Central State Hospital Findings Letter
June 30, 1997
The Honorable George Allen
Governor of Virginia
Richmond, VA 23212
Re: CRIPA Investigation of Central State Hospital
Dear Governor Allen:
On March 24, 1997, we notified you that we were conducting an investigation,
pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"),
42 U.S.C. § 1997 etseq., of Central State Hospital ("Central
State"), a psychiatric hospital near Petersburg, Virginia. Prior to initiating
this investigation, former Virginia Attorney General James Gilmore called
Attorney General Janet Reno to pledge the Commonwealth's full cooperation
in any Departmental investigation of the conditions. Special Litigation
Section Chief Steven Rosenbaum and his staff subsequently met with Virginia
Deputy Attorney General William Hurd and his staff to discuss the Department's
plans for investigating Central State and the Commonwealth's plans for
improving conditions at the facility. I am writing now to report our findings
with regard to this investigation.
Central State is a 495-bed psychiatric state hospital that was originally
established in 1870 as a separate institution for African-Americans who
had mental health disorders. Today, the hospital provides psychiatric services
to all persons. It serves adolescents and adult civil patients from a defined
geographic area surrounding the Petersburg area. In addition, Central State
houses the only secure forensic hospital unit in Virginia. The hospital
has six buildings that contain 20 patient wards. The patient population
is broken down as follows: the forensic unit (7 wards) is comprised of
176 patients; the adolescent unit (2 wards) houses 19 patients and the
adult civil unit (11 wards) has approximately 270 patients.
We conducted the investigation by touring the facility with expert consultants
in psychiatry and psychiatric nursing between April 28 through May 2, 1997.
During the course of this investigation, these experts made observations,
interviewed staff and patients, and examined numerous patient and facility
records, including incident and restraint statistics and summaries, committee
minutes, morbidity/mortality reviews, and facility policies and procedures.
At the conclusion of these tours, both experts provided Central State Hospital
staff and Commonwealth officials with a summary of their major findings.
On May 29, 1997, we met with Deputy Attorney General Hurd and his staff
in Fredericksburg, Virginia to discuss the status of our investigation
of Central State and matters related to our CRIPA activities in other institutions
in Virginia. We subsequently reached agreement with Commonwealth officials
on a process, with time frames, for resolving our Central State investigation.
As part of that process, the Commonwealth has agreed to take some immediate
steps to address serious deficiencies at Central State and to develop and
implement additional plans for remedial action, based upon the findings
and recommendations in this letter.
Before addressing the substantive violations, we would like to express
our appreciation to the staff of the Department of Mental Health, Central
State, and the Attorney General's office for their assistance and cooperation
during our investigation of Central State. We expect to continue to work
with these officials in the same cooperative manner to remedy the problems
at the facility.
In investigating Central State Hospital, our purpose was to evaluate
whether patients were being afforded their constitutional and federal statutory
rights. Patients in state-operated mental health facilities have a Fourteenth
Amendment due process right to adequate food, clothing, shelter, medical
care, reasonably safe conditions and adequate mental health treatment.
Youngberg v. Romeo, 457 U.S. 307 (1982); O'Connor
v. Donaldson, 422 U.S. 563 (1975). In addition, the Commonwealth
must provide public services to individuals with disabilities in the most
integrated setting appropriate to their needs. See, e.g., Title
II of the Americans with Disabilities Act ("ADA"), 42 U.S.C. §§
12132 et seq., 28 C.F.R. § 35.130(d); and Section 504
of the Rehabilitation Act of 1973, 29 U.S.C. §§ 794 et
seq. and the regulations promulgated pursuant thereto.
During our investigation, we found numerous conditions that lead us
to conclude that constitutional and federal statutory rights of Central
State patients are being violated. As detailed below, a major cause of
many of these deficiencies is that Central State has an insufficient number
of adequately trained professional and direct care staff to meet the needs
of patients. The facts that support our findings of unlawful and unconstitutional
conditions at Central State Hospital are set forth below, followed by the
remedial actions that we believe are necessary to remedy these conditions.
