Day One: A Nationwide Pattern of Death
This story ran in The Hartford Courant on October 11, 1998

Series Citation:
Weiss EM, et al. Deadly restraint: a Hartford Courant investigative report.
Hartford Courant 1998; October 11 – 15.

October 11, 1998
Page: A1
Section: MAIN
Illustration: PHOTOS 1-15 (color) mugs
[NO Photos or Graphics are available for posting.
However, their Captions remain included.]

With additional reporting by Dave Altimari, Dwight F. Blint and Kathleen Megan.
A Five-Part Series published in The Hartford Courant,
beginning on October 11, 1998.

A Nationwide Pattern of Death

Roshelle Clayborne pleaded for her life.

Slammed face-down on the floor, Clayborne's arms were yanked across her chest, her wrists gripped from behind by a mental health aide.

I can't breathe, the 16-year-old gasped.

Her last words were ignored.

A syringe delivered 50 milligrams of Thorazine into her body and, with eight staffers watching, Clayborne became, suddenly, still. Blood trickled from the corner of her mouth as she lost control of her bodily functions. Her limp body was rolled into a blanket and dumped in an 8-by-10-foot room used to seclude dangerous patients at the Laurel Ridge Residential Treatment Center in San Antonio, Texas.

The door clicked behind her.

No one watched her die.

But Roshelle Clayborne is not alone. Across the country, hundreds of patients have died after being restrained in psychiatric and mental retardation facilities, many of them in strikingly similar circumstances, a Courant investigation has found.

Those who died were disproportionately young. They entered our health care system as troubled children. They left in coffins.

All of them died at the hands of those who are supposed to protect, in places intended to give sanctuary.

If Roshelle Clayborne's death last summer was not an isolated incident, neither were the recent deaths of Connecticut's Andrew McClain or Robert Rollins.

A 50-state survey by The Courant, the first of its kind ever conducted, has confirmed 142 deaths during or shortly after restraint or seclusion in the past decade. The survey focused on mental health and mental retardation facilities and group homes nationwide.

But because many of these cases go unreported, the actual number of deaths during or after restraint is many times higher.

Between 50 and 150 such deaths occur every year across the country, according to a statistical estimate commissioned by The Courant and conducted by a research specialist at the Harvard Center for Risk Analysis.

That's one to three deaths every week, 500 to 1,500 in the past decade, the study shows.

"It's going on all around the country,'' said Dr. Jack Zusman, a psychiatrist and author of a book on restraint policy.

The nationwide trail of death leads from a 6-year-old boy in California to a 45-year-old mother of four in Utah, from a private treatment center in the deserts of Arizona to a public psychiatric hospital in the pastures of Wisconsin.

In some cases, patients died in ways and for reasons that defy common sense: a towel wrapped around the mouth of a 16-year-old boy; a 15-year-old girl wrestled to the ground after she wouldn't give up a family photograph.

Many of the actions would land a parent in jail, yet staffers and facilities were rarely punished.

"I raised my child for 17 years and I never had to restrain her, so I don't know what gave them the right to do it,'' said Barbara Young, whose daughter Kelly died in the Brisbane Child Treatment Center in New Jersey.

The pattern revealed by The Courant has gone either unobserved or willfully ignored by regulators, by health officials, by the legal system.

The federal government -- which closely monitors the size of eggs -- does not collect data on how many patients are killed by a procedure that is used every day in psychiatric and mental retardation facilities across the country.

Neither do state regulators, academics or accreditation agencies.

"Right now we don't have those numbers,'' said Ken August of the California Department of Health Services, "and we don't have a way to get at them.''

The regulators don't ask, and the hospitals don't tell.

As more patients with mental disabilities are moved from public institutions into smaller, mostly private facilities, the need for stronger oversight and uniform standards is greater than ever.

"Patients increasingly are not in hospitals but in contract facilities where no one has the vaguest idea of what is going on,'' said Dr. E. Fuller Torrey, a nationally prominent psychiatrist, author and critic of the mental health care system.

