A combination of time constraints and human error led to tragedy at the home of State Senator Creigh Deeds last November, according to a report released Thursday afternoon by the state inspector general's office.
The 46-page report was made public after Bath County Commonwealth's Attorney John Singleton determined no criminal charges would be filed in relation to the case. Singleton explained his decision in a memo to state police Wednesday. Deeds was never the target of any potential charges.
The report explains in detail what happened in the hours leading up to an attack on Creigh Deeds by his son November 19. Gus Deeds was released from an emergency custody order (ECO) hours earlier, after a psychiatric treatment facility could not be found within the six-hour window prescribed by law. He would later take his own life after attacking his father.
In part, the report blames that six-hour emergency custody window for the tragedy, noting, "the Commonwealth’s maximum six-hour time limit for ECOs is the shortest in the nation." Reforms passed by the General Assembly this year will extend the emergency custody window to 12 hours, ensuring treatment at a state facility within eight hours.
Time constraints and human error also kept Deeds' son from receiving timely treatment. The report says it took nearly three and a half hours before a mental health evaluator met face-to-face with Deeds' son on the afternoon of November 18, largely due to travel times and communication issues.
More communication issues kept workers from finding available psychiatric beds nearby. Before the ECO period expired the evaluator reported contacting 10 different private hospitals to admit Gus Deeds under a Temporary Detention Order (TDO). Investigators only found evidence the evaluator contacted seven hospitals.
“[The Office of the State Inspector General] found no evidence to support the CSB evaluator’s contact with the remaining three facilities," the report reads. "Two of these three facilities advised the OSIG that they had beds available that day."
One of those hospitals was Rockingham Memorial Hospital, an hour and a half north of Bath County in Harrisonburg. According to the report, after calling the hospital and waiting on hold for two minutes, the evaluator hung up the phone and faxed Deeds' Preadmission Screening Report for a second time. But the hospital never received that information, and thus never knew Deeds needed help.
"It was determined that the fax number for RMH was incorrectly recorded on the contact information sheet used by the CSB evaluator, and these two faxes were not received by RMH," the report says.
Gus Deeds' emergency custody order ran out at 6:26 p.m. November 18. Legally, nothing could be done to hold him against his will any longer. According to the report, Creigh Deeds and his son left Bath Community Hospital, agreeing "to escort the individual to the [Rockingham Area Community Services'] Lexington, VA office the next morning for a follow-up appointment."
Gus Deeds attacked his father hours later.
The report lays out a series of recommendations to improve the state's mental health system, many of which are already in the works. Deeds spearheaded a package of reforms passed by the General Assembly earlier this month, including a real time electronic psychiatric bed registry and a four year study of the state's mental health system.
Deeds is proud of the work he and other lawmakers accomplished, but in light of this report he says the real work is ahead.
No Criminal Charges in Deeds Case, IG Report ReleasedMore>>
Ed joined the NBC29 news team in May, 2011. A Charlotte, NC, native, he graduated from the University of North Carolina at Chapel Hill with degrees in journalism and political science.Full Story
Ed joined the NBC29 news team in May, 2011. A Charlotte, NC, native, he graduated from the University of North Carolina at Chapel Hill with degrees in journalism and political science. Email/Follow on Twitter/ Full Story
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