Virginia State Sen. R. Creigh Deeds. (Matt McClain/The Washington Post)

Virginia should dismantle its mental-health system and replace it with one that serves Virginians who are sick rather than the bureaucrats who should be helping them.

From 2010 to 2014, I served as Virginia’s inspector general for behavioral health and developmental services, which required me to cast a critical eye on the state’s mental-health services and recommend changes to improve the commonwealth’s system of care. I found a complex, dysfunctional and ineffective bureaucracy that was system-centered instead of person-centered. I found an ineffective bureaucracy that privileged the status quo over the people it should be serving.

There is no better example of the state’s inertia and ineptitude than the death of Austin “Gus” Deeds , the son of Virginia state Sen. R. Creigh Deeds (D-Bath).

On Nov. 18, 2013, Gus Deeds was examined by a state-certified evaluator, employed by the Rockbridge Area Community Services Board, where he was determined to be mentally ill and likely to cause serious physical harm to himself or others in the near future. Pursuant to the controlling statutes, he required involuntary hospitalization and treatment. The evaluator could not locate a facility willing to admit Gus Deeds within the six-hour time limit, so he was sent home with his father and a verbal safety plan. The next day, Gus Deeds attacked and seriously injured his father before ending his own life.

Two and a half years earlier, in a semiannual report, my office alerted the Department of Behavioral Health and Developmental Services, the Health and Human Resources secretary, the community services board system (which delivers health care in every city and county), the governor’s office, the General Assembly and the private hospital providers and advocacy groups that individuals with mental illnesses were being turned away from hospitals because of a lack of beds, even though they had been determined to be a danger to themselves and others.

The slang term for this practice was “streeting.” Gus Deeds was “streeted” on Nov. 18, 2013.

In February 2012, after a 90-day statewide study, my office issued a report documenting that scores of Virginians had been “streeted” during a three-month period. My office warned, “Each incident [of streeting] . . . represents a failure of the system to address the needs of that individual and places the individual, his family, and the community at risk.”

The 2012 report included no-cost recommendations that would have prevented “streeting.” The Department of Behavioral Health and Developmental Services endorsed the report’s findings and recommendations, but in the months following, no one took steps to end “streeting.”

It was only after Gus Deeds’s death that the department acted. Within days, it issued a transparently misleading “update” intended to convey that it had been working on the 2012 recommendations all along. In reality, it had failed to take meaningful action for almost two years. Weeks later, in January 2014, it issued its “guidance” requiring the community services boards to implement the 2012 recommendations. Those changes were in place by March 2014 — fewer than four months after Gus Deeds was streeted.

Simply put, in four months, the department implemented reforms that it had failed to enact during the 21 months preceding Gus Deeds’s death.

The state’s bureaucracy, with a centralized state Department of Behavioral Health and Developmental Services overseeing local community services boards, has resulted in an unaccountable but politically powerful state and local partnership that focuses on self-perpetuation instead of the people it is charged to serve.

We can only hope and pray that the Joint Subcommittee to Study Mental Health Services in the Twenty-First Century, chaired by Creigh Deeds, will create a truly person-centered structure that will serve our mentally ill family members and neighbors in the 21st century.

The writer was Virginia’s inspector general for behavioral health and developmental services from 2010 to 2014.