OFFICE OF THE STATE INSPECTOR GENERAL
Report to Governor Terence R. McAuliffe
INVESTIGATION OF CRITICAL INCIDENT
AT HAMPTON ROADS REGIONAL JAIL
April 2016

June W. Jennings, CPA
State Inspector General
Report No. 2016-BHDS-002

COMMONWEALTH OF VIRGINIA
Office of the State Inspector General
June W. Jennings
State Inspector General

Post Office Box 1151
Richmond, Virginia 23218

Telephone (804) 625-3255
Fax (804) 786-2341
www.osig.virginia.gov

April 5, 2016
The Honorable Terence R. McAuliffe
Governor of Virginia
Patrick Henry Building, Third Floor
1111 East Broad Street
Richmond, VA 23219
Dear Governor McAuliffe:
The Office of the State Inspector General (OSIG) performed a review of the August 2015 critical
incident at the Hampton Roads Regional Jail pursuant to Code of Virginia (Code) § 2.2-309.1:
Additional powers and duties; behavioral health and developmental services. The objectives of
this review were to: examine the sequence of events surrounding the death of an individual in the
Hampton Roads Regional Jail (HRRJ); review processes in place related to referral and
admission of HRRJ inmates to Eastern State Hospital (ESH); review the Department of
Behavioral Health and Developmental Services (DBHDS) Office of Internal Audit Investigation
Report released March 16, 2016; identify potential risk points; and make recommendations for
systemic improvement in order to prevent similar events in the future.
On behalf of OSIG, I would like to express our appreciation for the assistance of multiple
agencies and facilities including, but not limited to, Hampton Roads Regional Jail, Eastern State
Hospital, and Portsmouth Department of Behavioral Healthcare Services. If you have any
questions, please call me at (804) 625-3255 or email me at osig@osig.virginia.gov. I am also
available to meet with you in person to discuss this report.

Respectfully,

June Jennings, CPA
State Inspector General
CC:

Paul Reagan, Chief of Staff to Governor McAuliffe
Suzette Denslow, Deputy Chief of Staff to Governor McAuliffe
Dr. William A. Hazel Jr., Secretary of Health and Human Resources
Brian Moran, Secretary of Public Safety and Homeland Security
Members, Virginia Joint Commission on Health Care
Jack Barber, M.D., Interim Commissioner, Department of Behavioral Health and Developmental Services
Kathy Drumwright, Chief Deputy Commissioner, Department of Behavioral Health and Developmental
Services
Jennifer Faison, Executive Director, Virginia Association of Community Services Boards
Colonel David Simons, Superintendent, Hampton Roads Regional Jail
Dr. Curtis Edmonds, Chairman, Hampton Roads Regional Jail Board
Colleen Miller, Executive Director, disAbility Law Center of Virginia
Mira Signer, Executive Director, National Alliance on Mental Illness Virginia

TABLE OF CONTENTS
Executive Summary ............................................................................................................................................ i
Purpose and Scope of the Review ................................................................................................................... 1
Background ......................................................................................................................................................... 2
Mental Illness in Virginia Jails ..................................................................................................................... 2
Crisis Intervention Teams and Assessment Centers ................................................................................ 3
Jail Diversion .................................................................................................................................................. 3
DBHDS .......................................................................................................................................................... 3
Virginia Cross Systems Mapping................................................................................................................. 4
Eastern State Hospital .................................................................................................................................. 5
Jail Transfer Process ..................................................................................................................................... 5
HRRJ ............................................................................................................................................................... 5
PDBHS ........................................................................................................................................................... 6
OSIG ............................................................................................................................................................... 6
Review Methodology ......................................................................................................................................... 8
Review Results.................................................................................................................................................... 9
Observation No. 1 .................................................................................................................................... 9
Observation No. 2 ..................................................................................................................................11
Observation No. 3 ..................................................................................................................................12
Observation No. 4 ..................................................................................................................................12
Observation No. 5 ..................................................................................................................................15

Executive Summary
On August 24, 2015, the Office of the State Inspector General (OSIG) received a complaint
regarding the death of an individual at Hampton Roads Regional Jail (HRRJ). The original
complainant was a family member of the individual who was found dead in a jail cell on August
19, 2015, while awaiting transfer to Eastern State Hospital (ESH) in Williamsburg. The relative
reported the individual had been in custody since April 2015. The individual was also reported to
have lost a significant amount of weight in the four months spent in the jail, and the relative
suspected the death was related to the individual refusing to eat.
OSIG conducted a review of the sequence of events surrounding the death of the individual in
HRRJ, the processes in place related to referral and admission of HRRJ inmates to ESH, and the
Department of Behavioral Health and Developmental Services (DBHDS) Office of Internal
Audit Investigation Report released March 16, 2016, to identify potential risk points and make
recommendations for systemic improvement in order to prevent similar events in the future. The
review of this event involved multiple agencies and facilities including DBHDS, ESH, HRRJ,
Portsmouth Department of Behavioral Healthcare Services (PDBHS), Portsmouth General
District Court, NaphCare Inc., and Bon Secours Maryview Medical Center.
The scope of this review was not to evaluate the medical care provided in HRRJ, nor to repeat
every element of prior investigations related to this event. Select information related to the
clinical care and treatment of this individual was reviewed to identify additional areas for future
review.
The following observations were identified during the course of the review:
• The current process of transferring inmates from HRRJ to ESH has multiple, significant
risk points. In the absence of written and agreed upon protocols with responsible parties,
timelines, and monitoring systems in place, the root causes of the significant event in
HRRJ remain at risk for recurrence. For each step in the process, there must be a way to
consistently substantiate completion, and each of the identified risk points must be
addressed fully. DBHDS has facilitated regional admission and discharge protocols but
none exist for management of this vulnerable population.
• ESH has experienced a significant increase in its operational burden since the
implementation of the safety net law of 2014. The impact has been felt by multiple
departments, including the admissions office, which prior to this event, had not modified
its admissions process accordingly. While the structure of the admissions office and
communication were revised following this event, the process for developing and
ensuring the accuracy of the Jail Transfer Waiting List, also known as the Forensic Log,
or for facilitating regional ownership has not. As the maintenance and accuracy of this
document has been found to be one of the root causes of the significant event at HRRJ,
Executive Summary