Because nobody is tracking these tragedies, many restraint-related deaths go unreported not only to the government, but sometimes to the families themselves.

"There is always some reticence on reporting problems because of the litigious nature of society,'' acknowledged Dr. Donald M.Nielsen, a senior vice president of the American Hospital Association. "I think the question is not one of reporting, but making sure there are systems in place to prevent these deaths.''

Typically, though, hospitals dismiss restraint-related deaths as unfortunate flukes, not as a systemic issue. After all, they say, these patients are troubled, ill and sometimes violent.

The facility where Roshelle Clayborne died insists her death had nothing to do with the restraint. Officials there say it was a heart condition that killed the 16-year-old on Aug 18, 1997.

Bexar County Medical Examiner Vincent DiMaio ruled that Clayborne died of natural causes, saying that restraint use was a separate "clinical issue.''

But that, too, is typical in restraint cases. Medical examiners rarely connect the circumstances of the restraint to the physical cause of death, making these cases impossible to track through death certificates.

The explanations don't wash with Clayborne's grandmother.

"I'll picture her lying on that floor until the day I die,'' Charlene Miles said. "Roshelle had her share of problems, but good God, no one deserves to die like that.''

With nobody tracking, nobody telling, nobody watching, the same deadly errors are allowed to occur again and again.

Of the 142 restraint-related deaths confirmed by The Courant's investigation:

* Twenty-three people died after being restrained in face-down floor holds.

* Another 20 died after they were tied up in leather wrist and ankle cuffs or vests, and ignored for hours.

* Causes of death could be confirmed in 125 cases. Of those patients, 33 percent died of asphyxia, another 26 percent died of cardiac-related causes.

* Ages could be confirmed in 114 cases. More than 26 percent of those were children -- nearly twice the proportion they constitute in mental health institutions.

Many of the victims were so mentally or physically impaired they could not fend for themselves. Others had to be restrained after they erupted violently, without warning and for little reason.

Caring for these patients is a difficult and dangerous job, even for the best-trained workers. Staffers can suddenly find themselves the target of a thrown chair, a punch, a bite from an HIV-positive patient.

Yet the great tragedy is that many of the deaths could have been prevented by setting standards that are neither costly nor difficult: better training in restraint use; constant or frequent monitoring of patients in restraints; the banning of dangerous techniques such as face-down floor holds; CPR training for all direct-care workers.

"When you look at the statistics and realize there's a pattern, you need to start finding out why,'' said Dr. Rod Munoz, president of the American Psychiatric Association, when told of The Courant's findings. "We have to take action.''

Mental health providers, who treat more than 9 million patients a year at an annual cost of more than $30 billion, judge themselves by the humanity of their care. So the misuse of restraints -- and the contributing factors, such as poor training and staffing -- offers a disturbing window into the overall quality of the nation's mental health system.

For their part, health care officials say restraints are used less frequently and more compassionately than ever before.

"When it comes to restraints, the public has a picture of medieval things, chains and dungeons,'' said Dr. Kenneth Marcus, psychiatrist in chief at Connecticut Valley Hospital in Middletown. "But it really isn't. Restraints are used to physically stabilize patients, to prevent them from being assaultive or hurting themselves.''

But in case after case reviewed by The Courant, court and medical documents show that restraints are still used far too often and for all the wrong reasons: for discipline, for punishment, for the convenience of staff.

"As a nation we get all up in arms reading about human rights issues on the other side of the world, but there are some basic human rights issues that need attention right here at our back door,'' said Jean Allen, the adoptive mother of Tristan Sovern, a North Carolina teen who died after aides wrapped a towel and bed sheet around his head.

Others have a simple explanation for the lack of attention paid to deaths in mental health facilities.

"These are the most devalued, disenfranchised people that you can imagine,'' said Ron Honberg, director of legal affairs for the National Alliance of the Mentally Ill. "They are so out of sight, so out of mind, so devoid of rights, really. Who cares about them anyway?''

Few seemed to care much about Roshelle Clayborne at Laurel Ridge, where she was known as a "hell raiser.''