I. Central State Is Failing To Ensure The Reasonable Safety Of
A. Inadequate Protection From Injuries, Dangerous Behaviors, and
The facility's incident reports and special abuse investigations reveal
a high level of injuries and dangerous situations that place patients at
risk of harm. Patients are injured repeatedly due to self-injurious behavior
and aggressive acts of other patients. Many of these incidents are preventable
and reflect systemic deficiencies at Central State including lack of adequate
staffing, failure to supervise patients, and inadequate assessment and
treatment of mental illness, particularly patients with behavioral problems.
Central State does not provide needed treatment to abate or eliminate
these behaviors. For example, in the period just prior to our tour, one
patient engaged in almost daily incidents of self-injurious behavior, including
banging his head on the wall, hitting his face with his fist, punching
a wall, and assaulting others on a regular basis. Our experts concluded
that this patient did not have an appropriate treatment plan to address
his serious behavior problems. Another patient with numerous incidents
of self-injurious behavior was characterized by staff as "merely seeking
attention," resulting in her behaviors largely being ignored, rather than
The lack of supervision is prevalent throughout the hospital. It is
not uncommon, for example, for nearly half the acute admissions ward, approximately
76 patients, to be on "high risk status" necessitating staff observation
at least every fifteen minutes. In order to be placed on this status, a
physician must determine that the patient poses a special risk because
the patient is suicidal or homicidal, presents an elopement or arson risk,
or requires special precautions. Despite the potential for serious harm
posed by each of these conditions, Central State does not provide adequate
staffing to carry out the physicians' orders for enhanced supervision.
As a result, Central State patients fail to receive the professional judgments
by qualified professionals that is necessary to their care.
In addition to inadequate supervision on the acute admissions ward,
our experts found the lack of supervision and potential for harm particularly
significant on the Forensic Unit, which houses the most aggressive, assaultive
and self-injurious patients. Incident reports document numerous injuries
to these high-risk patients as a result of not being monitored adequately.
Central State also fails to take adequate steps to assess, supervise
and treat patients who are at risk of suicide. Central State has abandoned
the use of a formalized suicide assessment for incoming patients. Instead,
the standard currently used by Central State to determine whether a patient
will be closely monitored by staff rests solely on a verbalization of immediate
suicide plans at the time of admission. Without a formalized suicide assessment,
physicians are unable to determine which patients are at risk and the level
of staff supervision that is necessary to ensure a patient's safety. Our
experts found that the standard for assessing suicide risk at Central State
departs substantially from accepted professional standards.
The failure to assess and supervise patients at risk of suicide has
dire consequences for Central State patients. For example, last year one
patient was admitted with a history of suicide ideations, verbalizations
and gestures while confined to a jail. On admission, the patient denied
immediate plans to commit suicide and was not placed on any type of increased
supervision. The patient eventually hanged himself. Staff found another
patient, who had threatened to harm herself, gouging her abdomen and shouting
that she must pay for what she had done --but the patient was not placed
on increased supervision. She was found three days later underneath her
bed, nude, with a bra wrapped around her neck in an effort to strangle
herself. A review of incidents from January 1996 to April 1997 reveal numerous
suicide attempts, including repeated attempts by patients who were not
Other types of preventable incidents that occur routinely throughout
the facility demonstrate a systemic failure to protect patients from harm.
Staff also frequently fail to report injuries. For example, in one case,
a patient was discovered last year to have 42 bruises, ranging in size
from one to two inches, over his upper torso. He sustained these injuries
despite the fact that he was under supposedly 24-hour surveillance by Central
State staff. Although the facility suspected that the bruises occurred
during a two-week period of time, during which there were multiple opportunities
for staff to observe the bruises, none of the bruises were reported until
the end of the two-week period.
Central State also does not have an adequate procedure for investigating
untoward events, abuse allegations and deaths. We reviewed numerous incident
reports involving injuries where the medical staff conducted little or
no follow-up to determine the cause of the incident, its effect on the
patient, or how similar incidents might be avoided in the future. In addition,
Central State staff disclosed that follow-up is generally limited to reviewing
the initial incident report and quantifying the number of incidents rather
than identifying the reason for the incident and how to prevent it in the
future. Central State also fails to investigate allegations of abuse in
a comprehensive and timely manner. Many of the allegations of abuse cannot
be substantiated because the quality of the evidence is so poor or outdated.