i

•

•

•

the accuracy and management of the list is critical to preventing similar events in the
future.
DBHDS has convened or participated in numerous workgroups, committees, and subcommittees in the past several years centering on improving services for individuals with
mental illness who encounter the justice system. All of these, including the DBHDS
Transformation Team for the Justice Involved, have resulted in recommendations for
additional funding, ongoing committee work, oversight, training, and system re-design.
The DBHDS Office of Internal Audit Investigation Report’s two conclusions and two
recommendations did not include a review of all potential root causes.
o Although the first conclusion — that the ESH Jail Transfer Waiting List never
contained the information related to the Competency Restoration Order
(CRO) for the individual in question — is accurate and was substantiated by
OSIG, the resulting recommendation does not address the root cause of the
event. Educating the sole mailroom clerk and anyone who receives mail
related to admissions does not correct or suggest a revision to the process that
would ensure root cause(s) are addressed. Stating that admissions staff are to
log court orders as received was the existing process when court orders were
placed in an ESH desk drawer and remained there for weeks.
o The second conclusion — that PDBHS staff never completed the required
evaluation of the individual requested by HRRJ — is also accurate. However,
recommending that DBHDS develop guidelines relating to court orders has no
connection to that lapse in responsibility. The report recommends no process
change to the Portsmouth agency to ensure they meet their Code requirements
for emergency evaluations when requested. The last portion of that
recommendation— that DBHDS explore the feasibility of a single point of
entry for court orders — may address a process change but the connection to
the events is not entirely clear to the reader. The report also contains no
recommendations regarding the issues surrounding Crisis Intervention Teams
(CIT) and jail diversion.
HRRJ has a direct responsibility to provide quality medical and mental health care for
those in their custody. Although NaphCare is no longer the contract agency providing
medical and mental health services at HRRJ, a change in provider offers limited promise
of improvement in care or documentation in the absence of a change in oversight
practices. Review of NaphCare records raised significant concerns regarding the quality
of assessment, care, follow-up, and documentation. It is those professionals trained and
licensed to provide clinical care who have a duty to provide that care, and the agency that
contracts with the provider is responsible for ensuring that care is provided.

Upon completion of the review, OSIG makes the following recommendations:
• Observation #1 Recommendation

Executive Summary

ii

DBHDS should take the lead on development of a regional protocol relevant to the
management of individuals in HRRJ with mental illness, working together with HRRJ,
local police departments, ESH, PDBHS, and the Health Planning Region (HPR) V
Reinvestment Project Office. The focus of the agreement should include but not be
limited to:
o Cross Systems Mapping Sequential Intercepts (including re-mapping)
o Crisis Intervention Teams (CIT)
o Jail Diversion
o Court Orders
o ESH admissions and discharges
o Mental health contact in HRRJ by PDBHS and other HPR V CSBs, and ESH staff
The regional protocol should include clearly identified responsible parties, timelines, and
process flows. All five intercepts identified in regional Cross Systems Mapping efforts
should be included, and the protocol should address gaps and opportunities for
improvement. DBHDS should consider the applicability to regions across the state.
•

Observation #2 Recommendation
ESH should revise the process for the development, management, and oversight of the
Jail Transfer Waiting List. A system for consistently reviewing the individuals on the list
should be created and include the courts, CSBs, HPR V Reinvestment Project Office
through the Facilities Management Committee (FMC), and HRRJ.

•

Observation #3 Recommendation
The recommendations of DBHDS’s Transformation Team for the Justice Involved were
substantive and — had they been implemented at an earlier time — would have had a
significant impact on the justice-involved individuals with mental illnesses. This situation
should be considered urgent and implementation plans developed immediately.

•

Observation #4 Recommendation
DBHDS’s investigations of critical events should be conducted independently by
professionals trained and experienced in conducting healthcare root cause analyses and
who have experience working in the behavioral health system(s) in question. Reports
should include all relevant risk points and analysis of root causes with specific
recommendations targeting those root causes.

•

Observation #5 Recommendation
HRRJ should revise the process for overseeing the quality and outcomes of any contract
agency that provides medical and mental health care in their jail. This process should
ensure regular monitoring, direct oversight, and direct feedback and correction for areas
of concern.

