Wrong fax number hindered search for bed before Deeds attacked

RICHMOND, Va. (WTVR)–Virginia’s top investigator released his report Thursday, detailing what happened last year when State Senator Creigh Deeds tried unsuccessfully to have his son Gus placed in a psychiatric facility.

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.

For a complete coverage of this story, click here.

Timeline

  • 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.

State Protocol
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.

Recommendations
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.

15 comments

  • Glen Allen

    Such a sad story all the way around. The younger Deeds must have been fighting some awful demons, and it must have been a helpless feeling for his parents to stand by knowing there was little they could do to help him. I hope the younger Deeds is in a better place, and I know his passing has brought much more awareness to the cause.

  • Joe

    Welcome to the real world that the rest of the mental health field has been dealing with. Regular families have dealt with this and no one pays attention until some one with power has the problem. Typical, NEXT.

  • me

    Ignore the facts that beds were available from other sources and this
    man had the means, power, and political influence to make things
    happen Before this escalated. There were forewarning signs
    and he lived under the same roof.
    Oddly, this tragic incident, was politically convenient to political agenda
    and was used as a way to affect the means. Sad, but evidently,
    Correct.

  • Ashley

    Sadly they fail to mention that the CSB worker could’ve still obtained the TDO- providing 72 MORE hours of problem solving.. daily crisis workers across the state play the “is there a bed available” game- this time it cost a man his life. We’re going to chalk this up to a bad fax ##?? Where was the follow through with a human to human phone call of “hey, did you get the fax I sent? Here’s what we have.” But nooooo, way easier to send him home when that clock wound down.

    • Emily

      Sadly. people like Ashley above know nothing about the ECO/TDO system before passing ignorant judgment. I AM a CSB worker, and in Virginia you have to have an accepting bed before a TDO can be obtained. Why? Because the accepting facility is ON the TDO. Get your facts straight before posting.

  • Ashley

    The facility is actually listed on the pre-screen report if you would like to discuss technicality, but code does not state it must be secured PRIOR to granting a TDO. The purpose of listing the facility on the report is to ensure that it is “one that has been approved pursuant to regulations of the Board.”

    • Emily

      You really don’t know what you’re talking about. I don’t need you to leave me a code section, but it is impossible for the magistrate to issue a TDO without a bed. The TDO form commands the officer to take the person in custody to the location designated on the TDO. No designation? No TDO. The system won’t allow it to be issued. Call you local magistrate and ask if you don’t believe me.

  • Emily

    I’m well aware of what is listed on the prescreening report, but the prescreening report is quite different than the actual TDO. What the prescreening report says is irrelevant. We’re talking about a TDO form (an actual order) that is issued by a magistrate, not a prescreening report that is filled out by a prescreening clinician at a CSB.

  • Emily

    And I see how you’re interpreting the Code, but you obviously are not familiar with the process if you don’t know that the Magistrate System will not allow a magistrate to issue an actual TDO unless a bed is identified, or if you are a CSB worker and don’t know that a CSB clinician can’t ask for a TDO unless a bed is found. Obviously your experience is pretty limited.

    Have a great rest of YOUR day!

  • Sean

    Emily is correct,
    Deeds had an obligation to his son to get him the help needed. In situations like this, most people will do anything to to get the family member “a bed” even if it means going to other counties. Most Schizophrenics having an episode are not violent… There had to underlying problems at home. Some parents handle have a harder time coping with Schizophrenia than others… So we don’t know what occurred at the house after returning. Personally I’ve seen individuals berate there loved ones to the point where they feel like suicide is the only choice they have.
    It’s said no crime was committed… The fact the CBS had obligations, if young Deeds was having an episode it is the hospital duty to tdo or commit him simply based on the fact he was having an episode. So the crime I see at minimum is young Deeds rights were violated… He was registered by the hospital they are responsible for the patient. He was at harm to himself, to others he was returned to a volatile home… And then to blame it on a machine when it was human error, is just sick…

  • Sean

    What I find extremely frustrating and frightening is even when a Board was created to address the problem there wasn’t one consumer or Doctor on the board!

Comments are closed.

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