At least 11 hours restrained in a chair. That’s one of the details from an investigative report into the killing of Irvo Otieno, and the conditions that led to his death while in the custody of Henrico County sheriff’s deputies last year.

The report was published in August by the disAbility Law Center of Virginia, with Executive Director Colleen Miller presenting it along with a call for reforms to the state House Appropriations Committee during their meeting Tuesday.

Otieno died while pinned face down on the floor of Central State Hospital by deputies and hospital employees in what was later ruled a homicide by asphyxiation. Otieno had been in the custody of deputies for several days after a mental health crisis.

For Otieno’s mother, Caroline Ouko, the loss is still strongly felt and the need for change and accountability is more important than ever.

“They took his autonomy, they took his freedom,” Ouko said in a video call Wednesday alongside family attorney Mark Krudys. “They ran roughshod over my son’s patient’s rights in that hospital.”

Video of Otieno’s death attracted national attention and criticism, leading to a $8.5 million wrongful death settlement between his family and Virginia, Henrico and the sheriff. It also led to the creation of “Irvo’s Law” that guarantees access for family members to loved ones going through a mental health crisis. The bill was approved in both chambers in February and went into effect in July.

Two deputies and a former hospital worker involved in Otieno’s treatment and death face involuntary manslaughter charges.

The dLCV report includes a timeline tracking Otieno’s treatment across the last four days of his life from when a neighbor called the police about his mental health crisis on March 2.

Information shared in the report includes Otieno being placed in a restraint chair for at least 11 hours at Henrico Regional Jail West with a brief release to stretch. The report also notes unfulfilled recommendations made by the Henrico Community Services Board for him to be hospitalized for mental health care during this period.

“At this point [...] there are 158 people in the state hospital system who have been declared ready for discharge,” Miller said. “It is not a need for more hospital beds, it is a need for better community services so people can get out when it’s time for them to get out.”

According to Krudys, while the information in the report was known to them from their investigation last year, he still viewed the report as valuable. He highlighted its data on racial disparities in treatment by state police and its role in keeping Otieno’s death an ongoing concern for state lawmakers.

Ouko, Krudys and the dLCV all questioned the amount of police involvement during this period, with the report noting how they escalated the situation and interfered with Otieno’s admission and treatment.

The dLCV provided recommendations in the report and the meeting for changes and reform to prevent similar situations in the future. These included ending the criminalization of mental illness and removing the police from the response to mental crises.

They also called for improving behavioral health standards in jails and detention centers, ensuring those with serious mental illness receive appropriate care and ending the use of prone restraint, which they highlighted as a key factor in Otieno’s death.

“The events that happened to Otieno resulted in his death, and it got a lot of media attention,” Miller said. “But people with mental illness are encountering these same issues every single day in Virginia, and we really need to do something about it.”

Committee members acknowledged the tragedy of Oteino’s death and the need to ensure these situations don’t happen again.

However, they also noted these systemic issues are well known to the Virginia General Assembly, and made clear that the process to address these issues would take some time.

“It is something that all of us must get to the table and try to bring some greater resolution to,” House Delegate Delores L. McQuinn said. “I don’t think it’s going to happen swifty, it is going to be some years to get where we are trying to go.”

Ouko expressed hope that legislators would investigate and put an end to the use of prone restraints. She also emphasized the need for additional resources and training to prioritize the involvement of mental health specialists when responding to crises.

Police reform was also a critical part of mental health reform for Ouko, from changing their roles in addressing health crises to ensuring police reform would be part of changes Gov. Glenn Youngkin proposed for state behavioral health following Otieno’s death.

“So many changes are needed - Irvo’s Law is just one of them,” Ouko said. “We will need many more changes to get to a point where people who are living with mental illness or find themselves in a crisis like my son did are treated with dignity and respect.”

Criminal trials for the defendants are set to begin Sept. 30 at Dinwiddie County Courthouse.