To those who knew him in peace and served by his side in battle, Noah Harter was a born protector and an ideal Marine, so tailored for the role his edges might have had seams.

The only son and middle child of three born to Mark and Kim Harter of Colorado Springs, Noah made the decision to serve his country when he was 11 years old, while he watched with a horrified nation as news footage showed hijacked airliners plunging into the twin towers of the World Trade Center. Noah told his dad, a career Air Force man, that he wanted to protect America from the terrorists when he grew up. He began that trajectory as soon as possible, persuading his parents to sign off so he could graduate six months ahead of his class at Rampart High School and enter Marine Corps boot camp in December 2007, a few weeks after his 18th birthday.

From 2008 to 2011, in almost 300 combat missions during the surges in Iraq and Afghanistan, he put that determination into action as a field radio operator, serving honorably and receiving a meritorious promotion and certificate of commendation for his part in the discovery and clearance of unexploded bombs. A naturally gifted athlete who excelled at all manner of youth sports, Noah consistently earned the highest personal fitness scores in his platoon, as well as a reputation for excellence that Joe Inglis found somewhat intimidating before he met the man himself in 2010.

“A lot of guys that he served with talked about him with a lot of pride. I kind of had this idea I’m going to meet this guy and he’s going to be a big talker, talking about all the things he did … but he was extremely humble,” said Inglis, who struck up an enduring friendship with the 20-year-old “senior Marine” five years his junior during their time in Afghanistan. “If you didn’t know him and you ran into him, you wouldn’t know he was the guy people were always talking about.”

When not on patrol, Noah volunteered to help train his fellow Marines and challenged himself on the personal front, embarking on epic literature-reading campaigns, even building an electric guitar and teaching himself to play Spanish-style in the back of an old armored vehicle parked on base. He mastered juggling, a skill he would break out when on patrol to amuse and distract Afghan village children while the Marines got their job done.

“If Harter was interested in something, he would research it to death and then do it. He was very much a perfectionist; never, ever content with complacency,” Inglis said. “I think that he is one of the closest things to what a Marine should be that I’ve ever known.”

To help cope with PTSD, Noah Harter would sometimes climb the Manitou Incline twice a day. In 2015, Noah took his own life. His Marine boots, dog tags and hat are among his possessions that his parents have to remember him. They hold an enlargement of a photo of Noah at the base of the incline near where they hope to put a memorial bench. Tuesday, February 21, 2017. Photo by Jerilee Bennett, The Gazette

The downward spiral began for Noah when he returned from active duty, to a peacetime Marine Corps and, in late 2011, a civilian world with an embattled Veterans Affairs Department whose safety net for combat veterans with PTSD would prove fatally threadbare.

Noah Harter. Photo courtesy of the Harter Family

“When he separated and came back, we could tell he was different. He was a lot quieter; he would contemplate a lot about things … ,” said Noah’s father, Mark.

It’s clear now to Mark and Kim Harter that their son didn’t want his loved ones to know how bad things had become, that in the years after his discharge and subsequent diagnosis with PTSD, he’d repeatedly sought help from the VA for complaints including insomnia and worsening depression. Just weeks before his death, he’d been prescribed a drug with the potential to increase suicidal thoughts.

Noah Harter. Photo courtesy of the Harter Family

Noah Harter, 25, went missing May 4, 2015. Eight days later, on May 12, police located his car. He had taken his own life, becoming one of the 20 American veterans who die by their own hand each day.

On the passenger seat beside his body was a packet of information from the VA, including a list of emergency contacts with phone numbers to a suicide hotline and other resources for veterans in crisis.

After Noah’s death, in an attempt to understand what her son had gone through, Kim Harter tried calling each of the six numbers on the list.

It took 15 minutes, and she’d reached the final number, before someone finally picked up.

“If a person is going to get ready to commit suicide, you think they’re going to go through six numbers first?” Mark said.

He and his wife have some hard questions for the agency that promised, and failed, to care for their son after his service in the Marine Corps.

Noah with parents, Mark & Kim Harter, after graduating from USMC Basic Training in San Diego (March 2008) Photo Courtesy of Harter Family

Most importantly: Why was a combat veteran with a history of PTSD and documented “suicidal ideation” allowed to leave the clinic with no plan for follow-up treatment or counseling and a prescription for a drug that might put him at increased risk of self-harm?

Two years later, Mark Harter is still fighting for answers.

The retired Air Force space and missile operations officer began peppering VA officials with questions shortly after his son died. Getting a response from the VA has been slow at best and impossible at worst.

But he’s got a growing group of allies.

