Two Internal Memos Show Virginia Officials Knew Much Earlier Than Reported About “Streeting” But Did Nothing


Two internal memos, not previously made public, show that state mental health officials in Virginia were warned earlier than has been widely reported about “streeting” – the practice of turning people away from hospitals because of a lack of psychiatric beds.

The two in-house warnings were written by then Inspector General G. Douglas Bevelacqua and sent to James A. Stewart, who was serving as Commissioner of the Virginia Department of Behavioral Health and Developmental Services (DBHDS) at the time, and his upper management.  The memos are dated April 14, 2011 and May 12, 2011.

The public first learned about “streeting” from media reports when Bevelacqua issued an IG report on February 28, 2012, specifically about the practice.

These earlier two memos establish a timeline that shows DBHDS officials were aware of “streeting” some 31 months before State Senator Creigh Deeds and his son, Austin “Gus” Deeds were “streeted” with tragic results.

On November 18, 2013, Deeds took his son to a mental health facility operated by the Rockbridge Community Services Board but was told that no local hospital bed for Gus could be found within the necessary time period required by state law. Deeds and his son were sent home where Gus attacked his father with a knife before ending his own life.

In a $6 million wrongful death civil suit filed against the state, Deeds and his attorney cited Bevelacqua’s February 28, 2012 report about “streeting” as evidence that state officials were aware of a lack of hospital beds but didn’t implement recommendations contained in that report that would have curbed the practice and possibly saved Gus Deeds.

The two in-house memos that I am now posting document that state officials were initially warned much earlier by Bevelacqua that a lack of beds was putting the public and individuals with mental disorders at risk. Bevelacqua wrote this dire warning in his April 14, 2011 memo, the first that he sent to Commissioner Stewart.

“The current situation…is a human tragedy waiting to happen and, with each day that passes, the likelihood of a disastrous outcome increases.”

A month later, Bevelacqua sent Stewart a second memo — dated May 12, 2011 — warning the commissioner and his assistant, John Pezzoli, as well as two others in management about the risks of “streeting.”

“The OIG believes that streeting represents a failure of the Commonwealth’s public sector safety net system to serve Virginia’s most vulnerable citizens with serious mental illness and that the practice places these individuals, their families, and the public at-risk. The fact that over 200 individuals, who were evaluated by skilled clinicians and determined to be a danger to themselves or others and lacking the capacity to protect themselves, were denied access to a secure environment for temporary detention and further evaluation, greatly concerns the OIG and this important issue is profiled in our office’s soon to be released Semi-Annual Report.”

Days later, Bevelacqua issued his semi-annual report about the overall state of mental health care in Virginia. A section of that report mentioned that “streeting” was becoming a state-wide problem. That report was delivered to the DBHDS, distributed to the Community Service Boards (which deliver local mental health care services in Virginia) sent to the governor’s office, distributed to members of the general assembly, and other state health agencies.

However, Bevelacqua’s mention of “streeting” was largely overlooked until he issued his February 12, 2012 report specifically about the practice. That report was based on a 90-day statewide study that he’d conducted and it included recommendations that, if implemented, he said would have curbed the problem. It was that report which caught the attention of reporters. Several newspapers and television stations did stories about “streeting.” The Virginia chapter of the  National Alliance on Mental Illness condemned the practice. In response to that media attention, the DBHDS issued a statement supporting Bevelacqua’s recommendations.

It appears that no steps were actually taken to implement those changes.

After the Deeds’ tragedy in November 2013, Bevelacqua launched an investigation of the state’s conduct and submitted a draft of his findings to then Inspector General Michael F. A. Morehart. In that draft report, Bevelacqua concluded that if state officials had heeded his multiple warnings about “streeting” and implemented the recommendations that he’d made  – “it most likely would have produced a different outcome on November 18, 2013” – the day Deeds was attacked and his son ended his own life. He quoted Deeds in his report saying “the system failed that day.”

Bevelacqua also told reporters that “streeting” was still happening in Virginia because the DBHDS still had not taken steps to end the practice.

Morehart objected to Bevelacqua’s conclusion in his draft report and the inclusion of Deeds’ complaint about the state failing Gus Deeds. He ordered Bevelacqua to change his report. Bevelacqua resigned in protest. He told reporters that Morehart had complained that his report was “too emotional,” “incendiary” and “editorialized” as it was written. In his resignation letter to the governor, Bevelacqua wrote that he was convinced that higher-ups in the state government had interfered with his investigation.

Morehart released an edited version of Bevelacqua’s investigation that was much milder than the original. It later was revealed that Morehart had been telephoned by state officials who had complained about Bevelacqua and his investigation while he was conducting it.

After the Deeds’ tragedy, DBHDS officials announced that they had implemented the recommendations that Bevelacqua had included in his February 28, 2012 report. Then Governor Robert McDonnell appointed a special task force in January 2014 to investigate if DBHDS had corrected the problem. That task force was specifically appointed because of Gus Deeds’ death. The DBHDS officials assured panel members that “streeting” was no longer a problem in Virginia. Bevelacqua was the last witness called that day and he repeated his claim that the Deeds tragedy could have and should have been prevented. Testimony from that hearing was posted on line for the public, with one glaring exception. Bevelacqua’s critical testimony was not posted.

Last month, I reported on this blog that Bevelacqua’s February 28, 2012 report that exposed “streeting” based on a 90-day study had been removed from the state IG’s website, making it much more difficult for the public to find and read.

To recap the timeline:

Bevelacqua first warned DBHDS officials on April 14, 2011 that “streeting” was happening. In May 2011, he mentioned “streeting” in his semi-annual report that was widely distributed, but the “streeting” passages were largely overlooked. His office then undertook a 90-day study that led to the February 28, 2012 “streeting” report and recommendations to end the practice. That report was widely reported in the media and the DBHDS announced that it would implement Bevelacqua’s recommendations. On November 18, 2013, Gus Deeds was “streeted.” Bevelacqua resigned in protest, stating that his report about the Deeds case was being “soft-peddled” by Morehart. Shortly after that, the DBHDS assured the public that it had implemented the changes that Bevelacqua had recommended — more than two years earlier. Bevelacqua’s original “streeting” report, meanwhile, was removed from the IG website and his critical testimony was not posted after the task force meeting. 

In his lawsuit, Deeds charges:

“The acts of the Defendants (state mental health officials)…were willful, wanton, shocking, outrageous, and evince a conscious disregard for the safety of others, including but not limited to Gus, and offend generally accepted standards of decency…”

It will be up to a jury to determine if the state acted inappropriately but what is indisputable is that Bevelacqua, while he was Inspector General, sounded numerous warnings dating back to early 2011. Sadly, no one — neither the DBHDS, CSBs, the governor or state assembly — did anything in time to prevent Gus Deeds’ death.

What state officials have done is edit Bevelacqua’s draft report (causing him to resign), remove his original “streeting” report from the Intenet, and not post his critical task force testimony.

About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.