People in the Bexar County Jail who have been found mentally incompetent to stand trial can wait months for a psychiatric hospital bed before their criminal cases can move forward. A federal judge has now ordered Texas to eventually cut that wait to no more than 21 days — and this week refused the state’s request to put that mandate on hold while it appeals.
U.S. District Judge David Ezra on Thursday denied the Texas Health and Human Services Commission’s request to stay a sweeping July ruling that found the state’s prolonged detention of defendants awaiting competency restoration violates their constitutional rights.
A defendant is deemed incompetent to stand trial when a judge finds that, because of mental illness or an intellectual disability, they cannot understand the criminal proceedings against them or adequately assist their attorney. Their criminal case is paused while they undergo competency restoration — treatment intended to stabilize them enough for the case to resume.
That treatment typically takes place in a state psychiatric hospital. But a shortage of forensic psychiatric hospital beds — beds that serve those accused of crimes —has left thousands of defendants across Texas waiting in county jails for space to become available.
The ruling does not require Texas to meet the 21-day standard immediately.
Ezra gave HHSC four years to comply and ordered the state and plaintiffs to develop interim benchmarks and a monitoring plan during that period. By denying the stay, however, that process must continue while the state challenges the ruling before the 5th U.S. Circuit Court of Appeals.
The implications are significant in Bexar County, where defendants found incompetent to stand trial routinely spend far longer than three weeks waiting in jail for treatment.
Texas separates defendants awaiting inpatient competency restoration based on the level of security they require. Maximum-security beds generally serve defendants who require the state’s most restrictive forensic setting, while non-maximum-security beds serve those who can receive treatment in a less restrictive secure facility.
From September 2025 through the end of June, Bexar County defendants who were eventually admitted to state facilities waited an average of 196 days for a maximum-security bed and 229 days for a non-maximum-security bed, according to data obtained from the state.
In Texas, the maximum sentence for a Class B misdemeanor is 180 days in jail; for a Class A misdemeanor, up to one year. For some non-maximum-security defendants found incompetent on misdemeanor charges, the wait for a hospital bed can therefore exceed the sentence they could have received if convicted.
When that happens, defendants can legally time out — reaching the maximum period they can be confined without being restored — and their cases can be dismissed, often with referrals to civil or outpatient treatment.
At the end of June, 112 Bexar County defendants were still waiting for placement — 28 for maximum-security beds and 84 for non-maximum-security beds.
From September through June, an average of about 105 Bexar County defendants were on the state’s forensic waitlist each month, down 31% from an average of about 152 during the same 10-month period a year earlier.
The decline is also visible statewide. An average of about 1,669 defendants were awaiting competency restoration placement each month from September through June, down 19% from about 2,058 during the same period a year earlier. The statewide waitlist stood at 1,628 people at the end of June.
Even as the overall waitlist declined, Texas defendants who were admitted to state facilities during the current fiscal year still waited an average of 214 days for maximum-security placement and 180 days for non-maximum-security placement.
Reducing the wait
In response to an inquiry regarding the ruling, a spokesperson for HHSC said the state has spent billions of dollars expanding its psychiatric hospital system.
Since 2017, the Legislature has appropriated more than $2.5 billion to replace, renovate or expand state hospitals. The agency pointed to projects funded during that period that are expected to add more than 680 state hospital-owned beds, including more than 300 maximum-security beds when completed.
As of June, Texas had 2,110 operational forensic beds available for use and funding for 2,299, according to data provided by HHSC. The agency said construction is underway on state hospitals in Amarillo, Lubbock, Wichita Falls and Terrell, while expansion and renovation projects continue in San Antonio and Harlingen. Those projects are slated for “substantial completion” in late 2027, according to HHSC’s website.
Additional grant-funded construction projects approved by the Legislature are projected to add as many as 332 mental health beds, while capacity is also expected to increase as the Texas Behavioral Health Center ramps up operations in Dallas.
HHSC pointed to those investments in asking Judge Ezra to pause his order, arguing the state is already taking significant steps to increase capacity and reduce the forensic waitlist while additional hospital projects come online.
The state also argued that requiring it to begin complying with the ruling while its appeal is pending would interfere with decisions about how Texas allocates mental health resources and could force the agency to prioritize forensic patients over other people seeking state psychiatric care.
But the judge rejected the state’s characterization of his order as requiring an immediate overhaul of the system. HHSC is not currently being ordered to fund a particular project, build a hospital or enter into a specific contract. Instead, the agency retains discretion over how it reduces the wait, Ezra wrote.
In the immediate term, the state must work with the plaintiffs to establish interim benchmarks for reducing wait times and submit a proposed schedule to the court. Ezra dismissed HHSC’s argument that participating in that process while the appeal proceeds would cause irreparable harm, writing that, for now, the agency is simply being asked to “lay out a schedule” for meeting those benchmarks.
Unless the appeals court intervenes, that process will have to move forward while HHSC challenges the ruling.
Local efforts at play
While the state works to increase hospital capacity, Bexar County has increasingly relied on jail-based competency restoration to treat some defendants without waiting for a state hospital placement.
The Center for Health Care Services’ jail-based competency restoration program provides treatment inside the Bexar County Jail to defendants who have been found incompetent to stand trial. Since the program launched, 104 people have been restored to competency, according to CHCS.
The program screened 171 people and served 56 during the current fiscal year through June, with 88% of participants restored to competency. That is up from a 63% restoration rate in fiscal year 2025 and 58% in fiscal year 2024.
Dr. Amber Pastusek, CHCS’ chief medical officer, said additional state funding could expand that work, but jail-based restoration is only one piece of addressing the broader problem.
“I think there’s two sides of this,” Pastusek said. “If we can get people the right care at the right time, and not have to land in jail, I think that’s one area to target.”
That’s where the broader conversation on diversion could come into play.
CHCS is currently working with the city of San Antonio, Bexar County, law enforcement and other partners, including UTHealth Houston School of Public Health in San Antonio, on a feasibility study examining the creation of a diversion and deflection center in San Antonio.
Diversion and deflection programs are designed to steer people away from the traditional criminal justice process when treatment or other services may better address the underlying circumstances that brought them into contact with law enforcement.
In this case, the goal would be to identify some people whose alleged low-level offenses are driven by untreated mental illness or substance use and connect them with care before they are booked into jail.
The feasibility study is examining Bexar County jail data to determine how many diversion beds the community would need and is expected to conclude by the end of the year, with a formal report anticipated in January.
At roughly the same time, CHCS hopes to launch a pilot using an unoccupied wing of one of its facilities to test the concept on a smaller scale. The proposed 15-bed program would serve adults accused of certain low-level, nonviolent misdemeanor offenses whose mental illness or substance use is believed to have contributed to the alleged conduct.
Under the proposed model, officers would conduct an initial behavioral health screening in the field and consult with a clinician through STRAC’s MedCom system. Depending on that assessment, a person could be sent for emergency psychiatric care or detoxification, or, if eligible and willing to participate, taken directly to the diversion center instead of being booked into jail.
Participants could remain at the center for up to two weeks while receiving medical and psychiatric care, substance use treatment, counseling and case management.
Pastusek said the goal would extend beyond the initial stay, with discharge planning beginning on the first day and an aftercare team following participants for about 90 days as they connect with housing, benefits and ongoing treatment.
The pilot is expected to launch in late 2026 or early 2027 if funding can be secured. Pastusek said CHCS and its partners have developed a proposed budget but declined to disclose the amount.
