File: Sen. Creigh Deeds, C, flanked by Senators Mamie Locke, L, and Louise Lucas, R, puts his hand to his face in his first public appearance since the attack/suicide by his son. (Photo by Jahi Chikwendiu/The Washington Post)

Could a psychiatric bed registry have saved Gus Deeds?

It was one of many potential fixes to Virginia’s mental health system that has been talked about for years but wasn’t in place on Nov. 18, when crisis workers were not able to find Austin “Gus” Deeds a bed before his six hour emergency custody order ran out. He went home, and the next day he attacked his father, Virginia state Sen. Creigh Deeds (D-Bath) with a knife, then took his own life.

The registry went live Monday and became an instant example of the kind of frustrations that helped drive out a well-respected state official who was leading a probe of the Deeds tragedy, G. Douglas Bevelacqua.

In a letter of resignation that he sent to the Gov. Terry McCauliffe over the weekend, the former inspector general for the Department of Behavioral Health and Developmental Services said he resigned over meddling by superiors with his Critical Incident Report on the death of Gus Deeds. He said higher ups wanted to tone the report down.

One of the comments Bevelacqua said his bosses nixed had to do with a  February 2012 report that highlighted many of the problems that would later surfaced in the Deeds case, including the need for a bed registry.

The report looked at how long it takes to find a psychiatric bed for individuals who are being held under emergency custody orders. After looking at 5,000 cases handled by community mental health workers over a three-month period, Bevelacqua found that in 5 percent of them, no bed was located until well after the legally mandated six-hour time limit had ended. In 1.5 percent of cases, no bed was found at all. (Lawmakers are considering extending the custody order up to 24 hours.)

While infrequent, such outcomes, Bevelacqua wrote, represent “a systemic failure to address the needs of that individual” and could lead to an “unexpected occurrence involving death or serious physical or psychological injury.”

Bevelacqua also wrote that a real-time statewide registry of available psychiatric beds in private hospitals could “substantially decrease the time needed to secure a bed.” Such a registry had been in the works since 2009, but the project stalled due to deep budget cuts, Department of Behavioral Health and Developmental Services spokesman Maria Reppas said.

Work on it resumed in 2011 and it was a few weeks from beta testing on the day crisis workers with the Rockbridge Area Community Service Board tried and failed to find Deeds a bed. Afterwards, several hospitals said they had room that day, but were not contacted.

In his resignation letter, Bevelacqua said he had wanted to say in the Deeds report that had the state carried out the 2012 recommendations, “it most likely would have produced a different outcome on November 18, 2013.” But that statement was deemed by higher ups as “too speculative,” and was cut.

Reppas said in the two years since that report was issued, the agency has not been ignoring it and that agency leaders agreed with many of Bevelacqua’s conclusions. “It is a serious concern if even one person in a mental health crisis cannot locate and receive the services that are needed,” she said.

Reppas said the agency has been working with local services providers and public and private hospitals to address the concerns Bevelacqua raised, citing a report on emergency evaluations by the University of Virginia’s Institute for Law, Psychiatry and Public Policy that was completed in December and had similar findings.

While there has been progress, she acknowledged that “Virginia currently continues to lack the capacity to provide these services in all communities across Virginia so more people in crisis can get access to the mental health services they need.” The hope is that ongoing budget negotiations will lead to a much-needed infusion of funding.

One item that is sure to be approved is money to support the bed registry. It was one of several proposals Creigh Deeds introduced just before he returned to Richmond in January.