HENRICO COUNTY, Va. -- HCA Healthcare's Henrico Doctors' Hospital, the hospital where 28-year-old Irvo Otieno was first taken while he was in a mental health crisis days before his death, failed to give Otieno the emergency treatment he needed, according to an investigative report obtained by CBS 6.
In response to a complaint about how the hospital handled Otieno, the Centers for Medicare and Medicaid Services requested that the Virginia Department of Health (VDH) complete an investigation into whether the facility followed federal regulations.
The findings, obtained by CBS 6 reporter Melissa Hipolit, revealed hospital staff failed to provide the necessary stabilizing treatment after Otieno was "presented to the emergency department with an emergency medical condition."
“They failed him. They simply failed Irvo," his mother Caroline Ouko told CBS 6 in an interview in response to the findings. “This was the precursor of everything that happened to my son. It began right there — being denied to see him at Henrico Doctors’ Hospital.”
On March 3, 2023, Henrico Police placed Otieno under an Emergency Custody Order (ECO) after he displayed "concerning behavior in the community," according to a review of Otieno's medical records. Police then brought him to the emergency department at Henrico Doctors' Hospital at the Parham Road campus.
Ouko recalled she suggested that the crisis responding team take him to a closer hospital but was told that the Parham Road location had the more appropriate resources.
There is a crisis receiving center at Parham Doctors' Hospital, which according to a 2018 press release from Henrico County, provides "prompt care" to "individuals in psychiatric crisis."
It operates in partnership with the county's crisis intervention team made up of first responders and mental health professionals.
The VDH report does not reference the crisis receiving center. When asked if Otieno was taken specifically to the crisis receiving center, a Henrico Police spokesperson said officers took him to "Parham Doctors' Hospital where the crisis receiving center is located" within the emergency department.
"I was told that Henrico would be the place because they are specialized. They specialize in dealing with patients in a mental crisis. Very ironic that he made it to the right place where they had all the resources to be able to take care of him," Ouko said.
While there, the report stated Otieno was "extremely angry, agitated, and bizarre" and his behavior was described as "aggressive, combative, and uncooperative."
According to staff interviews conducted by VDH facility inspectors, Otieno was only cooperative for a blood test, a COVID test, and while eating lunch.
Otieno was given 20 mg of an antipsychotic medication used to treat symptoms of schizophrenia and manic bipolar disorder and 50 mg of Benadryl partly due to its sedating effects.
However, the effects of the two drugs wore off after less than one hour.
The report stated that an emergency care doctor ordered more medications. However, as the drugs were being administered, Otieno reportedly assaulted a Henrico Police Officer who was assisting at the bedside.
Otieno clawed, hit, kicked, and spat at the officer, according to the report.
Police then informed hospital staff they were going to arrest him and take him to jail for assaulting a law enforcement officer.
“And from that point, everything went downhill for my son," Ouko said. "That's what takes me aback. At what point did the doctor relinquish his responsibilities to a mere security officer?"
Otieno remained in the emergency department for six hours and never saw a psychiatrist during his time there, the report said.
According to the investigation findings, the emergency department doctor told VDH they did not feel like the facility could control Otieno's behavior in the emergency department.
However, investigators determined through their review of patient records and interviews with staff that the hospital failed to demonstrate it stabilized Otieno's emergency medical condition within the capabilities of the facility -- a violation of the Emergency Medical Treatment and Labor Act.
“Why wasn't he given medication and stabilized and make sure that he does not leave the hospital until he's stable?” Ouko said.
Ouko said the whole time Otieno was in an emergency room, she waited in the hospital lobby.
On multiple occasions, she said she asked to see her son but was denied access -- which has now prompted Governor Glenn Youngkin to propose legislation in Otieno's name that would allow family members to be with their loved ones as they receive a mental health evaluation in an emergency room.
Ouko said no one at the hospital told her that her son had been taken to jail.
Otieno sat in Henrico Jail West for a full weekend before he was transferred to Central State Hospital on March 6 under a Temporary Detention Order.
At Central State Hospital, Otieno died from suffocation while Henrico sheriff's deputies and hospital staff surrounded him and appeared to be pressing down on his body, according to surveillance video. Eight individuals currently face murder charges in connection to his death.
For Ouko, she said the fatal chain of events started at Parham Doctors' Hospital.
“All they did for my son was to create a path for him to be vacuumed in the criminal system," she said.
She believes the report from VDH sheds light on a larger systematic problem about the level of care that those in crisis receive, adding, "We need changes in the mental healthcare system."
When asked for a response to the findings of the investigation, HCA Healthcare spokesperson Pryor Green sent CBS 6 a statement reading, "We strive to always provide compassionate, high-quality care to all patients. Parham Doctors’ Hospital is working collaboratively with the Virginia Department of Health and has submitted the requested action plan."
A VDH spokesperson said the corrective action plan is still under review and therefore could not yet be released.
Otieno died in March while handcuffed and pinned to the floor of Central State Hospital for about 11 minutes by seven Henrico County sheriff’s deputies and three hospital employees. His death was ruled a homicide by asphyxiation. All 10 defendants were indicted on second-degree murder charges, but charges against two of the hospital employees were later dropped.
In September 2023, Otieno's family reached an $8.5 million settlement with the state, county, and the sheriff whose deputies were involved in his restraint.
The settlement agreement said the state, county, and the sheriff have not admitted any liability and deny that their actions caused Otieno’s death, but have agreed to collectively pay the $8.5 million to Otieno’s family.
The Associated Press contributed to this story.