One of them, Aurora Republican U.S. Rep. Mike Coffman, has been scrutinizing the VA in a big way in recent years.

He has had plenty to see.

In Colorado, the VA has moved from crisis to crisis since 2014. The agency’s effort to build a new hospital in Denver has racked up $1.1 billion in cost overruns.

In Colorado Springs, the VA’s new Floyd K. Lindstrom Clinic wound up in Coffman’s crosshairs after the agency’s internal watchdog found that workers there gave delayed care to hundreds of veterans and in some cases falsified records to make the situation appear better than it was.

Also in Colorado Springs, the VA has consistently subjected its patients to some of the nation’s longest wait times.

As of March, one veteran in five was waiting a month or more for VA care, according to a report from the agency.

A retired Marine Corps officer who had led the House’s VA oversight panel, Coffman said all of the VA’s woes, including the death of Noah, are rooted in a culture that’s short on accountability and effort.

In the case of Noah’s death, Coffman said, VA officials haven’t been able to explain why they didn’t follow up after he sought care for his suicidal thoughts and began taking the prescription antidepressant venlafaxine, the generic form of Effexor, which the FDA warns can lead to an increase in suicidal thoughts and behavior in young adults up until their mid-20s. No explanations have been offered to the family as to why the VA wasn’t aware Noah had gone missing until May 11, when Mark Harter’s quest for answers brought him into the clinic — and up against an impenetrable wall of federal health privacy laws.

“The guy was like, ‘We can’t tell you anything,’ and ‘He’ll show up,’ ” said Mark, whose son’s body was discovered the following day.

Coffman is worried that VA doctors are quick to prescribe powerful pills with powerful side effects before they turn to other options.

“The VA has a drug-centric modality of treatment,” Coffman said. “In my view, it’s lazy. I think they’re taking a shortcut. It becomes one drug to wake up in the morning and a drug to go to bed.”

Apart from treatment methods, Coffman also is alarmed that VA officials in Colorado Springs were so quick to allow Noah to leave the clinic without setting up any future appointments. In the private sector, a patient presenting with his symptoms and narrative would be triaged by a team of psychological professionals to determine risk of harm to self and others and, at the very least, not released without a confirmed support plan and aggressive follow-up.

The VA has told Mark Harter and the congressman that the lack of follow-up for Noah was caused by a software glitch that led to a malfunction in its scheduling system.

“Nothing was about disciplining people who were mistreating our veterans,” Coffman said.

Colorado Springs Republican U.S. Rep. Doug Lamborn, a former leading member of the House’s VA oversight panel, has been asking the VA to release an internal investigation that was conducted after Noah’s death. The agency, though, says it is barred by regulations from doing so.

“We’re still pushing through the committee to get some substantive answers back from VA,” Lamborn said. “We haven’t gotten answers.”

Noah Harter and his best friend in the military, Joe Iglis, poses after climbing the Manitou Incline. Photo courtesy of the Harter Family

Noah Harter and his best friend in the military, Joe Iglis, poses after climbing the Manitou Incline. Photo courtesy of the Harter Family

While they can’t get the VA to explain the mistakes behind Noah’s death, the congressmen are trying to make the agency’s employees accountable for wrongdoing.

The two have pushed measures that give VA leaders broader authorities to fire employees who mistreat patients. That plan has passed the House and is pending in the Senate.

Coffman also pushed a measure that now requires the VA to provide mental health care to any combat veteran who comes through the door. In the past, the agency could turn away veterans who were kicked out of the service with some form of disciplinary discharge.

Coffman and Lamborn also backed a successful effort to expand private health care options for veterans through a reinvigorated “Choice” program that gives them a private health insurance option.

But legislation may not fix the VA’s deeper problems, Coffman warns. He says it’s more about the culture.

“Their goal is taking care of themselves and not taking care of the men and women who sacrificed to serve our country,” Coffman said.

Taking care of others was what Noah Harter did best.

The little boy who liked to dress up in his dad’s Air Force uniform and wear a policeman Halloween costume, year-round, later would tell his parents that 9/11 made up his mind about service, but Kim Harter always knew her son would chose a path that contributed to the greater good.

“He always protected everyone around him,” said Kim, of the young son she recalls scooping up a cat-mauled mouse from the front stoop and nursing it back to health.

Like his dad, Noah had a yen for astronomy and could make a guitar sing. Mother and son, though, shared a deep appreciation of reading and words, and Kim — who home-schooled all three of her kids through the early grade levels — occasionally would find Noah with his nose buried in the dictionary, perusing just for fun.

