Deadly Failure: A sailor's struggle in a fractured military mental-health system

In this collaboration, Voice of San Diego and NBC 7 shed light on the mental-health crisis in the military, where more than 30,000 service members and veterans in the post-9/11 era have died by suicide

The following article is about suicide and related topics, and may be distressing for some readers. Call 988 if you or someone you know needs help — Ed.

March 6, 2018, was another mild and sunny day in San Diego. Petty Officer 2nd Class Tiara Gray, who was 21 years old, was somewhere off the coast, onboard the USS Essex, writing in her journal. It was 27 days before she died. 

"I sat on the hangar bay today. I felt the sun warm my skin and the shadows move as we rocked slowly back and forth."

"I haven’t been feeling like writing lately, and I fear it’s because I don’t want to reflect inward."

"I want to be strong and powerful. I want to be sure of myself. I want to have a deep understanding of myself."

"I know I get upset when people do slight actions that I perceive as rejection. Usually, I spiral downward and think of committing suicide. But I know it’s just distorted thinking that I have and that I’m just blowing it out of proportion. Need to make more of an effort to remember that in the moment when I’m upset."

This is how Will Huntsberry’s Voice of San Diego article Deadly Failure: A sailor was in crisis. Her command kept the pressure on Anyway begins.

It’s a tragic story of a young woman trying to find her place in the military while battling serious mental health challenges.

Gray was not the typical U.S. Navy recruit. During high school, she spent her free time making art and baking, but once she joined the Navy, Gray started experiencing serious mental health problems, from severe stress to heavy drinking and thoughts of suicide. Prolonged trips at sea frequently triggered mental-health struggles for Gray, who served as a machinist’s mate on the USS Essex.  

During her three years in the Navy, Gray saw dozens of medical providers. After one "underway," the Navy term for a short trip out to sea, on the Essex, she was hospitalized twice and received a list of diagnoses. One clinician, who had only seen her three times, diagnosed her with Borderline Personality Disorder.

Gray’s story sheds light on a mental health crisis within the U.S. military, where more than 30,000 service members and veterans in the post 9/11 era have died by suicide. That's more than four times the number of service members killed in combat during that same period, according to a study from Brown University’s Watson Institute of Internal & Public Affairs

Huntsberry reports that a growing number of suicide victims in the military have never been in combat and that young women in the military are more than twice as likely to die by suicide than their civilian peers. 

VoiceofSanDiego and NBC 7 teamed up to bring this years-long Voice of San Diego investigation to life in a feature-length documentary, “Deadly Failure,” a behind-the-curtain look at Huntsberry’s investigation, Gray’s life and the chaotic mental-health care she received in the months leading up to her death.  

In the documentary, Huntsberry details his reporting journey and the findings of his investigation that reveal gaps in the military’s mental-health care system that are difficult to ignore.

Gray’s mother, Tina Goss, and Gray’s boyfriend, Dylan Seeman, are interviewed and provide emotional accounts of the circumstances surrounding Gray’s suicide and their frustration with a system they say failed their loved one.

Perhaps the most powerful voice in this in-depth report is Gray’s, heard through her journal entries, which provide a compelling glimpse of her deep internal struggles and her desire to overcome her obstacles. Huntsberry describes the entries as “ghostly footprints.” Like a voice from the grave, Gray’s writing describes a young woman coming of age, wrestling with many of the insecurities, stresses and uncertainties of a young adult trying to understand herself and her place in the world, all while navigating her responsibilities within the U.S. Navy.

Huntsberry’s investigation revealed Gray saw more than 25 different licensed Navy therapists in less than a year.  Providers arrived at different diagnoses and made varying recommendations. The project raises many questions and concerns about continuity of care for service members and veterans struggling with mental health challenges.  

A U.S. Navy spokesman, Cmdr. Arlo Abrahamson, told Huntsberry: “The loss of a sailor due to suicide is tragic, and we mourn their loss. The health and welfare of our sailors is a priority, and we will continue to seek ways to strengthen the resiliency, care and wellness of our people."

NBC 7 requested an interview with U.S. Navy officials for the documentary to address questions surrounding Gray’s case and mental-health care protocol in the military, but the U.S. Navy declined the requests for an on-camera interview and would not comment specifically about Gray’s case, citing pending civil litigation involving VoiceofSan Diego. However, Cmdr. Jessica L. McNulty, a spokeswoman for the U.S. Navy Bureau of Medicine and Surgery. did issue this written statement:

“The Navy's leadership and Navy Medicine specifically are deeply committed to preventing suicide and take the mission of saving lives very seriously. Dying by suicide is a highly complex set of interrelated factors, and why it occurs is one of the most perplexing questions in mental health. Although there is no single cause, there are risk factors and warning signs that may indicate a need for mental-health support and crisis intervention. Navy Medicine’s priority is ensuring that sailors and Marines have access to a full range of mental-health services worldwide at Navy installation counseling centers, on the waterfront, embedded within the fleet, Fleet Marine Force, at military medical treatment facilities and via virtual health platforms. The goal is to ensure that support is always accessible. Non-medical mental-health services are available through our chaplains, Fleet and Family Support Centers, Marine Corps Community Counseling Centers, Military and Family Life Counseling and Military OneSource. Navy Medicine works with line units to implement programs like Warrior Toughness and peer-to-peer support programs. These peer-to-peer programs incorporate evidence-based practices to build and sustain toughness, resilience and peak performance. Each installation is appointed an Installation Director of Psychological Health, whose primary duty is to integrate and coordinate medical and non-medical services at installations to provide advocacy for the psychological health of service members and their families. This integration ensures the right care, at the right level, at the right time, allowing service members in crisis to be seen in a timely and efficient manner.”

The documentary also illuminates a military grappling with a recruitment crisis and how the needs for recruitment and retention potentially influence mental-health care. One former military psychologist explains the struggle some health care providers face serving the needs of patients in a health care system that is designed to ready service members for duty.

Could Gray’s death have been prevented?

It’s the unavoidable question at the center of this powerful story of a young woman’s struggle and a life that ended too soon.  

Contact Us