No criminal charges will be filed related to the suicide of Gus Deeds, according to the Virginia State Police.
Deeds, 24, died of a self-inflicted gunshot wound after stabbing his father, Virginia State Senator Creigh Deeds, on Nov. 19, 2013. And although the state prosecutor decided against pressing any charges in the case, a just-released report by the state's Office of the Inspector General (OIG) found that a long series of mistakes by people throughout the state's mental health system contributed to Deeds' death.
"There's really no excuse for it," says Mira Signer, the director of Virginia's chapter of the National Alliance on Mental Illness (NAMI).
Signer told CBS News' Crimesider that what is so frustrating about the report's conclusions is that the cracks Deeds fell through could have been plugged had the state's Department of Behavioral Health and Developmental Services implemented recommendations made in a 2012 report by the OIG. And indeed, the new OIG report accuses the department of a "lack of timely, effective action" on the 2012 recommendations.
The Department of Behavioral Health and Developmental Services did not immediately respond to a request for comment on the report on the Deeds case.
Deeds had been diagnosed with bipolar disorder and on the day before he died his family called police because he was acting strangely. A judge issued an emergency protective order to hospitalize the young man, but the facility where he was taken failed to find a bed for him in the six-hour window they were legally allowed to hold him, and he was released.
The OIG report found that although an employee at the hospital where Deeds was held claimed to have called 10 facilities looking for a bed, the employee actually called seven - and two of the ones he missed had beds available. At 6:35p.m., Deeds was released.
"I was concerned that if he came home, there was going to be a crisis," Sen. Deeds told "60 Minutes" in January.
And, indeed, there was a crisis. The next morning, Gus attacked his father and committed suicide.
After Deeds' death, the Virginia state legislature stepped in and enacted some reforms, including extending the emergency hold time from six to eight hours (short of the 24 hours Sen. Deeds pleaded for), and provided that should a bed not be found in any private facility within the state, the patient is to be transferred to a state hospital. The new report also recommends other major reforms, including the creation of a real-time database for tracking mental health beds - a database that, had it been in effect when Gus was admitted, may have saved his life.