, where he met with a psychiatrist, who assessed his suicide risk as "low," and placed him in an outpatient program.

A few days later, he was flown to Walter Reed Army Medical Center in Washington, D.C.

Before leaving Landstuhl, Coons spoke with his family to let them know he was being transferred to Walter Reed. He told them he only expected to be there a few days and that he was looking forward to seeing them in Texas on July 4. That was the last they heard from him.

"We kept calling to find out if he had landed [at Walter Reed]" said Carol. "We couldn't get anyone to say Master Sgt. Coons is here."

Missed Signs?

Coons arrived at Walter Reed on the night of June 30 and was initially evaluated by the psychologist on duty, a third-year resident at the hospital.

After the brief examination, during which Coons denied having suicidal thoughts, the doctor assigned Coons to building 17 of the Mologne House, an outpatient hotel on the grounds of Walter Reed. Coons was given an appointment the next morning for follow-up treatment, but he didn't show.

His family thinks that should have raised a red flag.

"He had three doctors' appointments scheduled. He didn't make any of those three appointments, and no one came to check on him," Richard said, and by this time, the family was becoming increasingly concerned, and made repeated phone calls trying to track down information about the whereabouts of James.

But, the family said, no one at Walter Reed seemed willing to make the effort to check on him.

"I called and spoke with the chaplain and asked her," Carol said, "could you please do something? Call. Go over. Knock on his door. And she told me, 'Well, I'll, uh, I'll call you back.' And she never called me back."

It took four days of phone calls from his wife and parents before hotel staff opened the door to his room -- and by then, it was too late.

"Someone told the desk clerk, the family's been calling so much, maybe we really should go and check on this soldier," said Carol.

Early on the morning of July 4, 2003, a hotel clerk at the Mologne House unlocked the door to room 179 and discovered the gruesome truth. "I opened the door, and noticed a strong smell of decay, then saw the body of a male hanging by the neck just inside the door," read the clerk's statement to Army investigators.

Coroners would later state that James had been dead for at least two days.

His family believes his death could have been avoided if the staff at Walter Reed had been more vigilant.

"They let him fall through the cracks," said Richard. Carol said, "He was a very strong soldier when he went over there. And whenever he came home, he was sick."

Officials at Walter Reed declined a request from ABC News to comment on the case.

An investigation by the Army cleared medical personnel of negligence related to Coons' death. But the report provided to the family does not address why there was no attempt to locate their son after he failed to show up for his appointments. "Where is the accountability?" asked Carol.

Congressman Michael McCaul, a Republican who represents the Coons' Texas district, calls the Army's conduct in the case "unforgivable" and "borderline criminal."

"I think it shows that we have a broken system," McCaul told ABC News, "a system that failed Master Sgt. Coons and his family, a system that resulted in his death. His death could have been avoided, it could have been prevented. All they had to do was keep him [as an] inpatient under observation."

The Coons say they are speaking out now because they fear other soldiers might end up in the same situation. "These soldiers give us their lives, their time, to protect everyone at home. And when they need to be helped, they should get it. They should truly get it," said Carol.

Though he was not originally listed as a casualty of war, Coons was finally added to the Defense Department's official list of casualties in April 2005 after a lengthy appeal by his widow, Robin.

The Army lists Coons' date of death as July 4, 2003, the day Coons' body was discovered at Walter Reed. But the family is fighting to have it changed to July 1, the day they believe he took his life. "He did not die July 4," said Carol. Richard added, "It's not a representation of when he died."

At the cemetery in Conroe, Texas, where he was laid to rest, the headstone reads: "James Curtis Coons. April 3, 1968 to July 1, 2003."

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