But Clayborne had made one close friendship -- with her roommate, Lisa Allen. Allen remembers showing Clayborne how to throw a football during afternoon recess on that summer afternoon in 1997.

"She just couldn't seem to get it right and she was getting more and more frustrated. But I told her it was OK, we'd try again tomorrow,'' said Allen, who has since rejoined her family in Indiana.

Within three hours, Clayborne was dead.

She had attacked staff members with pencils. And staffers had a routine for hell raisers.

"This is the way we do it with Roshelle,'' a worker later told state regulators. "Boom, boom, boom: [medications] and restraints and seclusion.''

After she was restrained, Roshelle Clayborne lay in her own waste and vomit for five minutes before anyone noticed she hadn't moved. Three staffers tried in vain to find a pulse. Two went looking for a ventilation mask and oxygen bag, emergency equipment they never found.

During all this time, no one started CPR.

"It wouldn't have worked anyway,'' Vanessa Lewis, the licensed vocational nurse on duty, later declared to state regulators.

By the time a registered nurse arrived and began CPR, it was too late. Clayborne never revived.

In their final report on Clayborne's death, Texas state regulators cited Laurel Ridge for five serious violations and found staff failed to protect her health and safety during the restraint. They recommended Laurel Ridge be closed.

Instead, the state placed Laurel Ridge on a one-year probation in February and the center remains open for business. In a prepared statement, Laurel Ridge said it has complied with the state's concerns -- and it pointed out the difficulty in treating someone with Clayborne's background.

"Roshelle Clayborne, a ward of the state, had a very troubled and extensive psychiatric history, which is why Laurel Ridge was chosen to treat her,'' the statement said. "Roshelle's death was a tragic event and we empathize with the family.''

With no criminal prosecution and little regulatory action, the Clayborne family is now suing in civil court. The Austin chapter of the NAACP and the private watchdog group Citizens Human Rights Commission of Texas are asking for a federal civil rights investigation into the death of Clayborne.

Medications and restraint and seclusion.

Clayborne's friend, Lisa Allen, knew the routine well, too.

For six years, Allen, now 18, lived in mental health facilities in Indiana and Texas, where her explosive personality would often boil over and land her in trouble.

By her own estimate, Allen was restrained "thousands'' of times and she bears the scars to prove it: a mark on her knee from a rug burn when she was restrained on a carpet; the loss of part of a birthmark on her forehead when she was slammed against a concrete wall.

Exactly two weeks after Roshelle Clayborne's death, Lisa Allen found herself in the same position as her friend.

The same aide had pinned her arms across her chest. Thorazine was pumped into her system. She was deposited in the seclusion room.

"It felt like my lungs were being squished together,'' Allen said.

But Lisa Allen was one of the lucky ones.

She survived.

[Here ends the BODY of the Day One article.
Photo Caption and Graphics descriptions follow.]

Caption: PHOTOS 1-15: They were mentally ill or developmentally disabled. They died in hospitals, treatment centers and group homes. Their stories, Page A11.

PHOTO 16: LISA ALLEN spent six years in mental health facilities in Indiana and Texas. In October 1997, she was released from Laurel Ridge Residential Treatment Center in San Antonio, Texas, where her friend and roommate, 16-year-old Roshelle Clayborne, died that summer after being restrained by aides. Just three hours earlier, during afternoon recess, Allen was teaching Clayborne to throw a football. Here, Allen, now 18 and living with her family in Fort Wayne, Ind., rests in her bedroom.

PHOTO 17: THE MEMORY OF BEING RESTRAINED remains all too clear for Lisa Allen, who estimates that she was restrained ``thousands'' of times in the six years she was a patient. Here, she demonstrates a hold in which aides cross the patient's arms and pin them against the chest. This type of restraint, combined with placing the patient face down on the floor, can be deadly, particularly for children.

GRAPHIC 1: Who died and how
(Library note: This graphic was published as a pie chart, but was not available electronically in that form for this database.)

* The Courant has confirmed 142 deaths during or shortly after restraint or seclusion.
Here is a breakdown of who they are and how they died.

