Virginia's Most Vulnerable Left to Die: When State-Licensed Care Facilities Fail

A devastating report from the Disability Law Center of Virginia reveals that dozens of people with intellectual and developmental disabilities died in state-licensed facilities after staff failed to provide basic life-saving care.

The report examined 181 unexpected deaths and found patterns of negligence Virginia authorities have known about for years.

The Failures Were Systematic

In 46 cases, staff found patients unresponsive and didn't perform CPR at all. In 33 more, CPR was delayed. Staff gave reasons including fear of catching diseases, not knowing CPR, or believing patients were "beyond saving." Some simply refused without explanation.

Virginia requires licensed providers to have at least one person on duty at all times who is certified in CPR and first aid. That requirement meant nothing when patients needed help.

Staff delayed calling 911 in 25 cases. When they did call, problems included ignoring dispatchers, becoming too emotional to communicate, refusing to answer questions, or literally putting the phone down to do something else. In many instances, staff called supervisors first—who then called 911without firsthand knowledge of the emergency.

Fourteen patients choked to death despite having food safety plans specifically designed to prevent choking. In three cases, staff deliberately gave patients food known to present choking risks.

Virginia Has Known About This

In 2018, Virginia's Department of Behavioral Health and Developmental Services found that more than half the deaths it reviewed involved failures to follow emergency protocols. That jumped to 82% in 2019 and 2020. As of 2024, DBHDS says it's "still looking into different proven methods" to improve compliance.

Legal Accountability for Institutional Negligence

These aren't isolated incidents of individual staff making mistakes under pressure. This is systematic institutional failure. Providers repeatedly violated the same requirements with minimal consequences. One provider failed to follow its own policies 26 times across four death investigations in the same year. Another had staff fail to provide CPR, implemented a corrective action plan, then had staff fail to provide CPR again within a month.

Virginia law recognizes that care facilities have independent duties beyond individual staff performance. They must ensure adequate staffing, proper training, effective supervision, and meaningful consequences for violations. When facilities create environments where vulnerable patients die preventable deaths because staff won't perform CPR or call 911 appropriately, that represents institutional negligence.

The average age of death in these cases was 50. The youngest was 19. Nearly half couldn't verbally communicate—they depended entirely on staff observations and care.

When Virginia's most vulnerable populations are entrusted to state-licensed facilities, those facilities must meet basic standards of care. Families deserve accountability when that trust is violated.