Because of his good grades and assessment test scores, Noah’s Marine recruiter encouraged him to apply to the U.S. Naval Academy. The teen was firmly set on his path, though, said his father.

After his discharge in late 2011, Noah spent a year working and going to school in Texas before moving back to his old hometown, where he lived with his parents for about nine months and enrolled in the business program at University of Colorado at Colorado Springs. He later landed a promising career-track internship at Northwestern Mutual that let him indulge a penchant for dressing nice and looking professional.

“He always used to say that it sucked no one really wears suits anymore,” Joe Inglis said.

Noah didn’t talk about his time in combat with his parents, and Mark and Kim were reluctant to press.

“I didn’t want to try to force him to talk because I didn’t want him to feel uncomfortable or bring up bad stuff,” Mark said. “I would ask him what it was like over there and he would never elaborate — not even to me, and I was 23 years in the military.”

Kim and Noah golfed together whenever weather allowed and though their conversations wandered far and wide Noah always was careful not to share anything that might worry or upset his mom. Even so, and especially in hindsight, Kim noticed tell-tale signs.

The five-foot-ten teen who melted 20 pounds from his already-sleek frame over 12 weeks of Marine Corps recruit training returned from Camp Pendleton, Calif., at age 22, with biceps big as bread plates and an unspoken story written in dark poetry and Marine-style skull and tiger tattoos. Noah still had that quick wit, disarming dimples and big toothy smile, but behind the humor was a weight and wariness Kim didn’t recognize. The 6-year-old who’d once expressed empathy for a wind-blown paper bag trapped in traffic now sat with his back to the wall at restaurants, watching people’s feet and pointing out if he thought someone was “packing.”

“He was so compassionate. The military kind of took that out of him and destroyed Noah in his spirit,” said Kim, who knew her son had trouble sleeping and occasionally was wracked by nightmares from which he’d awake heart-pounding, drenched in sweat. “He was having a tough time and I made myself available to him, but I just wish I had pushed more and asked more questions.”

The Harter family spent Christmas 2013 at a cabin up near Florissant. Noah Harter. Mother-Kim, sister-Kristina, sister-Joanna, and father, Mark (left to right) Photo courtesy of Harter Family

From what their son did choose to share about his time in service, the Harters knew the period leading up to Noah’s separation had not been a good one, marred by disciplinary actions for minor infractions and soured by a culture of pettiness and bias that Joe Inglis believes is another way the Marines failed his friend.

“It seems like the camaraderie in combat was more real than when we returned home and were out of harm’s way,” said Inglis, whose bond with Noah was so strong that it drew him from his native Texas to pursue a history degree at the University of Colorado at Boulder. “First thing I did when I got out, I drove up to meet him. At the time, he seemed really happy.”

Over the following years, the two buddies saw each other as much as their busy schedules would allow, meeting at their homes, for dinners out and to climb the Manitou Incline, which Noah sometimes did twice a day, often with his Siberian Husky, Melo. Whatever the occasion, conversation usually drifted to plans about the future. Noah helped found an online winter sports apparel company after he left the Marines, and wanted to continue that entrepreneurial bent in the non-virtual world.

“The last thing we talked about was maybe buying some property between Colorado Springs and Denver and starting a business,” said Inglis, who saw Noah for the final time about a week before he disappeared. “I knew he’d had some legal trouble that affected him a little bit, but when I last talked to him it seemed like everything had worked out and he was able to push on.”

Inglis knew his friend sometimes liked to wander off the grid, head out on his own to hike or snowboard and get his existential bearings. Still, when Noah’s sister got in touch to say her brother hadn’t been heard from in a week — and he wasn’t answering texts and calls — Inglis knew something was “really wrong.”

Inglis said he was shocked to learn that his friend had been battling depression and sought help from the VA.

“I feel a little guilty, like if I’d known him as well as I should have known him I should have seen these signs, but I didn’t. I didn’t see it,” said Inglis. “I was also basing it off my own personal experience, like, ‘If I’m doing well, he’s doing well.’”

PTSD is not a linear diagnosis, but a collection of symptoms caused by trauma that manifest in a range of ways, and to different degrees and along different timelines, in each individual.

“People want to know, were you in a D-Day-type situation, or were you in this or that kind of situation? I don’t think it matters. We were trained to do one thing but when we got back we were told to do another thing,” said Inglis.

He believes Noah’s experience after his return from combat played as much a role in his deteriorating emotional and psychological state as his time in battle.

