Va. health staff failed Irvo Otieno as he suffocated, experts say

But a year later, the criminal case has fractured, and little public scrutiny has been given to the actions of the clinical staff, including doctors and nurses, at Virginia’s Central State Hospital in Dinwiddie County, where Otieno died. No clinical staff members at the psychiatric facility have been charged; the orderlies were “special management technicians,” a position that focuses on security and requires no medical training beyond knowledge of CPR, according to a job listing. Meanwhile, an investigation into potential abuse and neglect related to Otieno’s care is on hold pending the results of the criminal case, which now involves just two officers and an orderly facing downgraded charges of involuntary manslaughter.

A new analysis by The Washington Post of nearly two hours of surveillance footage inside and outside the hospital, along with interviews with 10 medical and use-of-force experts, identifies serious shortcomings in Otieno’s care by clinical personnel as officers and hospital workers pinned him down for more than 11 minutes. Staffers failed to monitor Otieno’s condition, nor did they attempt to safeguard his life as he was suffocated, according to medical experts and video footage. After Otieno appeared limp, a nurse did not check for signs of life but injected him with a sedating mix of drugs that were later listed in court filings, according to video and experts, who described the action as medically unsound. When staff eventually attempted CPR, experts said, they performed it incorrectly.

“I’ve admitted many, many patients within a setting that looks just like this,” Jhilam Biswas, director of the Psychiatry, Law and Society Program at Brigham and Women’s Hospital, said after reviewing surveillance footage for The Post. “But I’ve never seen that.”

Experts say the stalled state behavioral health investigation — known as a DI-201 — is inadequate because of the magnitude of the mistakes. And while Virginia has moved forward with a series of behavior health initiatives — including passing a law named for Otieno that grants relatives improved access to loved ones facing mental health crises — officials have not offered an accounting of the actions of the medical staff at Central State that preceded Otieno’s death.

“There absolutely should have been a review other than the stalled 201 investigation,” wrote Jack Barber, who served as interim commissioner of the state’s department of behavioral health from 2015 to 2018 and previously was director of Western State Hospital in Staunton, Va. “This is too tragic an event to not examine thoroughly and make changes to prevent it ever happening again. If that has not happened (especially now a year later) it is a serious problem and, to me, would be unacceptable.”

Both Central State and the agency that oversees it, the Virginia Department of Behavioral Health and Developmental Services, declined to comment on The Post’s findings or to answer specific questions about whether clinical staff members were fired or faced any other repercussions while legal proceedings are still pending.

“DBHDS and Central State Hospital have fully cooperated with the Virginia State Police in this investigation and will respect the legal process while staff continue to care for the patients at the hospital,” said Lauren Cunningham, a spokesperson for the department.

In custody

Police detained Otieno — an aspiring musician whom family described as sensitive and caring — on March 3, 2023, for a mental health evaluation after a call that day about a suspected burglary. They took him to a Richmond-area hospital, and he was arrested there and transferred to the Henrico County Jail after he allegedly assaulted officers. On March 6, sheriff’s deputies took Otieno to Central State Hospital, where he was declared dead less than an hour and a half after entering.

For decades, Virginia has struggled to care for and house its mentally ill residents, among them patients who have died waiting for hospital admission. A state oversight report from December found that overcrowding at Virginia’s public psychiatric hospitals, which include Central State, created unsafe conditions for patients and workers. Underpaid staff have left, creating shortages and deteriorating the quality of care for patients, the report found.

After Otieno’s death, an investigation by the Virginia Department of Health into the events at Parham Doctors’ Hospital, where Otieno was originally taken, found that staff did not provide stabilizing care for the 28-year-old, who never saw a psychiatrist there. In response, the hospital said it had submitted an action plan to address the problems.

“Virginia’s mental health system failed him from the moment he went into crisis,” said Colleen Miller, who is executive director of the disAbility Law Center of Virginia and has reviewed hospital records on the case.

Otieno’s family said his condition deteriorated when he was locked up for a weekend at the Henrico County Jail without access to medication. The following Monday, footage showed deputies at the jail violently struggling with Otieno as they removed him from his cell for transfer to Central State Hospital.

Staff at Central State appeared unprepared to admit Otieno once he arrived, said C.T. Woody, a former Richmond sheriff who took patients to the hospital over more than three decades on the city’s police force. After waiting outside for more than 15 minutes, video shows, deputies pulled Otieno from a vehicle and dragged him, handcuffed and shackled, into the hospital, down a hallway and into an admissions room as orderlies trailed behind.

