RICHMOND, Va. -- The state government agency that licenses and oversees psychiatric facilities across Virginia has completed an investigation into HCA Chippenham Hospital's handling of Charles Byers before he was released from the hospital and killed by police.
The Department of Behavioral Health and Developmental Services (DBHDS) shared 45 pages of investigation findings and corrective actions, which showed the hospital failed to follow multiple required protocols related to Byers' admission and discharge processes.
"From what I understand from reading the document, there are some procedures that were required that were not met," said Charles Byers' mother Peggy Byers in response to the findings. "This report from the Department of Behavioral Health is a step in the right direction.”
As CBS 6 has previously reported, Byers, 34, was shot and killed by Chesterfield Police on July 8 less than 48 hours after he was arrested and released from HCA Chippenham Hospital's psychiatric unit Tucker Pavilion. Byers was ordered by the court to get emergency mental health treatment from Tucker Pavilion for up to 72 hours after he was issued a temporary detention order (TDO) on July 6.
A lawsuit filed by the Byers family alleged HCA and Richmond Police violated Byers' federal patient rights and "fabricated" an assault charge to have him removed from the facility while he was actively exhibiting symptoms of a mental health crisis.
“He wasn't handled with compassion and care, like you'd expect to see in a hospital. He was just treated like an inconvenience," said Charles Byers' father Michael Byers.
“You put your trust in them to take care of you and your family and to keep you safe, and it just didn't happen," Peggy Byers said.
Five months later, an investigation by DBHDShas cited Chippenham Hospital with 17 violations of state regulations pertaining to Byers' case.
The state agency found the hospital failed to provide evidence that it conducted an assessment of Byers' health and safety needs before admission.
The hospital failed to document his diagnoses, psychiatric needs, medical problems, current medications, past substance abuse and co-occurring mental health disorders, or behaviors that would put him at risk to himself or others, according to the investigation.
The inspection also found that the hospital failed to produce a discharge summary upon Byers' release from the facility. According to the investigation, the hospital said it did not complete one because Byers was discharged "against medical advice."
The hospital then provided a discharge summary to DBHDS dated Aug. 9, 2023 -- more than a month after Byers was actually discharged, which is another violation of DBHDS standards.
Additionally, HCA Chippenham failed to document on the discharge summary required information such as:
- The reason Byers was admitted and discharged
- Input from Byers or his authorized representatives, which could have been his parents, in the planning of his discharge
- Byers' level of functioning or limitations to his functioning at the time of discharge
- Recommended procedures to improve functioning
- Arrangements for future services
- Date the discharge summary was actually written
“If you've ever been discharged from the hospital, you know they give you pages and pages and pages of instructions and follow-up care and medications, and none of that was received by Charlie or by us even after the fact," Peggy Byers said.
Furthermore, attorney Paul Curley, who legally represents the Byers, said there were "discrepancies" between the discharge summary that Chippenham provided to DBHDS and the discharge summary that hospital staff provided to the officer who arrested Charles Byers on July 6.
Curley said he has personally reviewed the discharge paper given to Richmond Police, and it did not note that Byers was discharged "against medical advice."
“It had a handwritten note that indicated it was “D/C HOME,” indicating that HCA had discharged Charlie to his home, which of course is untrue," Curley said. “They are two different documents, and I think we need some answers on that.”
After reviewing body-camera footage, Curley wrote in the lawsuit that the arresting officer requested a discharge summary from a nurse. A nurse then printed off a form and filled it out. The complaint alleged the form was not endorsed by a physician or director.
"The manufactured “discharge summary” was also devoid of any evaluations, diagnoses, or treatment plan," the complaint stated.
CBS 6 reached out to HCA Healthcare and DBHDS about the alleged discrepancies between the discharge summaries and has not yet heard back.
In response to DBHDS' citations, Chippenham Hospital submitted a corrective action plan indicating it would revise its assessment policies, audit its assessments, train staff, review all incomplete discharge summaries weekly, and audit random discharge summaries.
The hospital also stated it would "[a]dd policy statement and specific process steps for AMA (against medical advice) discharge into law enforcement custody including hand-off of current plan of care and legal status."
“Maybe we can take a little solace that they'll fix some things and then someone else down the road will benefit. There won't be another set of parents in this nightmare situation," said Michael Byers.
A federal investigation requested by the Center for Medicaid and Medicare Services was also launched into this case. CBS 6 asked for an update on the status of that investigation and is still waiting to hear back.
On July 6, just three hours after Byers had been "delivered" to Tucker Pavilion per his TDO, hospital staff tried moving Byers to a different floor. However, Byers would not get into an elevator and that's when hospital staff called in a Richmond Police officer, who was working extra-duty at the hospital, for assistance, according to the complaint.
The lawsuit stated that while in a delusional state, Byers still refused to get into an elevator and accused the police officer of being "fake."
At one point, the RPD officer attempted to handcuff Byers and force him into the elevator, despite the complaint stating that Byers had committed no crime, but Byers resisted.
When that effort was unsuccessful, the officer then pointed a taser at Byers, the complaint stated.
"Do you want to go to jail, or do you want to go to the second floor?" the RPD officer then asked Byers, according to the complaint.
Before Byers could respond, a nurse said, according to the lawsuit, "At this point, we just want you to take him away."
The lawsuit alleged the officer and nurse then accused Byers of kicking a nurse, despite body camera footage showing no evidence of a kick.
The police officer then arrested and removed Byers from the hospital, and the arresting officer later admitted he had "no clue" why Byers was at the hospital in the first place, according to the complaint.
Byers was then taken to the Richmond City Jail for the assault charge, and a Richmond magistrate released Byers back into the public.
36 hours later, the complaint alleged that Byers was trying to get back to his home in Chesterfield County and was seen trying to break into peoples' homes.
Chesterfield Police were called to Wycliff Court on July 8 for reports of attempted break-ins, and when they arrived, police said Byers was carrying a hatchet he had picked up from a garage. When Byers did not comply with orders to drop the hatchet, police shot and killed him.
At the time of Byers' death, his TDO would have still been in effect as he never had a commitment hearing, a facility director did not sign off on Byers being discharged before a commitment hearing, and the 72-hour period from the time of issuance had not yet expired.
More than five months later, there have been essentially no updates in the criminal investigation of the Chesterfield Police shooting.
When asked for an update Tuesday on when the Chesterfield Commonwealth's Attorney's Office would make a decision on whether to prosecute or decline to prosecute the officer who shot Byers, a spokesperson said, "Our office has no comment at this time."
While the family continues to push for changes to what they called a broken mental health system, they said nothing will ever ease the pain of losing their 'Charlie.'
“It's all empty. I look at pictures from last Christmas and think that was the last Christmas that we'll ever have together. It's not fair. I'm sad and mad and it just doesn't seem fair. He should be with us," Peggy Byers said.
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