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Chances To Avert Rampage Cited

June 14, 2007

By Bill McKelway

In an even tone that betrayed neither bias nor alarm, the state's inspector general for mental health this week rolled out a litany of missed opportunities that could have altered the course of care for Virginia Tech shooter Seung-Hui Cho.

The investigative report from James W. Stewart III begs the question, too, of whether those missed opportunities may have altered the course of life for Cho's victims.

Almost disguised between the lines of psych-speak on the last page of Stewart's 33-page report is an image of what might have been:

"Effective interventions at the time of a psychiatric emergency not only ensure safety, reduce suffering, and mitigate the deterioration of adaptive functioning occurring at the time of the immediate crisis, but effective interventions also encourage the individual to resolve the crisis positively toward a more adaptive lifestyle."

Stewart and his staff focused their investigation on the events of December 2005.

It would be 16 months before the shootings April 16 would unfold, leaving 33 faculty and students, including Cho, dead, and two dozen others wounded.

But even in 2005 there were obvious signs of deep trouble.

Instead of receiving care designed to mitigate his deterioration, Cho instead became subject to a system that rushed to judgment, tossed him back into his bizarre world, and offered him no certain program of care or place for help, Stewart's assessment shows.

Stewart's report recounted the days preceding Cho's involuntary placement in a western Virginia mental health ward on Dec. 13, 2005.

"Those who lived around him were increasingly cautious about their own safety as the semester proceeded," he wrote. "Those who lived close to him took it upon themselves to warn other students about his behavior."

In the middle of the day on Dec. 13 he sent a roommate a message revealing that he "might as well" kill himself. The roommate called his father; the father called Virginia Tech police at 3:42 p.m.

Cho was taking an exam and then had dinner. When he returned to his dorm room, a roommate called police.

It was 7:09 p.m. Just 66 minutes later, Cho was in the custody of a Virginia Tech police officer and was evaluated by a social worker with the regional mental health agency, the New River Valley Community Services Board.

Kathy Godbey, the social worker, in the few hours she had under state law to assess Cho, learned from him that he regarded the suicide threat as a joke, that he couldn't come up with a plan to alter his behavior, and that he was unwilling to contact his parents.

But Godbey learned from others that Cho had been making threats and had a long history of harassing others.

She decided that Cho needed to be temporarily detained, that he wasn't willing to seek care voluntarily, that he was mentally ill and an imminent danger to himself and others. She was able to secure a bed for Cho that night at a psychiatric clinic near Radford.

Cho was admitted at 11:15 p.m.

Under state law, he could be held for the next 48 hours under observation; he was under psychiatric care; he could not leave voluntarily.

At 7 the next morning, Cho was examined by a clinical psychologist, Roy Crouse, who has a private practice near the Virginia Tech campus. For 22 years, Crouse has filled the role of independent examiner, a requirement of state law dealing with commitment proceedings.

Crouse spent 15 minutes with his patient. He did not consult with Cho's attending psychiatrist or examine Cho's hospital record, according to the inspector general's report.

Crouse decided that Cho was not a danger to himself or others and did not need to be involuntarily committed.

Nevertheless, Cho underwent a commitment hearing later that morning before a special justice to determine the best course of care.

Special Justice Paul Barnett, with only a court-appointed lawyer and Cho before him, as well as documents related to the temporary detention order, determined that Cho was mentally ill and a danger to himself but could be released for outpatient treatment.

Stewart's report found nothing in state law that requires the special justice to reconcile conflicts in the assessments Cho received. Nor is there any requirement that the justice have before him complete medical and evaluation records, police reports, criminal histories and information from any previous mental adjudications.

Barnett entered an order directing Cho to follow an outpatient treatment plan, but the order did not specify where or when it was to take place and who was required to monitor it.

Stewart determined that Cho was handed a telephone and told to make a voluntary appointment to see someone at Tech's Cook Counseling Center at 3 p.m. that day, Dec. 14. A hospital worker faxed details of the appointment to the community services board and to Cook.

Virginia Tech, citing privacy laws, has refused to confirm whether Cho showed up.

But Stewart's report reveals that Virginia Tech does not accept patients sent to it by court order. It only accepts patients who voluntarily appear.

With no one responsible for monitoring care, the involuntary commitment order issued by Barnett in effect became a voluntary appointment that Cho may or may not have kept.

After The Times-Dispatch reported last month that the community services board failed to monitor Cho's care or devise an outpatient treatment plan for him as required by law, the board has now decided to attend all commitment proceedings. Monitoring agencies and treatment agencies are being identified on court orders, as well.

Contact Bill McKelway at bmckelway@timesdispatch.com or (804) 649-6601.