Finally, the facility fails to conduct routine mortality reviews. Given
the problems with the health care delivery system at Central State, detailed
below, the failure to conduct routine, independent mortality reviews is
a serious deficiency because such reviews may reveal issues that require
These facts demonstrate that Central State residents are at serious
risk of harm and have suffered harm, in violation of their basic rights,
due to the facility's failure to provide adequate staffing, supervision
B. Unsafe and Inadequate Physical Conditions
The physical plant of the Forensic Unit is dangerous and compromises
the welfare and safety of patients residing there. The Unit has too many
patients, too little space and numerous blind spots. Moreover, temperature
control and ventilation problems pose a health risk to patients who receive
psychotropic medications that impair their ability to regulate internal
body temperature. In addition, the nurses' station does not have adequate
sight lines to allow adequate supervision of patients. Such poor environmental
and physical conditions subject Central State patients, as well as staff,
to serious risks to their personal safety and well being.
II. Central State Is Failing To Provide Adequate Mental
Health Care For Its Patients
Central State is not providing its patients with adequate psychiatric
and mental health services in accordance with generally accepted standards.
Psychiatric practices at Central State are typically characterized by superficial
evaluations, inadequate follow-ups, a lack of cogent treatment planning,
a lack of multi-disciplinary input into psychiatric treatment decisions,
and an over-reliance on restrictive interventions. Moreover, the psychiatric
and mental health services at Central State fail to provide patients with
a reasonable opportunity to be cured or function as independently as their
psychiatric conditions permit.
A. Inadequate Psychiatric and Mental Health Services
Central State frequently fails to diagnose patients' mental illness
appropriately. An adequate diagnosis is essential to develop appropriate
treatment. Inadequate diagnoses have led to improper treatment that has
harmed patients, either by subjecting them to needless or improper medications
and their attendant side-effects, or by failing to treat the underlying
mental illness, thereby exposing the patient to negative behaviors that
are not controlled properly.
Patient treatment is not multi-disciplinary, individualized or properly
managed, in accordance with accepted professional standards. Review of
patient records and interviews with Central State staff reveal little or
no evidence of multi-disciplinary participation in treatment planning.
Records demonstrate that staff are providing treatment without an adequate
understanding of the patient's problems. Treatment goals are vague and
fail to provide an objective, measurable basis for evaluating patient progress.
Treatment is also not adequately coordinated between disciplines. In
particular, master treatment and nursing care plans are inconsistent. Additionally,
nursing care plans suffer similar defects to treatment plans. For instance,
initial nursing care plans are not individualized. Patients are placed
in categories, and then all patients in the same category receive the same
nursing care plan without regard to their individual needs.
Behavioral management planning and psychological services are also inadequate.
Of the records reviewed, we found numerous patients with recurrent self-injurious
behavior who were not receiving appropriate behavioral management. This
is particularly true of the Forensic Unit. The failure to provide adequate
behavioral management has led to patients receiving little therapeutic
care, treatment and programming. To the extent that behavior programming
does exist, its negative nature predominates. The emphasis is primarily
on containment, rather than teaching alternative, adaptive behaviors.
Central State's Forensic Unit houses several patients who are dually
diagnosed as being both mentally ill and mentally retarded. Staff admit
that they are not trained to address the needs of this patient population
and that the facility offers no specialized programming. Central State
also fails to provide adequate treatment for the 22 percent of the patient
population who are dually diagnosed as having a substance abuse problem
in addition to being mentally ill.
B. Inadequate Discharge Planning and Community Services
Our consultants found that Central State's discharge planning is inadequate
and violates professional standards. Central State fails to ensure that
professional judgments about the most integrated setting appropriate to
meet each patient's needs are made and implemented with due regard to the
commitment status of the patient. Patient charts lack adequate discharge
criteria. This inhibits the exercise of professional judgment about readiness
for discharge. Our experts found Central State's discharge system to be
arbitrary, with some patients released too soon while others are hospitalized
for too long.
Discharge planning is given low priority at Central State. Discharge
plans are often developed only shortly before a patient is about to be
released, rather than being incorporated into treatment objectives in accordance
with accepted professional standards. Consequently, patients are often
discharged without a clear plan and adequate services to address basic
living needs. For example, one patient was discharged on a temporary leave
to a group home, without needed supervision, and was found shortly thereafter
in a creek near the facility where he apparently drowned. Finally, the
failure of Central State to provide adequate discharge planning for those
patients who are dually diagnosed as having a substance abuse problem in
addition to being mentally ill, results in frequent re-admissions after
these patients are discharged to the community.