Executive Summary

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OFFICE OF THE STATE INSPECTOR GENERAL
INVESTIGATION OF CRITICAL INCIDENT AT HAMPTON ROADS REGIONAL JAIL

Purpose and Scope of the Review
OSIG performed a review of a complaint regarding a significant event at Hampton Roads
Regional Jail (HRRJ) pursuant to Code of Virginia (Code) § 2.2-309.1: Additional powers and
duties; behavioral health and developmental services. The original complainant was a family
member of the individual who was found dead in a jail cell on August 19, 2015, while awaiting
transfer to Eastern State Hospital (ESH) in Williamsburg. The relative reported the individual
had been in custody since April 2015. The individual was also reported to have lost a significant
amount of weight in the four months spent in the jail, and the relative suspected the death was
related to the individual refusing to eat.
The objectives of this review were to examine the sequence of events surrounding the death of
this individual, the processes in place related to referral and admission of HRRJ inmates to ESH,
as well as the DBHDS Office of Internal Audit Investigation Report to identify potential risk
points, and make recommendations for systemic improvement in order to prevent similar events
in the future. The scope of this review was not to evaluate the medical care provided in HRRJ,
nor to repeat every element of prior investigations related to this event. Select information
related to the clinical care and treatment of this individual was reviewed to identify additional
areas for future review.

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INVESTIGATION OF CRITICAL INCIDENT AT HAMPTON ROADS REGIONAL JAIL

Background
Mental Illness in Virginia Jails
The Virginia State Compensation Board’s annual report on Mental Illness in Jails was released
November 1, 2015. Although there are limitations to the data, including the fact that it is a
snapshot survey and contains self-reported and unverified data, it is the only current source for
data on mental illness in the jails. The 2015 report states that there are 3,303 inmates (13.2
percent of the average daily jail population) with a serious mental illness (SMI) defined as
schizophrenia, schizoaffective disorder, delusional disorder, bipolar disorder, major depression,
and post-traumatic stress disorder. According to the Compensation Board Report, in 2015 jails
reported the highest percentage of both male and female inmates with mental illness in the four
years shown.
Percentage of Female/Male
General Population with Mental Illness
(Using Inmate Counts)
Year
Female
Male
2015
25.29%
13.63%
2014
20.87%
12.43%
2013
16.13%
12.64%
2012
14.40%
10.35%
Source: 2015 Compensation Board Report

In 2015, 10 out of the 60 local and regional jails and jail farms in Virginia accounted for 52
percent of the SMI population in jails, and HRRJ was second only to Riverside Regional Jail in
the number of inmates with an identified SMI. Forty-nine percent of inmates with SMI in all jails
were incarcerated for non-violent crimes. This was the case of the individual who died in HRRJ.
Although one-third of jails, including HRRJ, operate mental health units, inmates are frequently
held in segregation for either their own or others’ protection. More than two-thirds of Virginia’s
jail mental health beds are located in eight jails, three of which are located in the Tidewater
region (HRRJ, Chesapeake Jail, and Virginia Beach Jail). Those inmates not held in a mental
health bed or segregation are housed with the general jail population.
CSBs currently have no statutory requirement to provide treatment in jails, so, many do not
unless resources are provided by localities. According to the Compensation Board Report, the
greatest percentages (44 percent) of mental health services in jails are provided by private
contractors. According to the Compensation Board Report, CSBs provide 35 percent of jailbased treatment. CSB staff performing emergency evaluations in jails are the same emergency
services professionals that respond to community emergencies and have been significantly
impacted following the implementation of the 2014 changes to the civil commitment laws.

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OFFICE OF THE STATE INSPECTOR GENERAL
INVESTIGATION OF CRITICAL INCIDENT AT HAMPTON ROADS REGIONAL JAIL

Crisis Intervention Teams and Assessment Centers
The CIT model was originally developed by the Memphis, Tennessee, Police Department, and
has subsequently spread throughout the country as a recognized best practice. The CIT model
includes programs designed to improve responses to individuals experiencing behavioral health
crises who come into contact with law enforcement first responders. Virginia’s civil commitment
laws have made it such that law enforcement officers have consistent and prolonged exposure to
individuals in mental health crisis and are often the individual’s first contact during a crisis. The
40-hour CIT training enables law enforcement and others who participate in the training to better
understand individuals suffering with mental health issues, to communicate more effectively
with those individuals, to develop more effective ways to de-escalate crisis situations, and,
possibly, connect individuals with needed treatment, in lieu of incarceration.
Virginia’s first CIT was developed in the New River Valley area. In 2009, the Virginia General
Assembly acted to support the establishment of CIT programs in areas throughout Virginia. As
of August 2015, Virginia had 26 CIT programs at various levels of operation, with an additional
11 programs in planning or development stages. Essential to the CIT concept is the partnership
between law enforcement, mental health providers, and the community.

Jail Diversion
Beginning in 2007, the Virginia General Assembly approved funding to support efforts to divert
those with mental illnesses away from unnecessary incarceration by way of jail diversion
programs. Jail diversion programs are designed to identify individuals with serious mental
illnesses and co-occurring disorders early in the process, divert them from the criminal justice
system either pre- or post-arrest, and connect them with treatment in lieu of incarceration. Select
CSBs received funding to provide this program, while others have elected to do this without
additional funding.

