Investigation and Timeline of Events Surrounding Irvo Otieno's Death
An investigation into the death of Irvo Otieno, Executive Director of the disAbility Law Center of Virginia, reveals a timeline of events from March 2nd to March 6th, 2023. The report highlights issues concerning mental health crisis responses, hospital evaluations, and restraints, leading to serious calls for reforms in Virginia to prevent similar tragedies.
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Presentation Transcript
Report on the death of Irvo Otieno Colleen Miller, Executive Director disAbility Law Center of Virginia September 17, 2024
disAbility Law Center of Virginia Our mission: to advance independence, choice and self-determination; protect legal, human and civil rights; and eliminate abuse, neglect and discrimination of people with disabilities, through zealous and uncompromising legal advocacy and representation.
Our call for serious reform to prevent these tragedies in Virginia. These must include: Ending the criminalization of mental illness Strong behavioral health standards in jails and detention centers Protections for people with serious mental illness to receive appropriate care in hospitals Elimination of the use of prone restraint in all settings
Timeline of Events During dLCV s investigation, we reviewed records from Parham Doctor s Hospital, Henrico County CSB, and Central State Hospital, as well as news reporting and publicly available records, including security footage. Based on those records, dLCV constructed a timeline of what occurred with Mr. Otieno from March 2nd to March 6th, 2023.
March 2nd Neighbor calls police regarding Mr. Otieno s behavior. Police did not transfer Mr. Otieno to a hospital and Mr. Otieno remained in the community
March 3rd 11:30am was experiencing a mental health crisis. Police place Mr. Otieno under an Emergency Custody Order (ECO) Police arrive on scene after a report that Mr. Otieno 1:30pm Mr. Otieno arrives at Parham Doctor s Hospital.
March 3rd 1:50pm meets TDO criteria. Henrico CSB evaluates and finds Mr. Otieno Parham Hospital staff administer medications for agitation. 2:30pm Police. He is restrained. Mr. Otieno becomes agitated towards Henrico
March 3rd 3:20pm medication for agitation. 5:30pm Hospital staff find conduct that Mr. Otieno is not engaging in verbal or physical threats or attacking objects or people. 6:30pm Henrico CSB concludes that Mr. Otieno is to be admitted to Central State Hospital under a TDO. TDO does not reach the hospital Parham Hospital staff administer an anti-psychotic
March 3rd 6:40pm police holding him. He strikes out, scratching and hitting one of the officers. Henrico police arrest Mr. Otieno for assault on a law enforcement officer, property damage, and disorderly conduct. 10:30pm Police take Mr. Otieno to jail. Mr. Otieno becomes agitated. He is medicated with
March 3rd 11:30pm chair and take him to a cell. Jail staff place him into an emergency restraint
March 4th 10:15am Mr. Otieno continues to meet TDO criteria. 10:30am Mr. Otieno s restraints are removed one at a time to allow him to stretch and then replaced. At this point, he has been in a restraint chair for 11 hours. Henrico County CSB evaluates again and finds that
March 4th 12:30pm TDO 4:30pm still in restraint chair. They note aggressive behavior Henrico County CSB contacts magistrate for new Henrico jail nursing staff examine Mr. Otieno while
March 5th 9:30am no available beds for Mr. Otieno at that time. 3:50pm Mr. Otieno is no longer in the emergency restraint chair. He refuses medications and has not eaten. Henrico CSB communication states that there are
March 6th A Henrico County District Court Magistrate signs the TDO. 2:30pm A struggle breaks out while deputies attempt to deliver a food tray through the slot. Six deputies enter the cell and tackle Mr. Otieno to the ground. One officer throws multiple punches.
March 6th 2:45pm the cell to a van. 4:00pm Department arrive at Central State Hospital. 4:19pm Seven Henrico County Sheriff s deputies carry Mr. Otieno into the admissions suite and place him sitting on the floor. His hands and feet are in restraints. Six Henrico County deputies carry Mr. Otieno out of Mr. Otieno and the Henrico County Sheriff s
March 6th 4:20pm remove Mr. Otieno s leg restraints. At one point, four deputies and three hospital staff are physically restraining Mr. Otieno as he sits on the floor. 4:28pm Henrico County deputies and Central State hospital staff physically maneuver Mr. Otieno into a prone (face down) position on the ground. Seven deputies and one hospital staff physically hold him down and, at one point, at least two deputies are entirely physically on top of Mr. Otieno. Henrico County deputies begin attempting to
March 6th 4:35pm verbal order for medications for agitation. 4:39pm Central State Hospital staff begin replacing the police leg restraints with hospital restraints. Central State Hospital medical provider gives a One Henrico County Sheriff s deputy shakes Mr. Otieno. Mr. Otieno does not respond. Henrico County Sheriff s deputies and Central State Hospital staff roll Mr. Otieno onto his side. Mr. Otieno is motionless.
March 6th 4:40pm and injects the medications as ordered for agitation. Mr. Otieno remains non-responsive. 4:41pm Henrico County Sheriff s deputies and Central State Hospital staff roll Mr. Otieno onto his back. 4:42pm Central State Hospital staff check Mr. Otieno s vitals and begin CPR. Central State Hospital calls Petersburg Emergency Services. One Central State Hospital staff enters the room
March 6th 5:08pm measures. 5:35pm declare Mr. Otieno dead. EMS personnel arrive and take over life-saving EMS personnel cease life-saving measures and
Our call for serious reform to prevent these tragedies in Virginia. These must include: Ending the criminalization of mental illness Strong behavioral health standards in jails and detention centers Protections for people with serious mental illness to receive appropriate care in hospitals Elimination of the use of prone restraint in all settings
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