RICHMOND, Va. (WRIC) -- If there’s one thing that Virginia lawmakers agree on across the political spectrum, it’s that the Commonwealth’s mental healthcare system is broken. Eighteen months after Irvo Otieno’s in-custody death, they still find themselves reviewing how the cracks and chasms led to the death of yet another Virginian in crisis. Those cracks include insufficiently trained officers and healthcare workers, a system that funnels mental health patients towards jail instead of treatment and facilities already under strain that wouldn’t have the capacity to admit all Virginia’s jailed mental health patients even if the funnel was turned upside down. All of that only scratches the surface of Virginia’s problems, according to lawmakers who spoke Tuesday at a House of Delegates appropriations committee meeting. "We don't want to break people." Law enforcement consultant, former police chief Mike Jones In that meeting, they heard a presentation from the disAbility Law Center of Virginia (dLCV) about all the failure points in Otieno’s case. All the lawmakers agreed there are a host of issues that need to be solved to make a dent in the crisis. Law enforcement consultant and former police chief Mike Jones said that, as long as law enforcement has to continue responding to mental health crises, the initial solutions should center on giving them more tools and options with which to tailor their response to each individual. MORE: Report calls for changes after finding ‘cascade of systemic failures’ led to Irvo Otieno’s death “If you only have one way to do things, then that's the only way you're going to use,” Jones said. “And if you feel one thing doesn't work, you're going to escalate it until it either breaks or it works. We don't want to break people.” After reviewing new videos 8News obtained in one of three criminal cases related to Otieno’s death, Jones provided several recommendations he thinks could help prevent similar tragedies in the future. LAW ENFORCEMENT RESPONSE First, he said law enforcement should be trained to not reflexively respond to mental health patients with a large number of officers. He said that, while the initial call response seemed to go well — with Henrico County police officers outside Irvo Otieno’s home invoking his name and responding to his verbal threats with calm voices — the ever-increasing number of officers as they waited for one of the county’s crisis intervention teams probably didn’t help the situation. People in crisis may already be scared, he said, and large groups of officers may only increase that fear. “With mentally ill people in crisis that happens,” Jones said. “They're frightened. They don't know where they are, they don't know what they're doing. So there's a level of compassion that needs to be understood.” Having a single leader in charge of the scene, he said, can ensure that one single person is focused on the actions of the person in distress and how law enforcement’s interactions are helping or harming the situation. Jones said he was concerned that the videos indicated there was no clear scene leader in most cases across Otieno’s three days in Henrico police and deputy custody. MORE: New videos shed light on Irvo Otieno’s time at Henrico hospital and jail before in-custody death The videos, he said, underscore that law enforcement officers remain largely unprepared to handle the mental health patients who end up in their custody. He questioned whether they had the training and experience to deal with things in a more de-escalating manner, or the equipment that would’ve made getting Otieno to treatment easier. Trying to force Otieno into a cruiser, he said, likely only exacerbated Otieno’s condition. A paddy wagon -- or some other large vehicle -- would have given everyone more space to maneuver and may have left Otieno feeling less trapped. Eventually, an ambulance came to take Otieno to Parham Doctor's Hospital. But, when he arrived there, another chain of events began -- which Jones, the disability Law Center of Virginia and the Virginia Department of Health have all identified as another missed opportunity to help Otieno. “The fact is that Mr. Otieno was taken into custody for treatment and when he was at the hospital, he should have been there for treatment,” said dLCV executive director Colleen Miller. “Law enforcement, the sheriffs are not in a position to offer treatment, are not in a position to offer evaluations. It's not their job. And they should not have been engaged in that process at all.” TRANSFER OF CUSTODY Our review showed officers tussling with a shackled Otieno several times before and after medical staff delivered one of many calming injections he received over a six-hour period. At every point in videos where we see Otieno and officers physically engaging, at least two of his limbs are handcuffed to the hospital bed at all times. PREVIOUS: ‘My son was treated like a dog:’ Irvo Otieno’s family speaks after seeing video of the moments before his death Parham staff told the Virginia Department of Health investigators that their “care was interrupted by the intervention of Henrico County police officers.” Jones questions why Parham staff, like Central State Hospital staff days later, didn’t do more to communicate to officers that they were overstepping their role and that Otieno was now under their care. At that point, he said, all that was needed was for law enforcement to have eyes on Otieno to ensure he didn’t escape until he was admitted. Instead, several officers were often seen in the room, with multiple at any given time interacting physically with him. At different points over those six hours, one officer hits him and, eventually, Otieno hits him, too. According to Jones, officers should allow patients to self-calm and have cooling-off periods without their presence since officers can escalate aggressive behavior in times of crisis. While awaiting the arrival of the temporary