When Virginia state Sen. R. Creigh Deeds sought emergency psychiatric treatment for his adult son in the fall, Virginia’s mental health administration had failed to implement reforms recommended almost two years earlier, according to a new report from the state inspector general.

The long-awaited report centers on a question that have plagued mental health advocates and Virginia lawmakers for months: Why was Austin “Gus” Deeds released from custody for want of a psychiatric bed the day before attacking his father and killing himself?

The inaction on the reforms suggested in 2012, the report says, contributed to the failure to get help for the 24-year-old. But most of those changes — as well as several others aimed at providing a better safety net — were implemented by the General Assembly in the wake of the young man’s death.

Neither father nor son is named in the report, but Deeds (D-Bath) has spoken extensively of his experience with law enforcement and mental health authorities that day.

The two arrived at the Bath County sheriff’s office at 10:20 a.m. Nov. 18, and an emergency custody order was issued at 11:23 a.m. The younger Deeds was taken into custody at 12:26 p.m. and taken to Bath Community Hospital by a sheriff’s deputy. But the report says that the local community service board, a group tasked with evaluating such individuals and finding them beds, was not notified of the order until 1:40 p.m. — when the senator called. The board evaluator got to the hospital less than 80 minutes before the four-hour custody order was to run out.

Sen. R. Creigh Deeds, D-Bath, is seen at the State Capitol in Richmond on March 3. (Bob Brown/AP/Richmond Times-Dispatch)

As the order was about to expire, the evaluator determined that Deeds’s son should be hospitalized and called two private facilities, but neither had a bed. The order was extended by two hours.

The evaluator told the inspector general that 10 private facilities were contacted, but the investigation found evidence of only seven calls, according to the report. Two of the facilities where calls could not be confirmed said they had beds available that day.

The evaluator called Rockingham Memorial Hospital, which later reported having a free bed, but hung up after two minutes on hold, according to the report. Follow-up faxes were sent to the wrong number.

When the custody order ran out at 6:26 p.m., Deeds’s son refused to stay at the hospital of his own free will. The evaluator developed a “verbal safety plan” with him and his father and asked them to return the next day.

There “were no effective local, regional, or system-wide safety net protocols” in place to deal with the situation, the report concludes.

The next morning, the younger Deeds stabbed his father and shot himself.

The report notes that recommendations in March 2012 made by a previous inspector general concerning the lack of emergency beds were not acted on by the state until January of this year. Among the sought changes: protocols to ensure that state hospitals are contacted if a private bed cannot be found and the designation of senior executives who can intervene to find hospital space.

None of the recommendations required additional funding, the report notes. An online psychiatric bed registry, also suggested in 2012, was not active when the senator’s son died. It went live in March.

The evaluator did not spend enough time with Deeds, the inspector general said, left crucial information out of his screening report and made “inconsistent claims” about the day’s events.

However, the report says, there were factors beyond the board’s control that contributed to the incident.

At the time, Virginia’s six-hour time limit on emergency custody orders was the shortest in the nation, the report notes. The nearest state hospital, Western State, would not take a patient unless at least 10 private facilities had been called first, the report says, and had requested that admissions be diverted away during a move taking place from Nov. 18 until the 20th.

The University of Virginia Medical Center also would not have admitted Deeds, the report says.

Legislation implemented at Deeds’s urging doubles emergency custody orders to 12 hours and requires a state facility to take a patient if a bed has not been found eight hours into an emergency custody order. It also requires law enforcement to immediately notify the local community services board when an order is issued and doubles the time a patient can be involuntarily held in the hospital to 48 hours.

Lawmakers have expressed frustration that the report did not come out during the legislative session when those reforms were up for debate. Lead investigator G. Douglas Bevelacqua resigned in early March, saying his findings had been censored. He now says that recommendations have already been addressed.

“The General Assembly eclipsed this report with its actions in the last session,” Bevelacqua said.

The report was completed March 10 but held for a pending state police investigation, which was concluded without criminal charges.