The Office of the State Inspector General released its report into the Creigh Deeds stabbing investigation on Thursday.

The report provides a timeline of events that occurred on Nov. 18, 2013 – one day before Deeds’ son, Gus Deeds stabbed him and then committed suicide.

The report suggests recommendations on how the state can improve its response to psychiatric emergencies and contributing factors to Deeds' treatment and subsequent release. Virginia has a six-hour time limit on emergency custody orders. Since an evaluator was unable to find a facility to admit Gus Deeds in the six-hour timeframe, a temporary detainment order was not executed.

Since the incident Creigh Deeds has proposed increasing the time limit for emergency custody orders.

The report includes a timeline, stating that the emergency custody order was issued for Gus Deeds at 11:23 a.m. Nov. 18. Despite meeting the criteria for temporary detention, Gus Deeds was released because the emergency custody order expired. He stabbed his father and then committed suicide the next day. The report listed four contributing factors as to why Gus Deeds was released.

The first contributing factor is that the Department of Behavioral Health and Developmental Services did not “fully or in a timely manner” implement recommendations issued by the former director of the Office of the Inspector General, Douglas Bevelacqua. Bevelacqua resigned earlier this month over concerns about the report.

It also highlighted a practice known as “streeting.” That is when people who are classified as meeting the criteria for temporary detainment are not admitted to a psychiatric facility or provided with the appropriate care.

The report also cites Bath County’s rural location as a factor. After the emergency custody order was issued at 11:23 a.m., Gus Deeds was taken into custody at 12:26 p.m., and arrived at Bath Community Hospital at 12:55 p.m. But Rockbridge Area Community Services was not notified about the emergency custody order until 1:40 p.m. after a family member called checking on the status.

An evaluator left Lexington at 2 p.m. and arrived in Hot Springs at 3:10 p.m. Factoring in travel time and a lack of notification system, the preadmission screening time was shortened from six hours to three hours and 15 minutes.

Once the evaluator determined that Deeds needed to be hospitalized, the evaluator said he contacted 10 private facilities to see if one would admit Deeds under the temporary detainment order. The inspector general confirmed the evaluator contacted seven of the 10 facilities. Two of the three facilities that could not be verified as being contacted had beds available.

The final contributing factor listed was finding a facility with an available bed. The report mentions that finding a bed within the six-hour time limit is the shortest timeframe in the nation.

To improve treatment the report suggests creating a web-based psychiatric bed registry in the state, separating the bed search from the execution of the temporary detainment order, and having better coordination and procedures between law enforcement, evaluators, and temporary detainment assessment sites.

Click here to read the entire report: