The state agency that oversees Virginia's psychiatric hospitals hasn't set a clear custody transfer point for patients in the criminal justice system brought in by law enforcement, a new audit from the inspector general's office found.
Virginia Inspector General Michael Westfall's office reviewed the intake process for these patients — known as "forensic patients" — at facilities run by the state Department of Behavioral Health and Developmental Services from February 1, 2025, through March 30, 2025, and analyzed data from July 1, 2022, through June 30, 2025.
Forensic patients are made up of six groups, including people transferred from jail who need emergency mental health treatment, those who need treatment to restore their competency for trial and people involuntarily committed by the Department of Corrections.
OSIG's audit, which was sent to Gov. Abigail Spanberger and other state officials on April 1, found DBHDS lacks "a clearly defined, consistently implemented, or documented point" when these patients are transferred into its custody.
Staff told auditors that custody is "generally considered a transfer when law enforcement removes restraints or when DBHDS staff begin providing care, whichever occurs first."
"However, this understanding is informal and inconsistently applied," OSIG auditors wrote. "In some instances, law enforcement officers continue assisting patients after DBHDS staff have initiated care, further blurring custodial responsibility."
Colleen Miller, executive director of The disAbility Law Center of Virginia, says the audit covers a "very important and possibly life-threatening situation."
"That moment of transition from the police to the hospital is a very, very fragile moment," Miller said in a phone interview last week. "It's a very dangerous moment, and we have seen where the uncertainty around who is in charge at that moment has resulted in the death of individuals with mental illness."
Miller cited the 2023 in-custody death of Irvo Otieno, a 28-year-old Black man who died while being restrained by a group of Henrico County sheriff's deputies and Central State Hospital staff as he was being transferred to the state-run hospital in Dinwiddie County.
Video footage shows multiple deputies and hospital staffers surrounding and holding Otieno on the ground after he was brought to the facility. Minutes later, Otieno was motionless and pronounced dead. Otieno's family said he had a history of mental illness and was trying to breathe during the struggle caught on surveillance footage.
A grand jury indicted seven sheriff's deputies and three hospital workers on second-degree murder charges, but the charges were eventually lowered to involuntary manslaughter and most had their cases dropped by the local prosecutor. The only person who went to trial, a former Central State hospital worker, was found not guilty.
A 2024 disAbility Law Center report said "a cascade of systemic failures" led to Otieno's death, which it said "could have been prevented if it weren't for the complete breakdown of Virginia's mental health crisis system and the Commonwealth's culture of criminalizing individuals with mental illness."
The inspector general's office reviewed DBHDS policies, interviewed department and facility staff, reviewed surveillance footage and documents and conducted unannounced inspections at the nine facilities that take in forensic patients:
- Catawba Hospital
- Central State Hospital
- Commonwealth Center for Children and Adolescents
- Eastern State Hospital
- Northern Virginia Mental Health Institute
- Piedmont Geriatric Hospital
- Southern Virginia Mental Health Institute
- Southwestern Virginia Mental Health Institute
- Western State Hospital
The audit found that SVMHI and WSH lack camera coverage of their intake and custody transfer areas, while PGH conducts "handoffs in unsecured areas, like parking lots near facility entrances."
"In addition, DBHDS has not established standardized documentation or other verification requirements for custody transfer that balance patient privacy with accountability," auditors wrote.
State law doesn't establish statewide operational procedures for custody transfers. Without this guidance, the audit says, the department is expected to set policies clearly defining roles and accountability points.
These missing policies may have been the result of factors including "historical decentralization of admission policy development at the facility level" and limited DBHDS Central Office involvement in admissions before 2021, per the audit.
"DBHDS faces increased legal, safety, and operational risk" without a clear custody transfer point, auditors wrote.
OSIG recommended that the agency clearly specify the custody transfer point between a facility's staff and law enforcement or correctional officers during the admissions process, put in place minimum standards for where handoffs occur and set expectations for video surveillance of intake and transfer areas.
Auditors also suggested that the state's behavioral health agency require signatures from both sides of the custody transfer and provide guidance to facility staff and law enforcement.
The agency acknowledged to auditors that the custody transfer process is not defined in its current policies, and vowed to make these corrective actions from March 31, 2027, to June 30, 2027.
Lauren Cunningham, DBHDS' communications director, told VPM News in an email that the agency has "already been working to address this through a draft policy regarding transfer of custody from law enforcement."
Cunningham said the growing number of people in the criminal justice system with mental illness has had a major impact on state-run hospitals.
She told VPM News that Virginia had 2,236 adult forensic admissions to state hospitals in the 2025 fiscal year — 974 more than a decade prior. She added that "about a third of the forensic population is charged only with misdemeanors."
More than 90% of the patients at Eastern State Hospital and Central State Hospital between July 1, 2022, and June 30, 2025, were considered forensic patients. It was 63% at Western State Hospital in that timespan.
Nearly 48% of the 14,755 people admitted to a DBHDS-run hospital between July 1, 2022, and June 30, 2025, were forensic patients — which also includes people being evaluated on whether they can stand trial, those deemed incompetent for court and those found not guilty by reason of insanity.
According to the audit, the "largest proportion of forensic patients is the restoration of competency to stand trial patients."
These state-run facilities are meant to be "the backstop of the entire behavioral health system," Cunningham added. They must contend with Virginia's "bed of last resort" law — which requires them to take civil admissions when no alternative beds are available — and state laws for forensic admissions for restoration in 10 days or less, she said.
A report from JLARC, the Virginia General Assembly's research arm, found that during FY23 that all state-run psychiatric hospitals regularly filled more than 85% of their available beds, the industry standard for safe operating levels. Three facilities regularly filled all of their beds.
"When our hospital bed census is as high as it currently is, it puts pressure on our system and ultimately creates a less safe and therapeutic environment for patients and staff," Cunningham told VPM News.
Miller, of the disAbility Law Center, says she's grateful that OSIG conducted the audit, but she believes DBHDS should have addressed this years ago.
"They knew that this was a problem as soon as Mr. Otieno died in March of 2023," she told VPM News. "It adds some credibility, it adds some strength that it has come from the Office of Inspector General, but it's really kind of sad that this is what it takes for the department to revise their policies and practices."
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