(1-18-16) State officials have quietly removed two years worth of Inspector General reports from a government website that showed they were aware of a dangerous hospital bed shortage at least two years before state Senator Creigh Deeds and his son were told no hospital beds were available and turned away with tragic results.
When Deeds drove his mentally ill son, Austin “Gus” Deeds, to a mental health center on November 18, 2013, he was informed no local hospital beds were available and sent home. Later that day, Gus stabbed his father repeatedly before ending his own life. Sen. Deeds has filed a $6 million dollar wrongful death lawsuit against state mental health officials, claiming negligence.
The IG reports, which could help Deeds’ legal case, were removed from the Office of State Inspector General website sometime after May 2014 at roughly the same time speculation about the state’s liability began making the rounds at the state capitol in Richmond.
A spokesman for State Inspector General June Jennings told me in an email on Friday (1-15) that the missing IG reports were removed by the Department of Behavioral Health and Developmental Services (DBHDS), which oversees 16 state facilities and assists 40 local Community Service Boards in delivering mental health services. The DBHDS is a defendant in Deeds’ wrongful death lawsuit. An official at the DBHDS, however, told me Friday that it was Jennings’ office that decided to remove the reports from its website.
Jennings’s spokesperson said the IG reports have not been destroyed. They are stored in the IG Office’s electronic archives. While still available, removing them from the IG website makes them much more difficult for the public and for Deeds’ attorneys to identify, locate and read.
The content of those reports go to the heart of Deeds’ wrongful death lawsuit.
The first important report was issued March 31, 2011, by G. Douglas Bevelacqua, who was then the state’s mental health Inspector General. He reported that hospitals in the Hampton Roads area of Virginia were sending mentally ill patients away from hospital emergency rooms because the state had cut the number of beds at its Eastern State (Mental) Hospital in Williamsburg and there was no room for new arrivals.
Bevelacqua issued another warning in May and then a comprehensive report in February 2012, in which, he warned that other areas of Virginia besides Hampton Roads were turning away mentally ill patients because of a bed shortage. According to that report, some 200 patients who needed urgent mental health care had been turned away from hospitals during a three month period. Bevelacqua wrote that the practice had become so commonplace in Virginia that emergency room personnel had coined a term for it called “streeting.”
That February 2012 report — one of the key reports removed from the website — prompted a flurry of news headlines and badly embarrassed the DBHDS and its parent agency, the Virginia Department of Health and Human Resources. (DHHR) State officials assured the public that steps would be taken to end “streeting.”
Twenty-two months later, Sen. Deeds and Gus Deeds were “streeted” at the Rockbridge Area Community Services Board, the closest CSB near their rural home.
Almost immediately, Bevelacqua launched a new investigation into the Deeds’ stabbing and Gus Deeds’ death as part of his duties as an Inspector General responsible for auditing the performance and conduct of state mental health officials. But by 2013 his status and authority had changed. When he had issued his earlier reports about “streeting,” he had been the state’s lone mental health Inspector General. But by the time of the Deeds incident, his independent office had been brought under the umbrella of the Office of State Inspector General. This meant Bevelacqua had to get approval from his new boss before releasing his findings about the Deeds incident.
Bevelacqua submitted a draft to then Inspector General Michael F. A. Morehart in the spring of 2014. In it, he concluded that if state officials had heeded his multiple warnings about “streeting” — “it most likely would have produced a different outcome on November 18, 2013” — the day Deeds was attacked and his son ended his own life. He quoted Deeds in his report saying “the system failed that day.”
Morehart objected to Bevelacqua’s conclusion and the inclusion of Deeds’ complaint in his draft report. Both statements were clearly damning to the DBHDS and its Health and Human Resources parent. Morehart ordered Bevelacqua to change his report.
Rather than “censor” his report, Bevelacqua resigned. He told reporters that Morehart had complained that his report was “too emotional,” “incendiary,” and “editorialized” as it was written. In his resignation letter to the governor, Bevelacqua wrote that he was convinced that higher-ups in the state government had interfered with his investigation.
Once Bevelacqua quit, Morehart released an edited version of Bevelacqua’s investigation. It didn’t find any wrongdoing by the DBDS or the Health and Human Services department which is overseen by Secretary William A. Hazel Jr.
Not long after that, K. Brunell Evans, a Charlottesville newspaper reporter, revealed that Secretary Hazel had telephoned Morehart to complain about Bevelacqua and his investigation while he was conducting it. When questioned by Evans, Morehart said he vaguely remembered the call. “I don’t write these things down,” he was quoted saying. Hazel responded “Bevelacqua and I have a different approach to the way we deal with things.”
Inspector Generals are independent fact finders and are not supposed to be influenced by state officials, especially when they are conducting probes of their departments.
In May 2014, Morehart resigned. That same month, the 2011 and 2012 “streeting” reports that Bevelacqua had issued warning about the dangers of “streeting” patients disappeared from the Office of State Inspector General public website.
