The investigator examining the attack that left state Sen. R. Creigh Deeds wounded and his son dead has resigned in protest, sparking fears among mental health advocates that Virginia is resisting serious scrutiny of its troubled system.
Among the findings that G. Douglas Bevelacqua says were censored: State officials could have prevented the tragedy by acting on warnings he had delivered two years ago.
The resignation of Bevelacqua, director of the behavioral health and developmental services division of the state inspector general’s office, comes as Virginia lawmakers once again try to reform a mental health system that has repeatedly come under fire as underfunded and incomplete.
In his resignation letter Saturday to Gov. Terry McAuliffe (D), Bevelacqua wrote that higher-ups interfered with his report on the Nov. 18 incident that left Deeds (D-Bath) injured and his son dead from a self-inflicted gunshot wound.
Bevelacqua planned to conclude that state officials “failed to take meaningful action” to address recommendations from his February 2012 inspector general report on the state’s mental health emergency response system. That report focused on “streeting” — when a mentally ill person at risk of causing serious harm is not held in a psychiatric facility because of lack of access to a bed.
Had the state carried out his recommendations, “it most likely would have produced a different outcome on November 18, 2013,” Bevelacqua wrote in his original draft of the report. His inclusion of a quote from Deeds saying that “the system failed that day” also was removed.
“I regret this resignation more than I can put into words, but I feel that I can no longer be an authentic, independent voice of accountability for the citizens of Virginia on matters of behavioral health and developmental services,” Bevelacqua wrote.
State Inspector General Michael F.A. Morehart declined to comment, saying he is prohibited by code from discussing personnel matters.
Deeds’s son had undergone a psychiatric evaluation the day before his death. Officials initially said he was not admitted to a hospital because no bed was available, but several nearby hospitals later confirmed that they had available space but were never contacted. His emergency custody order ran out, and he went home with his father. The next morning, Austin “Gus” Deeds stabbed his father in the face repeatedly before fatally shooting himself.
Speaking to reporters after the Senate floor session Tuesday, Deeds expressed disappointment and concern that the final report would be incomplete.
“Bevelacqua was fair with me, he was honest, he was compassionate,” Deeds said. “I’m disappointed, and certainly I’d be very disappointed if it turns out the report was sanitized. . . . The truth should come out.”
Among Bevelacqua’s 2012 findings was that a real-time registry could substantially reduce the time to find a bed. The registry was in the works but not operational the day local mental health workers at the Rockbridge Area Community Services Board tried and failed to find Gus Deeds a bed before his six-hour emergency custody order ran out. Upon Creigh Deeds’s return to Richmond in January, he and other lawmakers made funding for the registry a priority in various reform measures.
The registry went live Monday, state officials said, two days after Bevelacqua resigned.
Bevelacqua, whose mother suffered from schizophrenia, has been active in mental health reform for the past quarter century. He was appointed to his current post by Gov. Robert F. McDonnell (R) in 2010.
“We were surprised. He’s done a number of pretty important reports, and we hope that there is a good deal of scrutiny of the claims that he’s making," said Mira Signer, executive director of the National Alliance on Mental Illness of Virginia.
Bevelacqua has clashed with state officials before. After his 2012 report was released, James W. Stewart III, then commissioner of the Virginia Department of Behavioral Health and Developmental Services, complained in e-mails to Bevelacqua that it made too much of a small percentage of failures in the system. Bevelacqua also resigned from the administration of Gov. George F. Allen in 1995 over a plan to transfer mental health treatment from community service boards to Medicaid managed care.
“It’s a very, very sad day for people with mental illness in Virginia,” said Peter Earley, a former Washington Post reporter and mental health advocate. “He’s just been a tireless voice in the wilderness that people have refused to listen to, and I think the fact that he feels compelled to resign shows me that Virginia is more interested in keeping its head in the sand than really taking positive steps to fix its system.”
The new report has yet to be released, even as the legislature is close to finalizing changes to the mental health system based on how the case of the younger Deeds was handled. It it expected in the next two weeks, according to the inspector generals office.
“If I were responsible for publishing this report, it would have been issued weeks ago and it would have contained conclusions that were removed because they were considered speculative or too emotional,” Bevelacqua wrote in his resignation letter.
At Deeds’s urging, the state Senate has proposed extending the time limit for emergency custody orders from six hours to 24 and mandating that state hospitals take patients under those orders when another bed cannot be found. It must be reconciled with House legislation that calls for an eight-hour custody period. Both chambers would boost spending on mental health support.
Behavioral Health and Developmental Services “agreed with the former inspector general that it is a serious concern if even one person in a mental health crisis cannot locate and receive the services that are needed,” department spokeswoman Maria Reppas said in a statement. “The funds provided by the Governor and included in the House and Senate budgets will help meet the need.”
Since the 2012 inspector general’s report, she said, the agency has been working with local services providers and public and private hospitals to address the concerns Bevelacqua raised.
Bevelacqua said in this letter that he had spoken to Deeds and saw his legislation as “consistent with the findings and recommendations in the Critical Incident Report as it was originally drafted.”
In a statement, McAuliffe spokesman Brian Coy said: “The Governor is committed to reforming our mental health system so that it works to keep all Virginians healthy and safe. He thanks Mr. Bevelacqua for his service to the Commonwealth and will review the content of his letter.”