“I think if you have a year left and you’ve spent the last three in deployment, that final year should be spent trying to ease that Marine out in some way,” Inglis said. “Noah wasn’t given: ‘Here’s how you deal with being in the civilian world; here are all the things you need to be successful once you get out.’ He didn’t get that at all.”

The tipping point appears to have come after a cascade of personal setbacks, including a late-night confrontation at his apartment complex, in December 2014, that — despite Noah’s assertions he’d used his Marine Corps self-defense training to disarm a knife-wielding attacker — led to his arrest. On the heels of that came a breakup with a girlfriend and yet another loss: The man who’d once told his mom his goal was to own “six businesses” by the time he was 35 found himself without a career.

After the December incident, Noah voluntarily resigned from his post at Northwestern Mutual and began spending more time in the Breckenridge area, and out of regular contact with his parents.

“That just pulled the rug out from under him. Things just got worse and worse, and all that added to his PTSD,” Kim said. “Most vets, when they don’t have access to medical care, they’ll self medicate with alcohol. Noah did a little bit of that, but he was pulling himself out of it. He did the things you’re supposed to do — working, staying active and keeping busy. He fought and fought and went to the VA for help. He wanted to live.”

The Harter family is far from alone in their grief and frustration.

While the number of veterans killing themselves each day has dropped by 10 percent, according to VA’s most recent statistics, it’s still at 20 per day. Every day.

That’s more Americans dying each day by suicide than the combined daily casualty rates of Vietnam and the Persian Gulf War.

“Twenty veterans die per day by suicide,” said VA’s Caitlin Thompson, who works in Washington D.C. as the agency’s top expert in the issue. “Six of those veterans were in VA care and 14 were not in VA care.”

The agency, again citing privacy rules, declined to directly address Noah’s suicide. But Thompson said the agency is trying to learn from cases like Noah’s with thorough reviews after veterans in VA care kill themselves, called “behavioral autopsies.”

In Noah’s case it’s unclear why he took his own life. What is clear is that a key factor in stopping suicides didn’t take place.

“There should always be follow ups,” Thompson said.

VA’s guidelines for doctors dealing with suicidal patients hammer home the need for return visits.

“If a veteran is found to be at high risk for suicide, they have weekly follow-up,” she said.

VA has come under fire in recent months for troubles in its suicide prevention efforts.

The agency’s internal watchdog released a report on March 20 that showed the VA’s suicide hotline was still not answering nearly a third of the phone calls it receives. The unanswered calls are routed to a VA contractor, often leaving suicidal veterans on hold for as much as 30 minutes, the report found.

West of Denver, Tom McCabe leads another VA call center aimed at helping combat veterans deal with life’s problems before they face the crisis of suicidal thoughts.

The veterans who call VA’s “Vet Center Call Center” are a tough crowd, he said. McCabe hires only veterans to answer their calls about the troubles of life after war.

An alcove that once held flowers, is now a memorial to Noah Harter at the home of Mark and Kim Harter. Noah Harter was a Marine veteran of both Iran and Afghanistan. He committed suicide in May 2015. His mother holds a photo pillow of Noah being a silly teenager with a stuffed Easter bunny. Photo by Jerilee Bennett, The Gazette

An alcove that once held flowers, is now a memorial to Noah Harter at the home of Mark and Kim Harter. Noah Harter was a Marine veteran of both Iran and Afghanistan. He committed suicide in May 2015. His mother holds a photo pillow of Noah being a silly teenager with a stuffed Easter bunny. Photo by Jerilee Bennett, The Gazette

“Nothing against 25-year-old social workers, but that’s not who vets want to talk to,” he said.

As many as 11,000 callers a month contact the center, which refers them to their local VA Vet Center for help. Some of the callers are suicidal.

“Our policy is we would then do a warm-transfer to the crisis line,” said McCabe.

But the crisis line doesn’t always answer the phone, even for the VA.

“There are occasions — and I don’t think I’m talking out of school here — when we call the crisis line and we get a busy signal,” he said.

They keep veterans on the phone and calm them down, eventually connecting them when the crisis line answers.

McCabe’s goal is to get veterans help before they slide into suicidal depths. He said veteran’s centers around the country are a great resource where counselors can get a vet needed help.

Still, judging from the volume of repeat business, veterans struggling with post-traumatic stress and other issues like talking to McCabe’s staff.

“They say ‘I’ll call you guys back because you’re there 24 hours a day and you’re all combat vets so I don’t have to explain myself’,” McCabe said.

Former Fort Carson commander retired Maj. Gen. Mark Graham runs Vets4Warriors, a nonprofit call center to help struggling veterans.

Veterans often have a tough time after serving because they feel isolated. Joining the military is joining a family and leaving it is divorce-like.

