A jet crashes. People die. A whistleblower reveals that airline officials were warned two years earlier about a fatal flaw in the engine that caused the crash but executives ignored those warnings.
How would the public react?
The Virginia Office of Inspector General issued a damning report in 2012 about “streeting” — emergency rooms turning away patients because there were no psychiatric beds available even though the patients were in the midst of a mental crisis. The author of that report, G. Douglas Bevelacqua, warned the state’s Department of Behavioral Health and Developmental Services that Virginia had a bed shortage problem that needed to be fixed.
No one listened.
On November 18, 2013, state Senator Creigh Deeds sought psychiatric help for his adult son, Gus, but was turned away because there were no local psychiatric beds available. Tragically, Gus attacked his father and then killed himself.
Rather than acknowledging they had failed to act earlier, state mental health officials issued a self-serving report on December 4, 2013 that made it sound as if they had paid attention to Bevelacqua’s findings, but simply hadn’t been able to implement his recommendations in time to prevent the Deeds’ tragedy.
At that point, the state legislature took matters into its own hands and passed legislation that, when implemented, will end streeting.
What happened next?
Bevelacqua resigned in protest, claiming his boss was watering down an investigation of how state mental health officials had bungled the entire “streeting” mess. Yesterday, State Inspector General Michael F.A. Morehart finally released the report that Bevelacqua had refused to sign.
It mentioned all of the dots — how could it not? — but failed to connect them. Instead, Morehart did exactly what Bevelacqua had predicted. His report didn’t take anyone to task for their failure to address “streeting” before Senator Deeds walked through the door seeking help for his son.
The result: Gus Deeds is dead, his family is devastated, whistleblower Bevelacqua is out of the IG’s office and it’s business as usual at the state mental health department.
All of us with a loved one, who has a mental illness, have been forced to deal with an unresponsive bureaucratic system. When that happens, there’s never anyone to blame. It’s policy. There’s no money. Or it’s simply “them” — some faceless group that is standing in the way.
A system that is broken will never change unless the public servants running it take responsibility for their actions and are held accountable for mistakes. That’s always the first step to reforms. I’m not looking for blood. People are human. Errors are inevitable. A simple “I’m sorry” and “we’ll fix it” would do.
That hasn’t happened here. The mere fact that it took the state legislature to intervene and do what the state mental health department should have done nearly two years ago should be enough for Virginia Governor Terry McAuliffe to question the leadership at the mental health department.
The toothless report that IG Morehart released yesterday also should cause McAuliffe to wonder if a change needs to be made there too.