The Commonwealth is not providing integrated hospital and community
services in order to ensure adequate patient transition into the community.
Because community treatment services are inadequate, persons who otherwise
could live in community settings end up being re-hospitalized.
III. Inappropriate Use of Restraints and Seclusion.
Restraint and seclusion practices depart substantially from accepted
professional standards. Despite recent improvements in hospital policy,
Central State employs an excessive amount of seclusion and restraint for
inappropriately long periods of time, contrary to accepted professional
practice. For example, incident reports reveal that staff placed patients
in restraints for extended periods of time simply because they did not
follow ward rules (e.g., left the ward without permission). In one
case, a patient was placed in restraints because he talked back to the
staff. Staff appear frequently to make ad hoc decisions about whether to
place a patient in restraints, often without appropriate precipitating
Central State's inappropriate use of restraints and seclusion as punishment
has had tragic consequences. Last year, a patient died after staff secured
her to a bed by her arms, legs and waist in five-point restraints and then
left her unattended in a locked seclusion room. Almost a year before her
death, her Central State psychiatrist had warned Central State officials
that she should not be left unattended in restraints because the patient
faced potentially life-threatening consequences from her asthma and epileptic
seizures. The psychiatrist in a memorandum titled "Duty to Warn," urged
staff members to avoid strapping down the patient as punishment. The memorandum
also noted that Central State staff continually ignored the patient as
she lay unconscious during potential fatal epileptic seizures. Appealing
for more humane treatment of his patient, the psychiatrist warned that
the seizures could be fatal to the patient because thick nasal mucus could
drain into her mouth and obstruct breathing. At the time of her death,
her behavior program provided that she be placed in restraints for 48 hours
to be renewed for an additional eight hour periods if inappropriate behavior
continued. Staff were instructed to not "engage in small talk" and to ignore
her protests. The patient had spent over 300 hours of the last two months
of her life in restraints. Our experts concluded that the facility's care
and treatment of this patient was clearly inappropriate. The year before,
another patient died while in restraints and locked alone in a secluded
Numerous other patients were documented as being restrained almost on
a daily basis. According to Central State's monthly reports on "Extensive
Use of Seclusion/Restraint," one patient was secluded/restrained for 1,727
hours over an eight month period. Another patient was reported as having
been secluded/restrained for 720 hours over a four-month period. In the
first three months of 1997, a third patient is reported as being secluded
or restrained for 668 hours. Our experts concluded that these and other
examples demonstrated an excessive use of restraint and seclusion -- a
problem that Central State staff have acknowledged. Following an internal
staffing and patient abuse report, the Medical Director announced on February
25, 1997, that seclusion and restraint would only be used as an emergency
intervention and would no longer be used as program interventions in behavior
Nonetheless, the inappropriate and excessive use of restraints and seclusion
for patients still remains a problem at Central State. While overall usage
is down, our review of restraint and seclusion data since the enactment
of the new policy still indicates the extensive use of seclusion and restraint
for many patients, particularly those with behavioral problems. For example,
on the Forensic Unit, one patient, in the one-month period just prior to
our tour, had been subjected to 33 orders of seclusion/restraint for a
total of 233 hours, an average of seven hours each time. Another patient
had 49 orders of seclusion/restraint for a total of 396 hours, an average
of eight hours each time. Moreover, Adolescent Unit physicians continue
to use the most restrictive intervention of restraint as the first choice
of behavioral treatment.
Our expert consultants found that the continuing problems in restraint
and seclusion are related to the facility's generally inadequate treatment
process. The low staffing level at Central State also contributes to the
excessive use of restraint and seclusion as the staff are unable to spend
sufficient time with agitated patients to prevent aggression or to implement
programs necessary to afford patient safety. Patients at Central State
are often kept in restraints and seclusion without any objective, recorded
criteria for their release or explanation of the problem behavior that
is being addressed by the use of restraints. Staff lack an understanding
of less restrictive measures that could be utilized where appropriate.
Patients, therefore, often remain in restraints long past the point when
professionals agree that release should occur. Monitoring of patients while
in seclusion or restraint is deficient at Central State as demonstrated
in the incidents during the past several years where patients have died.