GENDER PCT [Percent]:
Male – 71.8 ... Female – 28.2

10 & under – 2.6
11-17 – 23.7
18-29 – 17.5
30-39 – 27.2
40-49 – 13.2
50-59 – 2.6
60 & older – 13.2

Asphyxiation, suffocation, strangulation – 32.8
Cardiac-related causes – 25.6
Pulmonary- and respiratory- related causes – 8.0
Drug- or medication-related – 5.6
Cerebral-related causes – 3.2
Blood clotting (includes emboli, hematoma) – 3.2
All other causes – 16.0
Cause not determined – 5.6

Physical restraints, theraputic holds – 47.2
Mechanical restraints – 44.1
Combination of physical and mechanical – 3.1
Seclusion-related – 5.5

Hospitals (includes psychiatric hospitals, psychiatric wards of general hospitals) – 59.6
Residential facilities (includes group homes and residential facilities for troubled youths, and mental retardation centers and group homes) – 40.4

NOTES: Calculations are based on known data. Percentages exclude cases where information was not available. Percentages are rounded to the nearest one-tenth of 1 percent.

GRAPHIC 2: Improper technique

Lack of training can cause needless deaths

* Andrew McClain, Robert Rollins and many other patients across the country died after being placed in a face-down restraint hold.

A patient can asphyxiate in these holds even if the mouth and nose are not blocked.

These are particularly deadly for children, who because of their size, do not have the strength to expand their chest against the weight of an adult.

The restraint is more dangerous when coupled with mouth coverings or drugs that suppress respiration.

The hold depicted (right) is not taught by nationally recognized training programs. It is a common -- yet incorrect -- deviation of several safe holds. The Connecticut Department of Children and Families outlawed this particular method after the death of Andrew McClain. But in the absence of strong regulation and proper training, it is still being used by institutions across the country.

[I am not sure WHERE or HOW the following information was included with this article.
However, its text was within the article's archived file I obtained in March, 2005.
Unfortunately, much of the information here is terrifically inaccurate.
If you TRULY wish to understand how forceful-prone-restraint kills people,
please read Restraint Asphyxia – Silent Killer Parts One and Two.]

How asphyxia occurs

When we breathe, the chest expands, air is sucked into the lungs and oxygen attaches to the red blood cells. The blood then brings oxygen to the body's organs. Before the oxygen is loaded onto the cells, the trash -- carbon dioxide, or spent air -- is unloaded and expelled.

As a person is held down during this type of restraint, spent air pours through the nose and mouth. The lungs deflate like a balloon untied. But when the brain sends a signal to breathe, the chest muscles fight against the weight of another body.

In this restraint, the breathing process is interrupted. No air can get in if the chest muscles are unable to expand. Tiny cells that together power the brain, the heart, the kidneys and other organs are fighting for oxygen.

How fast death occurs depends on how much oxygen the body is able to get while being restrained. If oxygen cutoff is complete, brain cells die after five minutes. Once these cells die, the fight is over. The body goes limp.

PHOTOS 16 & 17: (b&w), Rich Messina / The Hartford Courant
GRAPHIC 1: (b&w), Eric Weiss, Hillary Waldman and Chris Moore / The Hartford Courant
GRAPHIC 2: (b&w) Source: ERIC M. WEISS
With reporting by Dave Altimari,
Dwight F. Blint and
Kathleen Megan; Courant Staff Writers
Additional research was contributed by Sandy Mehlhorn, Jerry LePore and John Springer.

[Here ENDS Day One: A Nationwide Pattern of Death.]

[The following "SIDEBAR" article is one I'd not known of

October 11, 1998
Page: A11
Section: MAIN
Illustration: PHOTOS: (16 b&w) mugs
Source: Compiled by Dave Altimari Dwight F. Blint, Eric M. Weiss, Kathleen Megan and John Springer; Courant Staff Writers
[NO Photos or Graphics are available for posting.
However, their Captions remain included.]


Few took notice when Robert Rollins, a 12-year-old from New Haven, died in April 1997 during a restraint at a Massachusetts school for children with behavioral problems.

