CBS 6 reported Wednesday that State Inspector General Mike Morehart said Virginia State Police (VSP) asked the report be withheld.
“The OSIG honored this request in order to ensure it did not impede or obstruct the VSP’s investigation,” Morehart said.
But by Thursday the Bath County Commonwealth’s Attorney told the VSP he will not pursue any charges in the matter.
“I find no criminal involvement in this matter, and accordingly decline to initiate criminal prosecution,” John Singleton wrote.
Inspector General Morehart released the report moments later.
Below is a breakdown of the timeline of events on November 18, 2013, according to the State Inspector General’s Report.
- Senator Creigh Deeds requested an emergency custody order (ECO) at 10:20 a.m. for his son Gus, after becoming concerned about his well-being.
- The Sheriff’s Department executed the order at 12:26 p.m.
- The order would last for four hours with the possibility for a two-hour extension.
- According to the report, six hours is the shortest ECO time limit in the United States.
- A doctor at Bath Community Hospital (BCH) evaluated Gus Deeds at 1:46 p.m.
- A Community Services Board evaluator was dispatched at 2 p.m. from Lexington, Virginia, which is 70 miles from BCH.
- By the time the evaluator was able to start calling around for available beds in psychiatric facilities, more than half the time on the ECO had expired.
- At 3:50 p.m., the evaluator started a frenzied search for a bed in a private hospital.
- The evaluator told the Inspector General he called 10 different psychiatric facilities in his search for a bed for Gus Deeds, but through phone records it was determined he had only called seven.
- At around 5:57 p.m., and with time almost up, the evaluator called Rockingham Memorial Hospital (RHM).
- The evaluator was placed on hold for roughly two minutes and hung up.
- The evaluator then sent the hospital two faxes, with no response.
- The ECO expired at 6:26 p.m. and Gus Deeds was sent home.
- He would attack his father and then kill himself the next morning.
- Investigators would later learn the evaluator had the wrong fax number for RMH, which did have a bed available.
According to the report, state protocol requires that evaluators call a large number of private hospitals before trying a public hospital when looking for available beds.
In this case, Western State Hospital (WSH)was never contacted before time ran out because the evaluator had been told WSH required calls needed to be placed to 10 private facilities before WSH was contacted.
Moreover, the hospital had asked evaluators not to send admissions their way between November 18th and November 20th because they were moving.
Also in the report, the state’s top investigator, Mike Morehart, outlined several recommendations made to the state’s mental health department in March of 2012, by the Inspector General for Behavioral Health and Departmental Services.
However, Morehart found the department did not take action on those recommendations until after the Deeds’ incident, which was more than a year and a half later.
Included in the suggestions, making sure a “safety net bed is always available,” so every person who is found to be a risk to themselves or to others gets a bed.
They also recommended a senior executive be allowed to intervene and find an alternative in cases where a Temporary Detention Order runs out before a bed was found.
Also included in the recommendations, the state facility should always be contacted regardless of the rule that 10 private facilities must be contacted first before the emergency custody order expires.