A recent incident where a patient set fire to the bed after staff restrained
him and left him unattended in seclusion highlights this deficiency. In
sum, Central State's restraint and seclusion practices require immediate
IV. Inadequate medical care and medication practices.
Central State's psychopharmacological practices substantially depart
from generally accepted medical judgment. Little or no effort is expended
to conduct the detailed review of a patient's medication history necessary
to avoid the risk of placing patients on medications that have produced
adverse side-effects in the past or that have proven ineffective.
The medication practices throughout Central State vary substantially
and appear to be based on decisions by individual physicians who are not
properly supervised. Physicians are underutilizing standard technologies
and medications. The problem is exacerbated by confusing and sometimes
contradictory memoranda defining medication practices. Physicians fail
to justify the medications chosen for treatment or changes made in treatment.
Medications are either not changed at all or changed so frequently that
it is difficult if not impossible to ascertain the efficacy of the medication.
Our experts found medications being prescribed at sub-therapeutic levels.
The result is that medications are not working, patients are acting out
more, and staff rely on restraints as a means of patient control.
We further found inappropriate and excessive use of medications on a
pro re nata ("PRN"), or "as needed" basis. This practice
gives discretion to unqualified staff to determine when medications should
be given to a patient. Moreover, nurses fail to document the effect of
PRN medications in violation of standard nursing practices.
Comprehensive assessments of patients' health care needs and evaluation
of the efficacy of treatment interventions are a critical component of
adequate health care. Central State physicians, however, are not routinely
performing adequate assessments. Nor does the staff act in an interdisciplinary
way to identify, plan for, and treat the specific needs of patients. This
lack of interdisciplinary communication is a basic failing that negatively
affects practically every aspect of patient care at Central State.
Emergency medical care at Central State is also inadequate. Our nursing
expert concluded that inadequate medical emergency response was a contributing
factor to two deaths at Central State that occurred during the past year.
In one instance, there was a delay in initiating cardiopulmonary resuscitation.
In another instance, there was a delay in providing emergency medical equipment.
One of the deaths occurred on the weekend in the Forensic Unit, where there
is only one registered nurse on duty for an entire building of 176 patients.
Central State staff and administrators admit that nursing care is particularly
understaffed. The nursing shortages have resulted in a lack of monitoring,
review and coordination of medical services. Our nursing consultant found
that to make up for the lack of nurses, Central State has had to use an
excessive rate of overtime since the beginning of the calendar year. To
continue the use of overtime at the same rate for the entire year would
result in the equivalent of hiring 53 additional full-time nurses. This
excessive use of overtime in a mental health facility is dangerous and
does not comport with accepted professional standards.
Inadequate and incomplete record keeping practices deprive Central State
staff of information necessary to make professional decisions concerning
patient care and treatment. Patient charts lack sufficient medical histories
of patients to allow professional judgments to be made regarding treatment.
Diagnostic evaluations lack appropriate documentation and justification.
Our consultants found that staff did not record patient response to prescribed
treatment and medication. Records regarding the detection, evaluation and
management of drug side effects were absent from patient charts. Nor do
the records reflect explanations for changes in treatment or follow-up
procedures pertaining to recognized medical conditions. In sum, Central
State records lack relevant clinical information necessary for staff to
make professional decisions.
MINIMUM REMEDIAL MEASURES
I. Protection From Harm
1. Central State must provide a safe environment for its patients. Staff
members should adequately monitor and safeguard the patients, especially
those with histories of exhibiting behaviors that cause injuries to themselves
or others. Patients also must be protected from being victimized by other
2. Central State should employ sufficient trained, independent investigators
to ensure that all incidents of abuse, serious injury or unexpected death
are adequately investigated.
3. Central State should develop and implement adequate suicide prevention
measures, including initial assessment protocols and a sufficient number
of qualified staff to adequately supervise suicidal patients.
4. The physical plant of the Forensic Unit needs to be modified to ensure
the safety and well being of Central State patients and staff.
5. Central State should hire and deploy a sufficient number of qualified
direct care and professional staff necessary to provide patients with adequate
supervision and medical and psychiatric treatment.
6. Physician orders for enhanced supervision must be communicated to
appropriate staff and implemented.