DBHDS
DBHDS operates seven adult behavioral health facilities including Eastern State Hospital in
Williamsburg. The DBHDS Office of Forensic Services serves individuals involved in the court
system and supports programs that provide screening and evaluations, treatment of individuals
with mental illness in jail, case management, and restoration to competency to stand trial. In
addition, the division focuses on providing services and supports to individuals at risk for
involvement in the criminal justice system.
In the past several years, DBHDS has been involved in numerous initiatives focused on
individuals with behavioral health issues who become involved with the judicial system. In 2014,
then-Commissioner Debra Ferguson, Ph.D., convened several Transformation Teams, whose
mission was to make recommendations to DBHDS for system-wide improvement. One of these
teams was specifically focused on justice-involved individuals. To date, these recommendations

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have not resulted in legislative action or system changes. A summary of recommendations made
by this team in spring and fall 2015 is listed below:
• Develop mechanisms for notification and ongoing communication between jails,
detention centers, correctional facilities, and CSBs to allow for a more seamless transition
between incarceration and the community, and, when unavoidable, from community to
incarceration.
• Implement a standardized system for prompt screening, assessment, and identification of
behavioral health (BH) and intellectual and developmental disability (ID/DD) issues, in
every jail, detention center, and correctional facility.
• Set standards requiring jails, detention centers, and correctional facilities to have a certain
percentage of their staff who have received advanced training in BH and ID/DD issues
(to include identifying individuals with BH/ID/DD issues, responding therapeutically to
individuals with BH/ID/DD issues, and responding to individuals in crisis).
• Increase capacity of jails, detention centers, and correctional facilities to provide a
minimum standard of BH services (comparable to outpatient level).
• In order to promote quality, access, and continuity of care it would be best if CSBs were
the designated provider of services for this population.
• Regardless of who is providing BH services in the jail, each CSB should have at least one
staff member whose primary responsibility is to coordinate planning for individuals being
released from jail and needing follow-up services from the CSB. The Virginia General
Assembly should fund the creation of these positions.
• Ongoing case management services throughout the period of incarceration or detention:
o Each CSB should maintain an open case for this population.
o For those not previously opened to the CSB, a case should be opened.
o Frequency/duration of case management will be dependent on an individual’s needs.
o Caseloads will be determined by acuity of clients served; however, every CSB
should have at least one designated staff member whose primary responsibility is
case management for those involved in the criminal justice system.
• Prompt access to inpatient psychiatric care (either at a DBHDS facility or a designated
facility) when the need arises.

Virginia Cross Systems Mapping
In 2008, then-Governor Timothy Kaine issued Executive Order 62 establishing the
Commonwealth Consortium for Mental Health and Criminal Justice Transformation. One of the
key programs that resulted from that Executive Order was the Cross Systems Mapping initiative.
The primary objectives of Cross Systems Mapping are as follows:
1. To develop a comprehensive map of how individuals with mental illness and cooccurring disorders flow through the criminal justice system along five distinct intercept
points:
a) Law enforcement and emergency services;
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OFFICE OF THE STATE INSPECTOR GENERAL
INVESTIGATION OF CRITICAL INCIDENT AT HAMPTON ROADS REGIONAL JAIL

b) Booking and initial detention/initial court hearings;
c) Jails and courts;
d) Re-entry from jails and prisons; and
e) Community corrections/community support.
2. To identify gaps, resources, and opportunities at each intercept for individuals in the
target population.
3. To develop a list of priorities and action steps designed to improve system and servicelevel responses for individuals in the target population.
The Cross Systems Mapping for Portsmouth was completed in April 2011. The progress on any
action plans was not evaluated as a part of this review. Since that time, DBHDS has assisted
several localities in updating their maps. The re-mapping program is voluntary and, although
PDBHS has expressed an interest, they have not completed a re-mapping as of March 2016.

Eastern State Hospital
ESH is a DBHDS-operated facility with an operational bed capacity of 304. That number does
not account for the closure of the five-bed acute hospital unit nor the beds taken offline several
years ago to support a programming revision.

Jail Transfer Process
Individuals in jails may be transferred to ESH for evaluation and treatment in one of two ways.
Individuals may be court ordered by a judge to ESH, as was the case with the individual who
died at HRRJ, or they may be admitted to ESH under a Temporary Detention Order (TDO) after
being evaluated by a CSB emergency services worker. At the time an individual receives a TDO
they are subject to the same laws as any individual in the community with the exception of
instances when a facility is not available as stated in Code § 37.2-81.

HRRJ
Regional jails, such as HRRJ, provide jail space to multiple localities, which may or may not
operate local jails in their own localities. They are administered by a superintendent, who serves
the regional jail board or jail authority. The Board of Corrections sets standards for
administration and operation of jails among other responsibilities, and the Department of
Corrections monitors jails’ compliance with those standards. HRRJ has a high population of
inmates with mental health and medical issues compared to other jails. The participating
jurisdictions send many of their inmates with severe mental health or medical issues to HRRJ,
which maintains a mental health pod and medical pod with 24-hour on-site nursing staff.
In August 2015, NaphCare was the contractor responsible for providing medical and mental
health care at HRRJ. Naphcare, based in Birmingham, Alabama, employs more than 1,000
medical professionals nationwide. The company provides on-site comprehensive care, dialysis,

Background

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OFFICE OF THE STATE INSPECTOR GENERAL
INVESTIGATION OF CRITICAL INCIDENT AT HAMPTON ROADS REGIONAL JAIL

electronic health records implementation and support, and off-site management services to
clients in 28 states, including the Federal Bureau of Prisons; the Departments of Corrections for
New York, Oklahoma, and Oregon; and the Virginia cities of Richmond and Virginia Beach.
NaphCare no longer holds the contract to provide medical care at HRRJ.

