Isolated Case or System Failure? The most critical questions of the Virginia Tech shootings are going unasked. Why did Virginia's mental health agencies let Seung-Hui Cho fall between the cracks? Is anyone else at risk? After the tragic shootings at Virginia Tech on April 16 2007, Virginia's mental health system, campus security, and campus emergency response have been subject to close scrutiny. So far, however, no one has seen fit to examine how well the Virginia Tech tragedy was covered by the media.   Four newspapers provided significant coverage of the Virginia Tech tragedy: the Roanoke Times, the Richmond Times-Dispatch, the Virginian Pilot, and the Washington Post. In the first hours and for the first several days after the shootings, reporters on those newspapers did exactly what they were supposed to do: They got to the scene quickly, constructed timelines, identified the shooter, and interviewed his roommates and firsthand witnesses.   Since then, the media has done a poor job of reporting on Virginia's public mental health system. Reporters have failed, for instance, to connect the dots between the Virginia Tech massacre and other shootings such as the 2006 assassination of two police officers in the Fairfax County, also by a mentally ill man. Journalists also have accepted the excuses of the New River Valley Community Services Board that insufficient funding was the reason why the board stopped participating in many judicial mental health hearings as required by law.   Public attention has rightly focused on the fact that Seung-Hui Cho, the Virginia Tech shooter, fell between the cracks of Virginia's mental health system. If he'd been helped, the tragedy potentially could have been averted. To its credit, the media did hone in on the question of why Cho never received his court-ordered outpatient treatment. But no one questioned the official answers.   According to Tom Geib, director of Prince William's Community Services Board, and Dr. Les Salzburg, director of the New River Valley Community Services Board, the failure was someone else's fault. The funds did not exist for the boards to fully participate in judicial mental health hearings and follow up on court-ordered treatment.   No reporter ever asked the question, "Where in your meeting minutes is the record of your decision to stop setting up treatment plans for mentally ill patients released into the community for outpatient care?"   Reporters generally are not experts on mental health quality control, nor should they be, but a good reporter knows how to talk to the right people and ask the right questions. Yet Virginia's press corps accepted the word of mental health administrators at face value. No one ever mentioned the quality control requirements on the New River Valley Community Services Board -- which the board boasts about on its web page.   The New River Valley mental health board has a special type of accreditation called CARF (Committee on Accreditation of Rehabilitation Facilities). On the board's website a stylized CARF Accreditation logo indicates, "Its programs and services are of the highest quality, measurable, and accountable".   What's a reporter supposed to get from that? Well, as the journalism school mantra goes, "Follow the money!" Community Services Boards are making a lot of noise about, and spending a lot of taxpayer dollars on, the benefits of quality control. A clever reporter would find someone to discuss the quality control system in the New River Valley and what went wrong.   The breakdown in treating Cho, it appears, occurred in QA (Quality Assurance). A key tenet of QA is to elevate the priority of critical issues until they are resolved. Who was the person in charge of Quality Assurance at the New River Valley Community Services Board?   The papers didn't say. It's unlikely any reporter ever asked, or knew to ask, or know who to talk to understand why they should ask. Perhaps some reporter was interested but he/she readers wouldn't be interested. Conceivably, someone made an editorial decision not to report on quality control on the grounds that it was just too boring.   Was it too boring?  Could a good reporter, or a good editor, or a good newspaper figure out a good way to make the topic interesting? I think the answer is yes.   To be blunt, the Richmond Times-Dispatch, the Roanoke Times, the Virginian Pilot, and the Washington Post dropped the ball, journalistically speaking. I think they did everything they needed to sell papers, and if that was their primary mission, they accomplished it. But they fell short when reporting the whole story, and in doing so, they robbed history.   The media in Virginia seems to view their role in the developing story of the Virginia Tech Tragedy as a passive one rather than an active one. New River Valley Community Services Board was only one of 40 community mental health boards in Virginia. Are the other thirty-nine boards in compliance with the Virginia laws about emergency mental health judicial hearings?   Did a reporter from the Danville Register-Bee pick up the telephone and call Lenard D. Lacke, executive director Danville Pittsylvania Community Services, and ask if that community services board is in compliance with Virginia law about emergency mental health judicial hearings? Did the Culpeper Star-Exponent call Executive Director Ron Branscome at the Rappahannock Area Community Services Board and ask about compliance?   Here is the basic question that astute reporters in every corner of Virginia should have asked: Is every community services board in the state of Virginia so under-funded that it is out of compliance with Virginia mental health law? Or are only some boards out of compliance? Or, is the problem limited to the New River Valley Community Services Board?   Of all the reporters who cover community mental health in Virginia, arguably Cyntha Pegram of the Lynchburg News & Advance is the most experienced.   She has been covering Central Virginia Community Services for more than 15 years. Yet I have seen no evidence that even Ms. Pegram asked the critical question of Central Virginia Community Services, "Is your agency in compliance with the law, and can you document with the quality records you keep that you are in compliance?"   The journalists who cover community mental health agencies in Virginia are content, it seems, to let government administrators and elected officials lead them around the nose. Journalists, who fancy themselves the tellers of truth to power, are not questioning whether mental health administrators are exercising lax oversight of their agencies.   Virginia's editorial writers are the first to pound the table and demand accountability. But there will NEVER be any accountability until the owners and editors of Virginia's Newspapers set and keep a higher standard of reporting on public mental health issues.   -- June 19, 2007