RICHMOND, Va. (WRIC) — An audit found several issues with how the state agency responsible for the care of vulnerable, mentally ill Virginians admits those patients into its facilities — and local experts are saying change is happening far too slowly.
Law enforcement leaders, civil rights attorneys, disability advocates and state lawmakers are all sharing concerns about how long the Virginia Department of Behavioral Health and Developmental Services (DBHDS) has to fix the problems found by state auditors.
In April, the Office of the State Inspector General (OSIG) looked at DBHDS procedures for admitting forensic patients, which includes people who have been court-ordered to a state facility to move forward with criminal cases.
OSIG found these policies were “inconsistent,” with custody transfer “not clearly defined.” That means when patients in the custody of law enforcement are transferred to DBHDS facilities, it’s unclear at what point hospital staff is in charge — and is wholly in charge of care for — the patient instead of local officers, deputies or corrections staff. This leads to unclear accountability.
While no concerning incidents happened during the time of OSIG’s investigation, the audit listed several recommendations to guard against future events.
Under the audit’s action plan, DBHDS committed to making five changes between March 30 and June 30, 2027. That’s not soon enough, according to some of the experts who spoke with 8News about this matter.
“The fact that the Department of Behavioral Health says that they intend to come up with some policies more than a year from now is … it’s really kind of tragic,” said Colleen Miller, executive director of the Disability Law Center of Virginia (dLCV).
DBHDS didn’t respond to most of 8News’ multiple attempts to request an on-camera interview. But Miller’s concerns were echoed by the author of the bill that mandated OSIG’s investigation of DBHDS admission procedures: Sen. Russet Perry (D-Loudoun County).
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“Part of the issue here is if something were to happen in that period of time, right?” Perry said during a Zoom call. “It creates all kinds of liability concerns, right? And all kinds of questions about who’s responsible, right?”
Perry said her experience as a prosecutor who helped stand up the mental health docket in Loudoun County led her to take a closer look at this issue.
In Virginia, behavioral health dockets help divert plaintiffs with serious mental illnesses, substance use disorders or both away from traditional incarceration. Instead, they receive supervised and typically community-based treatment.
Although Perry’s perspective came from her work in Loudoun, the problem exists throughout the state’s mental health system.
The state’s failures have had deadly consequences
8News has reported extensively on the lack of clear custody transfer policies since the high-profile deaths of two schizoaffective Central Virginia men in 2023.
The broader custody issue was highlighted at a local hospital, where a temporary detention order (TDO) should’ve legally mandated that 34-year-old Charles Byers receive 72-hour help.
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Instead, his family’s attorney says Byers ended up in a Richmond jail, was released despite the TDO and then left to wander barefoot 14 miles towards his parents’ Chesterfield County home. Confused and disoriented, he never arrived, instead spending about 36 hours searching for the home and ending up in another Chesterfield neighborhood.
A 911 call from one of those neighbors led to Chesterfield officers finding Byers in the throes of crisis. One of those officers ultimately shot and killed Byers in a series of events that has been in dispute ever since, despite the release of body camera video. The entire interaction lasted about 90 seconds.
Just months before that, Irvo Otieno died during his admissions process into a DBHDS facility after spending the weekend in a Henrico County jail, with his mental health deteriorating.
He, too, had been granted a TDO while at the very first hospital before ending up instead inside a jail cell. And he, too, ended up dead after 10 sheriff’s deputies and hospital workers laid on top of him in a Central State Hospital admissions room.
Expert says issues have been ‘really obvious’ for some time
The case of Byers — and doubly so, Otieno — highlighted how unclear this delineation was among multiple staff.
“When does that transfer occur?” asked Perry, noting the key questions clear policies would resolve. “Who’s responsible? And is everyone clear about what that process is to make sure that it — that we’re taking care of folks?”
While recent legislation clarified this division of custody at private hospitals, according to the OSIG audit, law enforcement and DBHDS facilities still don’t have clear answers to those questions.
“This is not a new thing,” Miller said. “We’re really grateful to the Office of the Inspector General for doing this report … but this was a finding that was really obvious three years ago, when Mr. Otieno was killed. One would hope that they would have started developing those consistent policies immediately after Mr. Otieno’s death, if not sooner.”
The report also reveals that not all hospitals have dedicated, recorded intake spaces.
“Things like cameras and safe intake procedures do something to protect everyone who is there,” Perry said. “And so I think … we shouldn’t be transferring people in the middle of a parking lot, right? I don’t know who that serves.”
A DBHDS spokesperson initially declined an interview with 8News, citing a lack of scheduling availability. Instead, they emailed a statement saying in part:
“We agree with OSIG’s findings and have already been working to address this through a draft policy regarding transfer of custody from law enforcement. This is one of many issues that has arisen as we have seen a dramatic growth in the number of forensic patients at state hospitals.”
The spokesperson said this uptick is a nationwide problem — something law enforcement experts confirmed to 8News. Now and during previous reporting, law enforcement have shared their frustrations with American society’s dependence on them as both criminal justice and mental health practitioners.
Cunningham noted the particular strain DBHDS faces, with a 77% increase in adult forensic admissions between 2015 and 2025 and over-capacity hospitals which she said “are designed to be the backstop of the entire behavioral health system.”
She said that’s because Virginia’s Bed of Last Resort law requires state hospitals to admit civil, or non criminal justice-related, admissions when no alternative bed is found.
Plus, she said a separate law requires forensic admissions for restoration of competency to stand trial in 10 days or less. All of this pressure on the system she concludes, “ultimately creates a less safe and therapeutic environment for patients and staff.”
However, the spokesperson wasn’t clear about when DBHDS started working on the draft policy and whether the audit prompted that effort. If it didn’t, what about the process requires a year’s time or more to complete? This is a question 8News could not ask DBHDS in an on-camera interview.
Despite communicating subsequent deadline extensions for such an interview, DBHDS spokesperson Lauren Cunningham did not respond to those emails.
While forensic patients are the focus of the audit — which wouldn’t have covered Byers or Otieno — the audit does state DBHDS is committing to standardizing intake procedures for all patients.
In addition to more clearly defining when and where custody transfers from law enforcement to DBHDS and recording all transfers, OSIG also recommended DBHDS get signatures from both parties involved in the custody transfer and provide guidance to facility staff and law enforcement so implementation is consistent across the state.
The experts we spoke with say more clarity will help everyone involved in admissions.
“Sometimes these situations are incredibly complex and difficult,” Perry said. “But I don’t think we do anyone any favors by making the situation vague and by not providing clear guidance.”
You can find all of 8News’ coverage of the Charles Byers case here. You can find all of our coverage of the Irvo Otieno case here.
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