PDBHS
According to the PDBHS website, “DBHS gives precedence to the following Priority
Populations (sic) with intellectual disabilities, mental health and/or substance use disorder;
pregnant females, intravenous (IV) drug users; HIV+, and individuals who are experiencing a
mental health crisis, have been discharged from a psychiatric hospital or state training facility,
and/or diverted from a psychiatric hospital or jail. Individuals are assessed and triaged within 24
hours of contact with the agency.” As HRRJ employs a contractor to provide medical care,
including mental health services, PDBHS does not provide mental health services in the jail
except on occasions when PDBHS is called to complete an emergency evaluation.
PDBHS began receiving funding for its jail diversion program in 2008. PDBHS also supports a
CIT assessment center that was established in partnership with Chesapeake Integrated
Behavioral Healthcare Services, local law enforcement, and a local medical center. Funding also
supports one full-time position to provide pre- and post-booking services for individuals
currently in jail identified as having symptoms of mental illness, and are charged with minor,
non-violent crimes.
CSBs, including PDBHS, often consider themselves “out of the process” if an individual, even
those known to the CSBs, is in a local or regional jail, as the individual is deemed to be “in a safe
environment.” A November 2015 report to the House Appropriations Committee titled Overview
of Mentally Ill in Local and Regional Jails states:
“Individuals held in jails are deemed to be in a safer environment than referrals from
community, so are lower admission priority for DBHDS … In June of 2015, Jails
reported that 77 inmates were waiting for transfer to state mental health facility [sic]
more than 72 hours after TDO issued.”
This mindset is in conflict with the fact the jails are not currently considered to be an appropriate
or “safe” setting for treating the mentally ill. If jails are to be providing quality behavioral health
services to inmates, funding and operations must support that intent and not leave the jails to
simply absorb and house an increasing mental health population.

OSIG
In January 2014, OSIG released a report entitled A Review of Mental Health Services in Local
and Regional Jails. Several recommendations remain relevant to the focus of this review
including:

Background

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OFFICE OF THE STATE INSPECTOR GENERAL
INVESTIGATION OF CRITICAL INCIDENT AT HAMPTON ROADS REGIONAL JAIL

•

“CSBs and local jails should develop written and joint agreements among affected CSBs
when individuals with mental illness are in regional jails. At a minimum, these
agreements should address:
o The timely exchange of information at point of entry and release.
o The capacity for CSBs to provide onsite engagement with individuals identified as
current consumers or likely to need CSB community follow-up on release.
o Transition procedures for individuals who are actively receiving mental health
treatment at release.
o Pre-admission screening roles and responsibilities, including time limits for
responding to jail requests.”

Background

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OFFICE OF THE STATE INSPECTOR GENERAL
INVESTIGATION OF CRITICAL INCIDENT AT HAMPTON ROADS REGIONAL JAIL

Review Methodology
This review was conducted in compliance with the Association of Inspectors General Principles
and Standards for Offices of Inspector General: Quality Standards for Inspections, Evaluations,
and Reviews (May 2014). In preparation for this review, OSIG utilized the following documents
as part of conducting extensive background research into the events preceding and following the
death of the inmate at HRRJ:
• HRRJ documents
• NaphCare documents;
• Maryview Medical Center documents;
• ESH documents and policies;
• State Compensation Board Report (2015);
• Numerous reports from DBHDS and members of the General Assembly; and
• DBHDS Office of Internal Audit Investigation Report.
Interviews were conducted with:
• Hampton Roads Regional Jail staff;
• Portsmouth Department of Behavioral Health Services staff ;
• Eastern State Hospital staff;
• NaphCare staff;
• Virginia Community Services Boards Association (VACSB) leadership;
• DBHDS staff;
• Virginia Deputy Secretary of Public Safety and Homeland Security;
• HPR V Reinvestment Project Director; and
• Hampton Newport News CSB (current) Executive Director.

Review Methodology

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INVESTIGATION OF CRITICAL INCIDENT AT HAMPTON ROADS REGIONAL JAIL

Review Results
Observation No. 1
In reviewing the process for jail transfers to ESH, OSIG identified multiple decision points, risk
points, and opportunities for variation in the process, all of which have the potential to create
risks through which unanticipated and egregious outcomes may occur. In summary, the entities
involved include the following in order of occurrence:
1. Portsmouth Police Department
2. Portsmouth CIT
3. HRRJ, which includes NaphCare
4. PDBHS-Jail Diversion
5. Portsmouth General District Court
6. ESH
7. Bon Secours Maryview Medical Center
8. PDBHS-Emergency Services
The following is a list of decision points that create the potential for variation in decision-making
and outcomes, thus creating risk for individuals. OSIG also found no evidence of the existence of
any standards, protocols, decision trees, or required time frames, or that monitoring had been
established for these decision points at the time of the HRRJ death.
1. Decision Point 1 — At the time of the alleged crime, the determination is made whether
or not to engage the local CIT and assessment center. This may be impacted by
availability of CIT trained personnel and assessment center availability.
2. Decision Point 2 — Once in jail, a decision is made whether or not to bond out an
individual who does not appear to have a mental illness and has committed a minor or
non-violent offense.
3. Decision Point 3 — If not bonded out, an individual with a suspected mental illness may
receive an evaluation by the local CSB with one of the following possible outcomes:
• The individual may be placed under a TDO, if it is determined an inpatient bed is
needed urgently;
• Recommend to the court that the individual should be transferred to ESH at some
time in the future; or
• The individual remains in the jail and receives treatment there. Note: It is not clear
why this individual was permitted to decline jail diversion and that this decision
did not call into question the individual’s competency to be able to make that
decision.
4. Decision Point 4 — Following the evaluation by the local CSB — and dependent upon
the evaluator’s recommendations — the court makes the decision whether or not to issue
a Restoration to Competency Order (RCO).