No one from the hospital but the orderlies appeared to initially approach Otieno once he was in the room.

Central State and behavioral health department officials declined to say who at the hospital oversaw Otieno’s admission.

“I think emergency people should have taken over as soon as the officers got him inside,” said Woody, who reviewed the surveillance footage.

No visible intervention

In the admissions room, the video shows that two deputies pushed Otieno to the floor and leaned his upper body against a large chair. Shortly afterward, a third deputy held down lower on his body, then a fourth pushed on his legs.

Virginia State Police said in a statement after Otieno’s death that it was reported he had become combative during the intake process. But several experts consulted by The Post noted that Otieno offered little visible resistance as he was taken into the hospital.

“Otieno was handcuffed and shackled and presented no present threat to the sheriff’s deputies and hospital staff,” said Philip Stinson, a professor of criminal justice at Bowling Green University who reviewed the footage at The Post’s request.

After Otieno appeared to briefly move, the video shows that deputies and orderlies piled on him and that, for more than 11 minutes, as many as 10 people tried to restrain him. Otieno could be seen at times facing the floor as deputies and orderlies held him down. Central State policy at the time prohibited restraint of a person facing the floor, linking it to the risk of sudden death. The technique has been cited as a contributing factor in high-profile deaths at the hands of law enforcement, including George Floyd’s.

Trained clinical staff should have intervened once Otieno was on the ground and substantial weight was being applied, especially to vital parts of his upper body, said Jeffrey Metzner, a professor of clinical psychiatry at the University of Colorado. That training should have included how to recognize whether someone was at risk for positional asphyxia, he said.

According to a statement that lawyers for the Otieno family released May 30, after a Virginia prosecutor reduced charges against the three remaining defendants in the case, a witness said that “defendants were directed by staff more than once to place” him on his side. But surveillance video from the hospital has no sound and deputies did not wear body cameras, leaving it unclear when this allegedly took place or what else was communicated in the room.

Video shows clinical staff passing in and out of the room without visibly intervening. The hospital personnel consistently nearest to Otieno were orderlies involved in the restraint.

One hospital staffer entered the room several times holding restraint devices used by the hospital, which others attempted to place on his legs.

But clinical staff did not appear to assess his condition before the attempts, the video shows. Hospital policy says restraints should not be applied before an assessment, according to documents obtained by The Post via a Freedom of Information Act request.

Employees at Virginia public psychiatric hospitals told the state oversight body that reviewed facilities and issued the December report that they were not sufficiently trained in employing restraints in response to “patient aggression.”

At 4:39 p.m., 11 minutes after deputies piled on Otieno, one of the officers seemed to register that something was wrong. In the video, a deputy appeared to jostle Otieno’s head and attempt a pulse reading. Otieno remained limp. Hospital staff still did not appear to check his vitals.

A patient suffering from asphyxiation is in need of rapid medical intervention, experts said. Hospital policy requires staff to start lifesaving measures in such instances.

“Once Otieno becomes nonresponsive, there should have been an immediate attempt to assess his responsiveness,” said Utsha Khatri, an assistant professor of emergency medicine at the Icahn School of Medicine at Mount Sinai Hospital in New York. “If he does not respond to verbal or physical stimuli, a pulse should be checked and breathing should be assessed immediately. If no pulse is felt within five to 10 seconds, chest compressions should be started.”

None of that took place as soon as it should have, she said.

As a deputy continued searching for a pulse on Otieno’s neck, others rolled his limp body onto its back. For the first time, a hospital staffer stepped over and appeared to attempt a pulse reading.

“The one thing that could have saved his life in my opinion is if the medical staff had tried to intervene to either access and assess the patient or warn the deputies about the possibility of restraint asphyxia,” said Peter Canning, a paramedic and EMS coordinator at UConn John Dempsey Hospital.

Attorneys for some of those involved in handling Otieno have asserted that their clients had minimal physical contact and were positioned in such a way that it would have been hard to observe Otieno’s breathing.

Injection

Surveillance footage shows that a nurse entered the admissions room and administered two injections to a motionless Otieno at 4:40 p.m., according to the video time stamp — at least a minute and a half after deputies first appeared to sense something was wrong. The nurse did not appear to check for vitals. At least a dozen other hospital staff members, some in scrubs, looked on.

In court filings, prosecutors identified the drugs as olanzapine, an antipsychotic medicine, and diphenhydramine, a commonly administered antihistamine.

Four medical experts consulted by The Post said Otieno appeared to be unresponsive at that time — and may have been unconscious for minutes. They said the drugs should not have been administered because of that.