“I think everyone wants to be part of something bigger than themselves,” Graham said of those who join the military.

Amid the loneliness after the military, the problems of everyday life compound with the mental wounds of war to hit veterans with a firehose of trouble, he said.

“We take those fire hoses and break them down into garden hoses,” he said.

Graham’s dedication to preventing suicide and helping military families deal with trauma is personal. The general lost his son Kevin to suicide in 2002. In 2003, his son Jeff was killed by a roadside bomb in Iraq.

“We want to get them calling before that point of crisis,” he said.

That Graham and McCabe are so in demand shows the staggering extent of the problem they’re trying to fix. Both worry that only a small number of those who need help are brave enough to seek it.

Thompson said VA is pushing a new outreach campaign to reach veterans. VA clinics have guaranteed rapid service to suicidal patients.

But it’s difficult to keep people schooled in the art of taking the lives of America’s enemies from taking their own, she said.

“If you are suicidal and you use a firearm there’s a 90 percent probability you will die,” she said.

Noah Harter didn’t use a gun. He didn’t want to subject his loved ones, or anyone, to that horrific scene. Before leaving his apartment for the last time, he wrote a note, and put on dress pants and a shirt with cuff links. He last was seen near Old Colorado City around 10:30 p.m. on Monday, May 4, 2015.

The contents of that final letter left little room for optimism, said Joe Inglis, but in the days after Noah’s disappearance, family and friends posted flyers and organized search parties that desperately scoured the city, and beyond, for his white Toyota Camry.

Kim recalls one of those trips, ahead of an unseasonably brutal snowstorm over the Mother’s Day weekend. She was by herself and carried a soft, warm blanket. She knew that her son would be cold when he was found.

“I was so close. I went right by the parking lot where he was,” said Kim, her voice trembling. “I guess God didn’t want me to find him.”

The following Tuesday, a couple Noah had befriended at his favorite west-side hang-out, Colorado Mountain Brewery, was visiting the Harters when police arrived with the devastating news: Noah had committed suicide, by suffocation.

Since that day more than two years ago, she has gained a new understanding of her son and the battles he continued to fight after serving in the U.S. Marine Corps. It’s a collage built of revelations from conversations, eulogies and paperwork, including a two-inch stack of VA files and medical records the Harters fought for months to pry from bureaucratic hands.

Some of what Kim learned makes her well up with pride and “happy-sad” tears. Some of it makes her want to scream.

In addition to the lack of follow-up, during almost three years of treatment by the VA, why is there no indication Noah’s primary care provider ever recommended him for counseling or evaluation by a mental health specialist?

Why was it so difficult for someone with a 50 percent PTSD disability rating to access the services put in place expressly for veterans like himself?

And why, after he was identified as being at risk of suicide, were no attempts made to include Noah’s family in his “safety plan,” a move that’s common practice when dealing with such patients in the civilian sector?

“We didn’t know he had PTSD diagnosed ‘til his last year,” said Kim, who since her son’s death has devoted countless hours to researching his diagnosis, advances in its treatment, and the resources that exist — often close by but on the comparative down-low — outside the VA setting. “There’s a big disconnect between the services that are available and an individual getting those services. I think that’s irresponsible of the military, I really do.”

It’s not easy for a combat-forged Marine to admit weakness and seek help, and the fact that Noah did says to his parents that he knew the challenge he was facing, this time, was one he couldn’t overcome alone.

“The VA were the only ones who heard his cries for help, and they didn’t listen,” said Mark. “Noah was strong and smart and compassionate. He shouldn’t have died.”

The Harters hope that sharing their son’s story will help lead to sweeping changes in how the VA assesses and treats patients with PTSD, so that no other combat veteran — and no other family — has to suffer as they have.

“Ethically, morally and legally, how could the VA let this happen?” Mark said.

Going through papers and photographs over iced tea at a Panera Bread near her home, Kim stopped on a printout of a shot of Noah at the top of the Manitou Incline, taken with Joe Inglis on July 4th the year before he died. He’s wearing a sleeveless T-shirt, his thick-muscled arms crossed at the chest. His mouth is set in a firm line but there’s humor in his eyes, like some unseen director had counseled him to “look tough.”

Gazing at the photo, Kim smiled despite her tears.

The image isn’t the best quality, but it’s one of her favorites. She likes how the slight blur transforms the skull tattoo on Noah’s bicep from the grim image she knows it to be into something that feels almost like hope.

“See how it looks like a star? He’s my shining star,” she said. “He’ll always be my shining star.”