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5. Decision Point 5 — If a RCO is written, the court determines the manner by which to
communicate the order to ESH including U.S. Postal Service, email, or fax. No
confirmation of receipt was required in the case of the individual who died at HRRJ.
There have also been occasions when the order has been sent to DBHDS Central Office
before or in lieu of being sent directly to ESH.
6. Decision Point 6 — Once ESH receives the RCO, the decision is made by individual
ESH staff regarding how much and when to obtain collateral information from the jail
and to schedule admission. ESH also established a process in 2011 allowing staff to
bypass the policy to obtain collateral information and decide to admit individuals with
significant symptoms if the individuals were arrested for minor or non-violent crimes.
(That exception was not exercised in this instance.)
7. Decision Point 7 — In the case of the individual who died at HRRJ, and with other
inmates, the jail staff may decide during the course of the inmate’s stay that the
individual meets the criteria for an emergency evaluation and probable TDO. Currently
there is no process in place regarding timelines for completion, communication,
responsible parties, or follow-up.
In the absence of written and agreed upon protocols with responsible parties, timelines,
and monitoring systems in place, the root causes of the death of the inmate in HRRJ
remain at risk for recurrence. For each step in the process, there must be a way to
consistently substantiate completion, and each of the identified risk points must be
addressed fully. DBHDS has facilitated regional admission and discharge protocols but
none exist for management of this vulnerable population.
Observation No. 1 Recommendation
DBHDS should take the lead on development of a regional protocol relevant to the
management of individuals in HRRJ with mental illness, working together with HRRJ,
Local Police Departments, ESH, PDBHS, and the HPR V Reinvestment Project Office.
The focus of the agreement should include but not be limited to:
o Cross Systems Mapping Sequential Intercepts (including re-mapping)
o Crisis Intervention Teams (CIT)
o Jail Diversion
o Court Orders
o ESH admissions and discharges
o Mental health contact in HRRJ by PDBHS and other HPR V CSBs, and ESH staff
The regional protocol should include clearly identified responsible parties, timelines, and
process flows. All five intercepts identified in regional Cross Systems Mapping efforts
should be included, and the protocol should address gaps and opportunities for
improvement. DBHDS should consider the applicability to regions across the state.

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OBSERVATION NO. 2
ESH is the state facility that has most significantly been impacted by the 2014 civil commitment
law changes. However, during the time period this individual was under a CRO these changes
did not limit the bed availability on the ESH unit that accepts jail transfers. At the time of the
individual’s death in HRRJ last August, ESH operated two units that accept jail transfers, 3B, a
female unit, and 4A, a male unit. The maximum bed capacity for unit 4A is 22. OSIG learned
during the course of this review that between the dates of the individual’s court order for transfer
to ESH (May 21, 2015) and the individual’s death (August 19, 2015), Unit 4A only had one day,
May 21, 2015, where its average daily census was at full capacity (22). Although the average
daily census for that one day may have indicated that ESH’s male jail transfer unit was full, had
the individual been placed on a TDO, the 2014 commitment law changes should have meant a
bed would be available prior to a jail transfer of someone who was not on a TDO. On July 31,
2015, the date of the second court order and the day HRRJ also requested PDBHS perform a
preadmission screening for a possible TDO, Unit 4A had an average census of 18 indicating that
several beds were available to accept admissions.
On August 28, 2015, following the death of the individual at HRRJ and more than a year after
the implementation of the safety net law, ESH re-organized admissions in an effort to streamline
the process and improve efficiency. The revised process included:
1. Re-organizing the skill mix of admissions staff;
2. Adjusting admission staff hours to enhance response to inquiries and admissions from
CSBs, area jails, and Central State Hospital; and
3. Improving readiness of individuals already admitted under a TDO to attend court
hearings.
Prior to this revision, the ESH admissions office had up to four staff present during the hours of
7 a.m. and 3 p.m. and none present for the remaining hours of the day or on weekends, despite
reports that the majority of admissions occur between 3 p.m. and 2 a.m. During these hours,
nursing supervisors coordinated all admissions in addition to their responsibilities for patient care
and staff supervision. The revised plan does not address the completion or updates to the Jail
Transfer Waiting List or the development of a monitoring system to ensure it is kept up to date.
This list is utilized by ESH forensic leadership, the DBHDS’s Competency Restoration
Counselor, and the Region V Facilities Management Committee (FMC). The FMC is comprised
of representatives from HPR V’s nine CSBs, ESH, and the HPR V Reinvestment Project Office.
During the weekly meeting, staff review updates on non-forensic individuals in private
community beds who are receiving regional funds for payment and briefly discuss the number of
individuals on the ESH Jail Transfer Waiting List. In years past, the committee reviewed the Jail
Transfer Waiting List in detail and discussed individuals’ clinical status and updates on progress

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in obtaining a bed at ESH. Among the staff interviewed, no one was able to recall why or when
that in-depth review stopped.
ESH has experienced a significant increase in its operational burden since the implementation of
the safety net law of 2014. The impact has been felt by multiple departments including the
admissions office, which prior to this event, had not modified its admissions process accordingly.
While the structure of the admissions office and communication were revised following this
event, the process for developing and ensuring the accuracy of the Jail Transfer Waiting List or
for facilitating regional ownership has not. As the maintenance and accuracy of this document
has been found to be one of the root causes of the death of the inmate at HRRJ, the accuracy and
management of the list is critical to preventing similar events in the future.
Observation No. 2 Recommendation
ESH should revise the process for the development, management, and oversight of the
Jail Transfer Waiting List. A system for consistently reviewing the individuals on the list
should be created and include the courts, CSBs, HPR V Reinvestment Project Office
through the Facilities Management Committee (FMC), and HRRJ.