detention order a magistrate determined was needed, Otieno was charged with assault on a law enforcement officer, disorderly conduct and vandalism. Officers took him to jail instead of leaving him in the care of Parham workers. After the VDH investigation, Parham committed to reeducating all its staff on proper protocol when police bring a patient to them for care. It now requires its staff to “clearly communicate to law enforcement when a patient is in a mental health crisis and that the [emergency department] staff intends to continue to provide stabilizing treatment.” PREVIOUS: Family, defense attorneys weigh in after murder charges in connection to death of Irvo Otieno were downgraded Staff also must communicate to law enforcement a patient’s commitment status, that the patient is actively receiving treatment and that removing the patient would be against medical advice and explain the risks and potential harm. If officers still decide to take them, staff must document the notification in the patient’s medical record and also notify the following of law enforcement’s decision: the hospital administrator on call, the behavioral health authority or community services board, the magistrate and the police department that removed the patient. This kind of protocol is something advocates like the dLCV would like to see standardized and mandated across the commonwealth in order to “protect the rights of patients in hospital settings to ensure necessary care." Jones noted that such a mandate would ensure that law enforcement isn’t unnecessarily dealing with people in crisis. It would also improve the ability of law enforcement to follow another of the dLCV’s recommendations, which is to “prevent the criminalization and unnecessary incarceration of people with disabilities." But even if Otieno had never ended up in jail, the dLCV’s report found he likely wouldn’t have gotten the care he needed in a timely manner. In the six hours he spent at Parham, he remained in the emergency department. He never once saw a psychiatrist. PREVIOUS: Irvo Otieno’s family settles with Virginia, Henrico and county sheriff for $8.5 million over his death The report references a 2015 study by the National Alliance on Mental Illness, which found that 38% of mental health patients in the ER waited more than seven hours to see a mental health professional. Miller revealed to lawmakers on Tuesday that “many Virginia providers report that, since 2015, the situation worsened after the passing of the ‘bed of last resort’ legislation.” On top of that, had Otieno been stabilized appropriately at Parham and thus ready to be transferred to a state-run behavioral health facility, it isn’t clear there would’ve been one to take him. Two days later, on March 5, as his condition deteriorated in Henrico Jail West, the Henrico CSB communicated that there were no beds available. At that time, there were 158 patients across the state who had been clinically ready for discharge for at least seven days. FINDING SOMEWHERE FOR PATIENTS TO GO House Appropriations Committee chairman Del. Mark Sickles (D-Fairfax) said during Tuesday's meeting that stabilizing care for a person in crisis is meaningless when a person will leave a facility homeless. “I'm surprised it's only 158 ready for discharge, to tell you the truth,” Sickles said. “But this committee has put a lot of money into permanent supportive housing to attack this problem. We have got to have housing or they can't leave the hospital. They shouldn't be in these situations.” Figuring out how to acquire, build and fund more permanent housing is a goal of the committee. It’s one of the next steps several seemed to agree must be a priority to free up more bed space. But money seems to be one of the central issues in solving this crisis. Lawmakers noted behavioral health workers don’t get paid enough to recruit enough people to the field, leaving hundreds of openings across the state. Opening crisis response centers also requires money. Then, you need to staff them with people who, again, aren’t willing to work for the wages being paid. PREVIOUS: Construction begins on youth mental health crisis center in Henrico It also costs money for jails to have psychiatric treatment available on the weekends -- which Henrico County Jail West and many others do not -- despite the fact that jail populations are increasingly filled with people struggling with mental illness. So far, lawmakers have not made it a priority to make funds available to fulfill the dLCV’s recommendation “to implement adequate health and behavioral standards in jails” by implementing the “Minimum Standards for Behavioral Health Services in Local Correctional Facilities” that were drafted by an advisory group half a decade ago. But one thing that requires no money to do, Miller says, is to ban law enforcement from using the prone, or face-down, restraint under any circumstances. Virginia already bans it for its behavioral health facilities -- as the dangers of this position have been well-documented for decades. The dLVC notes that “restraining someone in a face-down position for an extended period of time disrupts the flow of oxygen, increasing the risk of losing consciousness and potentially cardiac arrest." PREVIOUS: ‘He was just gasping for air:’ Family attorney weighs in on Otieno’s cause and manner of death In addition to licensed mental health providers, Virginia assisted living facilities, private and public schools all ban the use of the restraint. The report goes on to state that law enforcement “has been aware of the risks of prone restraint since the 1990s” and that the International Association of Chiefs of Police cautions against its use. Using dangerous restraint types, Miller said, can and should immediately change. “They are, if not deadly, going to be very dangerous to an individual's health prone restraint should just not be permitted,” Miller said. “There shouldn't be discretion.”