Eleven months later, a Bridgeport boy named Andrew McClain died in a restraint hold in a Portland psychiatric hospital -- under very nearly the same circumstances. In the intervening months, at least 21 other patients died during or shortly after a restraint in psychiatric hospitals, mental retardation facilities and group homes nationwide.

Together, the cases illustrate why restraint use can be deadly. The reasons -- poor training, inadequate standards, inferior emergency response, shoddy investigation -- show up time and again.

Here are the people known to have died in the 11-month period and here are their stories:

[Plz note: Medical Examiners often label causes of death that occur during restraint as, "Cardiac arrest" or "Cardiac arrhythmia," or the like. This happens when the Medical Examiner is uneducated about restraint asphyxia; or the Medical Examiner wished to avoid calling the death a homicide.]

Robert Rollins, 12
Died: April 21, 1997
Cause: Asphyxiation
Patient at: Devereaux School, Rutland, Mass.

Robert was restrained for 10 minutes, face down on the floor, after a dispute escalated over his missing teddy bear. Investigators found a significant delay in emergency response. The staffer who restrained the boy left him lying, unresponsive, on the floor. No criminal charges were filed.

Donald Hunt, 39
Died: April 25, 1997
Cause: Cardiac arrest
Patient at: The Holliswood Hospital, Queens, N.Y.

A state licensing investigation found staffers used their feet to pin patients to the floor. While working on the case, investigators also witnessed staff covering aggressive patients' mouths with towels to keep them from biting.

Benjamin Halfacre, 37
Died: May 6, 1997
Cause: Respiratory and cardiac arrest
Patient at: Hummer Lake Group Home, Brandon Township, Mich.

Halfacre struck a staffer during an argument and turned to walk away. The staffer then restrained Halfacre from behind, taking him to his knees, then face down on the ground. The death was ruled accidental. No arrests were made.

Sherilee Pettit, 35
Died: May 18, 1997
Cause: Positional asphyxiation
Patient at: Cambridge (Minn.) Regional Human Services Center

Pettit was held down in a prone restraint to prevent injury to herself or others. Four minutes into the restraint, Pettit went limp and her skin turned bluish. Her death later that day was ruled accidental.

Sakena Dorsey, 18
Died: June 10, 1997
Cause: Asphyxiation
Patient at: Foundations Behavorial Health Center, Bucks County, Pa.

Dorsey stopped breathing while she was being physically restrained, face down. No criminal charges were filed. Dorsey had a history of asthma and problems with swollen tonsils that hindered her breathing.

Maximo Martoral, 40
Died: June 24, 1997
Cause: Asphyxiation
Patient at: Newark (N.Y.) Developmental Center

A state licensing report found Martoral's care to be ``appropriate and timely with no deficiencies,'' but police were not notified of the death. The senior state police investigator in Newark said a law enforcement agency should have been contacted.

William Roberts, 34
Died: July 13, 1997
Cause: Aspiration of gastric contents
Patient at: Broome Developmental Center, Binghamton, N.Y.

Roberts was restrained to prevent him from hurting himself. Recent changes at the center had affected him adversely. He was transferred to a new unit, which led to a change in his behavior and changes in his medications. The departure of veteran staffers -- people who knew Roberts and how to deal with his fits -- also played a role, his parents say.

Michael Arnold, 19
Died: July 15, 1997
Cause: Asphyxiation
Patient at: Keystone Camp, Gouldsboro, Pa.

Family members first were told Arnold died from cardiac arrest. It turned out Arnold died while being restrained at this summer camp for group home residents. The state medical examiner ruled his death was an accident and that he died of asphyxiation caused by a seizure.

Melissa Neyman, 19
Died: July 24, 1997
Cause: Asphyxiation
Patient at: Judith Young Adult Family Home, Tacoma, Wash.

Staffers strapped Neyman to her bed at 10 p.m. and didn't check on her until the next morning. By then, she had been dead about six hours -- hanging out of her window, entangled in her own restraints. Restraints were not medically authorized, but her death was ruled accidental and no charges were filed.