OBSERVATION NO. 3
DBHDS has convened or participated in numerous workgroups, committees, and sub-committees
in the past several years centering on improving services for individuals with mental illness who
encounter the justice system. All of these, including the DBHDS Transformation Team for the
Justice Involved, have resulted in recommendations for additional funding, ongoing committee
work, oversight, training, and system re-design.
Observation No. 3 Recommendation
The recommendations of DBHDS’s Transformation Team for the Justice Involved were
substantive and — had they been implemented at an earlier time — would have had a
significant impact on the justice-involved individuals with mental illnesses. This situation
should be considered urgent and implementation plans developed immediately.

OBSERVATION NO. 4
A panel of national experts in healthcare and safety authored the 2000 book entitled To Err Is
Human. The publication challenged prior assumptions surrounding medical errors and their
consequences — not by placing blame on the backs of individual healthcare professionals who
make honest mistakes. Instead, the book called for a more sensible and effective plan for
reducing errors and improving patient safety through the design of a safer health system. In order
to accomplish that, the book recommended that a careful examination should be made of how the
surrounding forces of legislation, regulation, and system activity influence the quality of care
provided by healthcare organizations and before reviewing the handling of healthcare mistakes.

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To Err Is Human asserts that the problem is not bad people in healthcare; rather, it is that good
people are working in bad systems that need to be made safer.
In Chapter 3 of the book entitled Why Do Errors Happen, the authors describe the difference
between active and latent errors. Active errors are defined as being those caused by individual
front line staff and whose effects are noted almost immediately. Such was the case of the
admissions director at ESH placing forms in a desk drawer. Latent errors are those that are
removed from the control of front line staff and include such things as poor process design, poor
policy, and poor management. Latent errors are also those that pose the greatest threat to safety.
Often, superficial corrective actions focus on disciplining or re-educating an individual, usually a
staff member lower down the organizational chart. At times, this may be appropriate as a part of
the action if it is determined that there was a deliberate negative action by the individual staff
member. According to the book’s authors, it is not an effective way to correct a system or
process problem or to prevent recurrence of similar events.
In an April 2015 article from the Joint Commission (TJC) periodical, The Source, the authors
discuss the importance of considering Human Factors Engineering and developing root cause
analyses and corrective actions following a significant event. The article also reinforces the
importance of reviewing active and latent failures when analyzing an event. The article goes on
to report that the most common strategies for addressing active errors, training and policy
changes, are less sustainable and weaker actions and neglect to address the more systemic issues
related to latent errors. Although more time consuming and requiring a tolerance for examining
management, systemic, and process issues, any action plan that does not include them should be
considered weaker and incomplete.
On March 16, 2016, OSIG received a copy of the DBHDS Office of Internal Audit Investigation
Report on the death at HRRJ. The investigation was performed by the DBHDS Internal Audit
Director and one internal audit staff member. According to emails from the Office of Internal
Audit, the report was completed last December and forwarded to the Assistant Commissioner for
Forensic Services for review and then the Office of the Attorney General for several weeks prior
to its release.
Included in the DBHDS investigation was a brief background, timeline, summary of interviews,
review of documents determined to be pertinent to the investigation including phone records,
DBHDS forensic admission waitlists, PDBHS records, and Portsmouth General District Court
records. Omitted from the investigation were the following documents determined by OSIG to
also be relevant to a thorough investigation of this event:
• Census reports from ESH for the male jail transfer unit (4A) between April and August
2015;
• ESH records related to the individual in question;

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•
•
•
•

ESH policies related to admissions of jail transfers;
ESH Admission Process re-organization dated August 28, 2015 (and updated September
24, 2015);
PDBHS policies; and
Medical records from Bon Secours Maryview Medical Center.

As part of the investigation, the DBHDS internal auditor emailed Dr. Kristen Hudacek, ESH
Psychology Director, regarding ESH’s work at HRRJ. Dr. Hudacek reported that the DBHDS
Competency Restoration Counselor, employed by DBHDS Central Office, visits HRRJ to work
with individuals on the Jail Transfer Waiting List generated by the ESH Admissions Department
and that she and another psychologist use the same list to “work off,” although the meaning of
that is not clear in the report. As the Jail Transfer Waiting List is generated by the Admissions
Department, verifying the accuracy of that list is critical as it is now known that the list was
inaccurate at the time of the HRRJ inmate’s death. Additionally, the DBHDS investigation,
reported on House Bill 645 that details revisions to orders for sanity evaluations, competency to
stand trial, and competency restorations. The bill requires the clerk of the court to provide a copy
of the relevant order to the appointed evaluator or hospital as soon as practicable or no later than
the close of business on the next business day after the order is signed. The evaluator or hospital
must acknowledge receipt of the order to the court clerk on a standardized form. The bill requires
the same confirmation process for an order to a psychiatric hospital of an inmate from a local
correctional facility. The bill does not address the process for adding individuals to the Jail
Transfer Waiting List or confirming the accuracy of that list.
The DBHDS report made two conclusions. The first conclusion, that the ESH Jail Transfer
Waiting List never contained the information related to the CRO for the individual in question, is
accurate and was substantiated by OSIG. The second conclusion, that PDBHS staff never
completed the required evaluation of the individual requested by HRRJ is also accurate.
The DBHDS report recommendations were for ESH to educate mailroom staff (and others) who
receive mail on the importance of ensuring admissions staff receive court orders despite the fact
there was no clear evidence in this case that the court order was ever mailed or that the failure
was that of the mail room staff, and that admissions staff should log in receipt of the court orders.
Educating mail room staff and others who receive mail does not correct or suggest a revision to
the process that would ensure root causes are addressed. The recommendation also makes the
incorrect assumption that logging in the mail will ensure the orders are not lost, misplaced, or
placed in a drawer, or translates to adding the individual to the Jail Transfer Waiting List. The
second recommendation is that DBHDS develop more uniform guidelines regarding how courts
should convey court orders to DBHDS. The recommendation does include a statement that these
guidelines should include more standardized processes (than current ones, of which there are
none) for forensic admissions. While OSIG supports DBHDS’s recommendation that DBHDS