II. Mental Health Care
1. Central State must evaluate, diagnose, treat, and discharge patients
consistent with generally accepted professional standards. Individualized
psychological assessments should be performed promptly in accordance with
professional standards. In particular, such assessments should be conducted
for patients who repeatedly engage in problem behaviors.
2. The treatment process should be reformed. Patient treatment must
be appropriate, individualized, coordinated, and properly managed. Such
programs should give each patient a reasonable opportunity to be cured
and function as independently and effectively as possible given his or
her individual condition. To that end, treatment planning should reflect
multi-disciplinary thinking. Patients should have appropriate input in
the treatment process. Treatment should be based on objective data and
clearly established goals. Staff should be trained to write professionally
appropriate behavioral goals and objectives. Data collected by staff for
treatment decisions should be adequately incorporated into the treatment
planning process. Master treatment and nursing care plans need to be consistent
and adequately organized for staff review.
3. Central State needs to provide adequate treatment for patients with
specialized needs. If mentally retarded patients continue to be housed
at Central State, they must be provided with adequate individualized treatment
and training. Patients with a dual diagnosis of substance abuse should
be provided adequate treatment for that problem.
4. Qualified professionals at Central State must evaluate patients to
determine the most integrated setting appropriate to meet their needs.
Discharge criteria need to be adequately developed and discharge planning
should be a consideration long before a patient is about to be discharged.
Central State must develop and implement adequate discharge plans that
identify the necessary aftercare services to meet the needs of patients
upon discharge. The Commonwealth should develop a quality assurance/improvement
system to oversee the discharge process. This system should ensure that
patient discharge plans are implemented and that appropriate aftercare
services are provided that meet the needs of the patient in the community.
Individualized, professionally justified placement decisions should consider
a patient's needs.
III. Seclusion and Restraint
1. Seclusion and restraint policies must comport with professional standards
and must be conducted in a safe and appropriate manner. The practice of
using seclusion for the convenience of staff, or in lieu of treatment,
must cease immediately. The decision to seclude and/or restrain a patient
should only be employed pursuant to the exercise of professional judgment
by a qualified professional (i.e., psychiatrist, medical doctor,
psychologist, or registered nurse). Patients in seclusion and/or restraint
should be adequately and appropriately monitored. Use of seclusion and
restraints should be properly documented and reviewed in a timely fashion
by qualified staff. Criteria for release from seclusion and restraints
should be clearly identified, and use of seclusion and restraints as part
of any treatment process should be professionally appropriate and regularly
IV. Medical Care and Medication Practices
1. Central State's psychopharmacological practices must comport with
generally accepted professional standards. Patients should receive prompt
professional evaluation of medical problems. All use of drugs should be
professionally justified, carefully monitored, documented, and reviewed
by qualified staff.
2. Central State must provide adequate and appropriate psychiatric and
mental health services in accordance with accepted professional standards.
3. Central State must ensure that its patients receive adequate medical,
including emergency, care in accordance with generally accepted standards
of care. Central State should ensure adequate and appropriate interdisciplinary
communication among relevant professionals, and Central State physicians
should write appropriate, complete and clear orders pursuant to professionally
4. Central State should develop and implement an adequate quality assurance
process in accordance with professionally accepted standards.
* * *
Pursuant to the Civil Rights of Institutionalized Persons Act, the Attorney
General may initiate a lawsuit to correct deficiencies at an institution
forty-nine days after appropriate officials are notified of them. 42 U.S.C.
§ 1997b(a)(1). We know that Virginia is already engaged in efforts
to improve conditions at Central State and look forward to receiving the
initial plan of correction based upon these efforts. As we have agreed,
we will give the Commonwealth an opportunity to respond to this findings
letter in accordance with the time frames agreed to in the correspondence
between Special Litigation Section Chief Steven Rosenbaum and Virginia
Deputy Attorney General William H. Hurd.
Again, we want to thank you for your cooperation. We will continue to
work with you and other Commonwealth officials to resolve the serious deficiencies
we have identified.
Isabelle Katz Pinzler
Acting Assistant Attorney General
Civil Rights Division
cc: The Honorable Richard Cullen
Commonwealth of Virginia
Mr. Robert Metcalf
Department of Mental Health and
Mr. Timothy Kelly
Department of Mental Health
Mr. James C. Bumpas
Central State Hospital
Helen F. Fahey, Esq.
United States Attorney
Eastern District of Virginia