Roshelle Clayborne, 16
Died: Aug. 18, 1997
Cause: Cardiac arrhythmia
Patient at: Laurel Ridge Residential Treatment Center, San Antonio, Texas.

Staffers placed Clayborne in a face-down floor hold, gave her a 50-milligram shot of Thorazine, rolled her into a blanket and put her alone in a seclusion room. Five minutes passed before a staff member noticed she hadn't moved.

Christopher Mulkey, 26
Died: Aug. 19, 1997
Cause: Severe asthma attack.
Patient at: Corpus Christi (Texas) State School

Mulkey was restrained after a fight with another patient over a radio. He died soon afterward, after complaining of breathing difficulties. The death was ruled to be due to natural causes, even though the medical examiner said the stress of the fight and restraint triggered the asthma attack.

Demetrius Jeffries, 17
Died: Aug. 26, 1997
Cause: Strangulation
Patient at: Crockett (Texas) State School

Jeffries lost consciousness while being physically restrained by two staff members after assaulting staffers. It was the second time he had been restrained that day. A grand jury did not issue any indictments.

Jimmy Kanda, 6
Died:Sept. 20, 1997
Cause: Asphyxiation
Patient at: Crows Nest Family Care Home, San Martin, Calif.

Jimmy was strapped to a wheelchair and left unattended. The workers on duty, including the home's owner, were unable to revive Jimmy because none was certified in CPR. No charges were filed, but the home was shut down.

Chris Campbell, 13
Died: Nov. 2, 1997
Cause: Undetermined
Patient at: Iowa Juvenile Center, Toledo, Iowa.

Staffers restrained Chris four times in the last 24 hours of his life. Chris, who had a pacemaker, had been transferred to four different facilities in the last five months of his life.

James Galligan, 59
Died: Dec. 1, 1997
Cause: Hypertensive heart disease
Patient at: Pembroke (Mass.) Hospital

Galligan's heart gave out as staff members held him down. No criminal investigation was undertaken, and a state licensing investigation found the situation was "handled appropriately.''

Kelly Young, 17
Died: Jan. 5, 1998
Cause: Positional asphyxiation
Patient at: Arthur Brisbane Child Treatment Center, Wall Township, N.J.

Young died in a restraint hold, but her family was initially given a different story: that Young had choked on an object. A grand jury was convened, but no indictments were issued.

Sandra Gordon, 45
Died: Jan. 6, 1998
Cause: Strangulation, blunt trauma
Patient at: Rosewood Terrace Care Center, Salt Lake City, Utah.

Gordon was discovered on the floor, entangled in restraints intended to confine her to a bed. The initial death certificate labeled it an accident. After her family sought a thorough investigation, the death was ruled a homicide. The duty nurse pleaded guilty to a misdemeanor, and the facility was shut down.

Betty Jean Knisley, 60
Died: Jan. 23, 1998
Cause: Asphyxiation
Patient at: Laurelton (Pa.) State Mental Retardation Center

Knisley was strapped in a wheelchair watching a movie in her room when a nurse checked on her about 3:45 a.m. When the nurse returned to the room 25 minutes later, Knisley was dead. She had slid downward and had strangled in the strap, which had been used to stabilize her in the wheelchair.

Edith Campos, 15
Died: Feb. 2, 1998
Cause: Asphyxiation
Patient at: Desert Hills Center for Youth and Families, Tucson, Ariz.

Edith was looking at a family photograph when a male aide instructed her to hand over the ``unauthorized'' personal item. The dispute escalated into a face-down floor restraint. Charges against the aide were dismissed.

Edward Sleeth,66
Died: Feb. 3, 1998
Cause: Blunt trauma
Patient at: Woodward State Hospital, Des Moines, Iowa

Sleeth was supposed to be restrained to a wheelchair. Although the case is closed, family members say they still do not know the circumstances in which he died.

Dustin E. Phelps, 14
Died: March 1, 1998
Cause: Undetermined
Patient at: Unnamed home for developmentally disabled children, Lancaster, Ohio.