“If the patient is unresponsive, sedatives can have adverse effects,” said Biswas, the director from Brigham and Women’s Hospital.

The state behavioral health department declined to comment on drugs that were administered to Otieno.

In March 2023, then-Dinwiddie Commonwealth Attorney Ann Baskervill claimed at a hearing that the drugs injected into Otieno “didn’t have a chance to even go through his veins, because his heart wasn’t pumping at the time that it was given because he died of asphyxia, which shut down all of his organs.” The office of Virginia’s chief medical examiner declined to comment on that assertion. Baskervill stepped down from her position in June 2023, and a new prosecutor has since taken over the case.

Questions over CPR

Hospital staff began chest compressions at 4:42 p.m. — at least three minutes after the deputy appeared to check for a pulse.

Otieno was still handcuffed when hospital workers began compressions, which they did from a standing position. According to the American Red Cross and the experts consulted by The Post, a person should kneel to give chest compressions.

“You can’t be effective that way, and there was no reason for the person not to get in the proper position to start chest compressions,” said Bill Toon, a retired paramedic and former EMS training manager for Loudoun County, Va.

Initial attempts to ventilate Otieno using a bag valve mask began at 4:44 p.m., five minutes after a deputy first appeared to check his pulse.

A minute later, staff tried using a defibrillator machine, then returned to chest compressions and continued doing those for about 25 minutes while waiting for an ambulance to arrive.

It’s unclear exactly what was happening in the video when Central State called 911. A behavioral health department spokeswoman acknowledged that the time stamps on surveillance video in the admissions room are out of sync with other cameras by about two minutes.

The department of behavioral health said the hospital did not have an emergency department. Barber, the agency’s former interim commissioner, said the hospital historically would not have employed an emergency physician. Clinical staff, he said, were typically not trained in advanced life-support measures and would rely on emergency services to respond to a patient in Otieno’s condition.

Dinwiddie County Fire & EMS records show that it received a 911 call from the hospital at 4:40 p.m. requesting an ambulance for a patient who wasn’t breathing, then another at 4:48 p.m. and a third at 5:02 p.m. “This is just totally unacceptable, and y’all know it, too,” a caller from the hospital said about the wait. “Totally unacceptable.”

According to the surveillance video, paramedics arrived in the admissions room at 5:08 p.m. and seven minutes later began to insert a breathing tube. They worked to revive him for another 25 minutes — but it was fruitless. At 5:48 p.m., they covered Otieno’s body with a white sheet.

“This is delayed, and earlier intubation could have potentially made a difference,” said Khatri, the Mount Sinai physician.

The state legislature tasks Virginia’s inspector general with investigating complaints about public psychiatric facilities like Central State, but an oversight report said the office reviewed less than 20 percent of the more than 600 complaints received in the last fiscal year. A spokesperson for the inspector general’s office declined to comment on whether it is investigating Otieno’s case. A spokesperson for Youngkin’s office said the only inquiry into the conduct of Central State staff is the halted abuse-and-neglect inquiry.

Miller, of the disAbility Law Center, said state policy allows the director of psychiatric facilities to suspend investigations pending criminal charges.

“If they make that decision to resume the investigation later, all that information is stale and unreliable,” she said.

In September, the commonwealth and Henrico County and its sheriff’s office paid Otieno’s relatives $8.5 million to settle a wrongful-death lawsuit, but did not admit wrongdoing.

Those still charged criminally in the case — orderly Wavie Jones and sheriff’s deputies Kaiyell Sanders and Brandon Rodgers — have pleaded not guilty, and their trials are scheduled to begin in September. Edward Riley, an attorney for Sanders, said in a statement that “Kaiyell did nothing wrong and he remains ready to defend himself against this allegation.”

“Kaiyell, working with the other deputies, were doing their jobs,” the statement said. “They were tasked with getting the inmate to Central State where he could get the help needed to address his severe mental health issues. There was no desire or intent to hurt him.”

An attorney for Jones declined to comment, and an attorney for Rodgers did not return messages. The prosecutor has said the cases were dropped against the others because she inherited the case and was unable to change her office’s trial strategy by the time she took over.

Mark Krudys, a lawyer for Otieno’s family, said the criminal cases should not sidetrack any other investigations.

Barber recommended that Central State conduct a wide-ranging review of Otieno’s death, “to identify changes to prevent it ever happening again,” he said. “This is not simply the right thing to do, but a debt we owe the deceased and his family.”

Salvador Rizzo contributed to this report.