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should “consider” developing a single point of entry for court orders for the entire system,
recommending that DBHDS develop guidelines for the management of court orders has no
connection to the lapse by PDBHS in meeting their Code requirements for emergency
evaluations when requested. The report makes no comment on issues surrounding CIT or jail
diversion.
Observation No. 4 Recommendation
DBHDS’s investigations of critical events should be conducted independently by
professionals trained and experienced in conducting healthcare root cause analyses and
who have experience working in the behavioral health system(s) in question. Reports
should include all relevant risk points and analysis of root causes with specific
recommendations targeting those root causes.

OBSERVATION NO. 5
OSIG reviewed NaphCare records relevant to the individual who died in HRRJ and the clinical
care received. Documentation provided was incomplete and inconsistent, but several key points
were noted. The individual’s weight on April 22, 2015, at the Portsmouth City Jail where the
individual was originally placed, was documented as 178 pounds. On May 8, 2015, the
individual’s weight at the Portsmouth City Jail was 182 pounds. HRRJ documented a weight of
190 pounds on a Daily Confinement Record that spanned the dates of June 15-21, 2015. This
weight was closer to the individual’s 2013 weight of 193 found in records from a prior ESH
admission.
On July 15, 2015, it was noted that the individual had “4+ pitting edema in the lower
extremities.” Pitting edema may be defined as an observable swelling of body tissues due to fluid
accumulation that may be demonstrated by applying pressure to the swollen area (for example:
depressing the area with a finger). If pressing results in an indentation that persists for greater
than 20 seconds (and may last for more than four minutes) after the release of the pressure, the
edema is referred to as pitting edema. 4+ pitting, described as severe, also means that a finger
pressing on the area is able to depress the flesh by 8mm. HRRJ records indicate that no action
was taken at that time.
On July 30, 2015, a medical clinic note documented 4+ pitting edema extending to the backs of
the individual’s knees and that the individual was, “disheveled, psychotic, and uncooperative.”
The individual’s weight was recorded as 158 pounds, 13 pounds more than the weight of 145
pounds obtained at the emergency room the same day. The manner and frequency by which each
setting calibrates their scales — or other possible reasons for the discrepancy — were beyond the
scope of this review.
NaphCare records provided to OSIG included care plan goals and interventions addressing

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suicide risk. There was no documentation provided to indicate that the individual was actively
evidencing suicide risk at any time. Suicide risk assessments provided were incomplete and
interventions required the individual to independently report changes in lethality, use, “effective
coping skills as needed,” and independently put in sick call requests as needed. As the individual
was thought to lack capacity to assist an attorney in his own defense, expectations that the
individual would have the ability to seek out medical treatment independently while acutely
symptomatic seems unreasonable and likely to fail. There was no mention in the treatment
planning notes that were provided of psychosis, inability to care for self, meal refusal, or weight
loss. Documentation provided for sick calls on July 7 and 16, 2015, only addressed medication
management. No mention was made of the individual’s weight loss or edema.
Currently, unless a court ordered individual inmate is seen as being in crisis and in need of a
TDO in order to expedite inpatient treatment, individuals subject to a CRO remain in HRRJ until
such time that a bed is available at ESH and an admission can be facilitated. In the event that the
jail determines the individual warrants emergency inpatient treatment, the responsibility lies with
the jail to contact the local CSB requesting an evaluation as was the case in this instance on July
31, 2015. There was no evidence that HRRJ sought to follow-up on either the first or second
CRO or their request for an emergency evaluation by PDBHS.
HRRJ has a direct responsibility to provide quality medical and mental health care for those in
their custody. Although NaphCare is no longer the contract agency providing medical and mental
health services at HRRJ, a change in provider offers limited promise of improvement in care or
documentation in the absence of a change in oversight practices. Review of NaphCare records
raised significant concerns regarding the quality of assessment, care, follow-up, and
documentation. It is those professionals who are trained and licensed to provide clinical care who
have a duty to provide that care and the agency that contracts with the provider is responsible for
ensuring that care is provided.
Observation No. 5 Recommendation
HRRJ should revise the process for overseeing the quality and outcomes of any contract
agency that provides medical and mental health care in their jail. This process should
ensure regular monitoring, direct oversight, and direct feedback and correction for areas
of concern.

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