Dustin died when the owner of the home wrapped him in a blanket and a mattress and tied it together with straps, investigators said. He was left in the mattress for four hours.

Tristan Sovern, 16
Died: March 4, 1998
Cause: Asphyxiation
Patient at: Charter Greensboro, psychiatric hospital in North Carolina.

Workers restrained Sovern face down on the floor. During the struggle, staffers put a towel over the boy's mouth and held a bed sheet around his head. No one checked Sovern's breathing or pulse during the restraint. One criminal indictment has been issued against a staffer.

Andrew McClain, 11
Died: March 22, 1998
Cause: Traumatic asphyxiation
Patient at: Elmcrest psychiatric hospital, Portland, Conn.

An aide engaged in a "power struggle'' with Andrew because the boy disobeyed instructions to move to another table at breakfast, child welfare officials found. The emergency response was marred by a minutes-long delay in calling 911, and by lack of training in CPR among staffers. No criminal charges were filed.

Caption[s]: PHOTO 1: Robert Rollins; PHOTO 2: Benjamin Halfacre; PHOTO 3: Sakena Dorsey; PHOTO 4: William Roberts; PHOTO 5: Michael Arnold; PHOTO 6: Melissa Meyman; PHOTO 7: Roshelle Clayborne; PHOTO 8: Jimmy Kanda; PHOTO 9: Chris Campbell; PHOTO 10: Kelly Young; PHOTO 11: Sandra Gordon; PHOTO 12: Edith Campos; PHOTO 13: Edward Sleeth; PHOTO 14: Dustin E. Phelps; PHOTO 15: Tristan Sovern; PHOTO 16: Andrew McClain

[The following "SIDEBAR" article is one I'd not known of

October 11, 1998
Page: A12
Section: MAIN
Illustration: GRAPHIC: (b&w)
Source: ERIC M. WEISS; Courant Staff Writer
[NO Photos or Graphics are available for posting.
However, their Captions remain included.]


Their stories were never told.

No headlines chronicled the death of Katalin Zentai. The former journalist died at a Middletown psychiatric hospital in December 1996 after being held in restraints for 30 of the last 36 hours of her life. No public outrage surrounded the death of Richard Jacob. He died after being restrained, face down on the floor, in a Windsor group home for the mentally retarded in March 1990.

Both of their cases were closed after questionable investigations by the state of Connecticut: one by the state's patient advocate that did not even address the near-daily use of restraints in Zentai's case; the other by the state Department of Mental Retardation that only obscured the cause of Jacob's death.

Their stories -- and the lessons that could have been passed along -- were simply slipped inside state filing cabinets.

Katalin Zentai spent many of her last hours, including most of Christmas Day 1996, strapped to a restraint chair at Connecticut Valley Hospital, a state-run psychiatric facility.

No one would know that, though, from reading an investigation commissioned by the state's patient advocate, the office charged under federal law with protecting patient rights.

A nine-page report, intended to probe how her death could have been prevented, discussed in detail her medication and relegated the use of restraints to footnotes.

But the hospital itself acknowledges that restraint use may well have played a role.

With breaks for meals and to use the bathroom, Zentai was restrained for 30 hours -- either tied to her bed or strapped into a ``cardiac chair,'' a sort of adjustable recliner.

Dr. Kenneth Marcus, the hospital's psychiatrist in chief, said that while restraints should be used only as a last resort, the amount of time Zentai spent in restraints was not excessive. In this case, he said, restraints were used to prevent Zentai from injury after she was hurt in a fall on Christmas Eve.

"She was unsteady and the staff didn't want her to hurt herself in another fall,'' Marcus said. He said hospital records show Zentai was constantly in view of staff, and a psychiatrist reviewed the use of restraints every three hours.

As Zentai was released from the chair on the evening of Dec. 26, blood clots traveled from her legs to her lungs. The 43-year-old former journalist, who fled Communism in Hungary and worked for the Voice of America, died in the arms of mental health aides while on a bathroom break.

The cause of death was listed as "bilateral pulmonary emboli.''