This is not the only time when statements by Bevelacqau criticizing Secretary Hazel’s administration have not been made public. Before leaving office, then Governor Robert McDonnell appointed a special task force in January 2014 to investigate if the state had a sufficient number of psychiatric hospital beds. That task force was specifically appointed because of the Deeds’ incident. DBHDS officials assured panel members that “streeting” was no longer a problem.
Bevelacqua was the last witness called that day and he repeated his claim that the Deeds tragedy could have and should have been prevented. He also challenged the statements of earlier witnesses by insisting that mentally ill patients were still being “streeted” — even after the Deeds’ incident.
Testimony from that hearing was posted on line for the public, with one glaring exception. Bevelacqua’s critical testimony was not posted. The co-chair of the task force on Improving Mental Health Services and Crisis Response was Secretary Hazel, the same official who had telephoned the IG’s office to complain when Bevelacqua was investigating his agency.
Printed below is an excerpt from a 2011 report that Bevelacqua issued warning about “streeting.” This document is one of the damning reports that were removed from the Office of State Inspector General website. It contains an horrific example of a “streeting” incident that happened months before Deeds and Gus were turned away.
As you read about this “streeting” incident, ask yourself if state officials should have been alarmed by what Bevelacqua was reporting. Ask yourself if Deeds was justified in telling Bevelacqua “the system failed that day” because he and his son, Gus, were “streeted.” Ask yourself, why Bevelacqua’s IG reports about “streeting” were removed after he resigned when rumors began swirling about a possible lawsuit. Ask yourself why the Office of the State Inspector General says the DBHDS took down the reports and the DBHDS says the IG’s office removed them.
Finally, ask yourself if state mental health officials have been more concerned about damage control than being transparent.
(Note: I have boldfaced key lines.)
THE PRACTICE OF “STREETING” IN THE COMMONWEALTH:
The Office of Inspector General was introduced to the term “streeting” during our follow-up on the impact on Hampton Roads…We subsequently learned that, while streeting appears most prevalent in Hampton Roads – where eight of nine Community Service Boards [mental health providers in Virginia] acknowledge streeting last year, this practice occurs throughout the Commonwealth and, that between April 1, 2010 and March 31, 2011, approximately 200 individuals, who met criteria for a Temporary Detention Order (TDO) [taken into custody], were released from custody because no psychiatric facility was willing to admit these people.
In order to understand the extent of this problem, the OIG conducted an informal survey of emergency services directors across the state. Twenty three of the forty Community Services Boards acknowledged having cases where streeting occurred last year…
Definition of streeting: “# Streeted: The person was released. For example, a person who is brought in under an Emergency Custody Order who meets Temporary Detention Order criteria, but has to be released from custody at the expiration of the ECO as there is no bed available.” [This is exactly what happened in the Deeds case. Mental health officials had to find a bed in six hours or release Gus, which is what happened.]
… One such case is profiled below:
This case involved a 66 year old female who was very delusional and paranoid. The woman was brought to Emergency Services on a weekday at approximately 6:00 p.m. for psychiatric evaluation after attempting to choke an intellectually disabled relative.The woman, in her delusional state, believed that the other individual was trying to kill her and that she was reacting in self defense.
Emergency services personnel contacted 15+ private providers across the state in an effort to secure services [a bed] under a TDO. None of these hospitals reported that they had an open appropriate bed. Two state facilities were contacted; one denied admission because the facility does not accept TDOs and the other denied admission because they do not accept persons over the age of 65.
With no possibility of obtaining a TDO bed, the individual was released from custody and transported home by the Sheriff’s Department. The person’s relative was removed from the home to decrease the risk of homicide, but this fragile and vulnerable individual was left alone overnight. The following day emergency services made further contacts in an effort to secure a willing treatment facility for this deteriorating individual, but discovered that after multiple calls a TDO bed was still not available. Although not ideal, emergency services contacted a crisis stabilization unit in another catchment area, who agreed to take the person as long as she was medically cleared for their setting. Staff decided this was a better option than returning the person to her home to be alone for an additional night. Two trained staff members accompanied the person to the local hospital for medical clearance and then transported her to the crisis stabilization program, approximately 100 miles away, only to have her denied upon arrival because the person was lethargic from PRN medications she had received during the medical clearance process.
This left the person and the two staff members without options and a considerable distance from the home community. The person’s need for treatment and deteriorating status was very apparent to the accompanying staff members, so it was decided to transport her to yet another emergency room of a hospital in the area of the crisis stabilization program in an effort to either obtain a bed or get her medically cleared again so that admission to the crisis stabilization program might occur.
The person was admitted to a medical unit at that facility. The entire process took more than 48 hours. Unfortunately this case was not unlike other cases noted in the information provided the OIG, but thanks to the persistence of emergency services personnel, this individual was kept safe during this period. The record reflects that emergency services staff around the state routinely go far beyond reasonable expectations to keep clients as safe as possible despite sometimes daunting obstacles.
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