"Sometimes inactivity sets the stage for emboli,'' Marcus said. "We'll never definitively know. But it makes sense to assume it did and improve our policies.''

In the wake of her death, CVH officials instructed their nursing staff on the need to provide exercise to those in "extended restraints.''

Such cautionary words were not spread, though, to other institutions that use restraint chairs.

The state's patient advocate office, which can fill the role of messenger, did not look into the use of restraint chairs elsewhere in Connecticut, nor did it warn other facilities about the dangers of emboli.

"This death had nothing to do with restraints,'' said Susan Werboff, director of Protection and Advocacy for Individuals with Mental Illness, in an August interview.

She based her conclusion on the report commissioned by her office and done by Dr. Cynthia D. Conrad. While Conrad found that Zentai's medication may have contributed to her worsening mental condition, the report did not look into the cause of Zentai's death. Conrad declined further comment when contacted for this story.

The case was filed away.

Three months later, the extended use of a restraint chair was found to be a factor in a death at a Utah facility.

In March 1997, a Utah prison inmate died of a pulmonary embolism shortly after being released from 16 hours in a restraint chair. The inmate's family sued the state, saying that the long hours of immobilization caused the embolism.

Patient advocates and other civil rights groups pressured the state to eliminate use of the restraint chair. In July, the state of Utah settled the suit for $200,000 and discontinued use of the restraint chair.

How Richard Jacob died seems straightforward.

He stopped breathing on the evening of March 25, 1990, when aides at his group home restrained him face down on the floor with his arms tucked under his chest.

The chief state medical examiner's office said the 40-year-old retarded man died "as a result of a cardiac arrhythmia during the struggle.'' State police later cleared the staffers involved.

An outside consultant hired by the state Department of Mental Retardation noted that "an improper restraint technique might have been used.''

With these opinions in hand, officials with the state Department of Mental Retardation -- which is charged with investigating itself -- overruled both the medical examiner and its own consultant.

The department's final conclusion: Jacob died of "probable cardiac arrhythmia -- could have been caused by the lithium.''

While records show Jacob was taking lithium, neither the chief state medical examiner's office nor the outside consultant, Columbus Medical Services, found that the drug contributed to Jacob's death.

"I don't remember what the rationale was for any of the notes or any of the final finding,'' said Catherine Daly the DMR official who was in charge of Jacob's death review.

Death findings, she said, were determined during a roundtable discussion of the internal mortality review team. "It's possible that it was just noted that someone suggested that it was lithium,'' Daly said.

The team's final report also ignored five of the six recommendations offered by its outside consultant, and distanced itself from Columbus' finding.

"It is not clear that improper restraint was used or that it may have contributed to his death,'' the department's final report concluded.

The department's commissioner at the time, Toni Richardson, said she was not at the mortality review meeting and has no recollection of the case. She noted the Jacob case was handled under what was considered a new and improved review procedure.

Eight years later, 11-year-old Andrew McClain died in a Portland psychiatric hospital -- in a restraint hold virtually identical to the one used on Richard Jacob.

Peter O'Meara, the current DMR commissioner, said his department is trying to improve the way it handles allegations of abuse. A new, seven-person investigative team, which is about to begin work, includes a former FBI agent and several police officers.

"The public needs to feel that all questions are being answered, and hypotheses are either supported or they are dismissed,'' O'Meara said. "We're trying to get to a more professional level of investigation and review.
"There shouldn't be any questions lingering eight years later.''

Caption: Ignoring the experts: A twisted paper trail

A series of documents shows conflicting findings in the death of Richard Jacob, a 40-year-old client of the Connecticut Department of Mental Retardation. The conclusion reached by the department appears to ignore earlier reports pointing to an improper restraint leading to Jacob's death.

Restraint is cited...

Columbus Medical Services, an outside consultant, was hired by the state Department of Mental Retardation to investigate the circumstances of Richard Jacob's death in 1990. Its report suggested the restraint hold used on Jacob may have been improper.

...then linked to death...

A state police investigation into Jacob's death quotes the findings of the state autopsy. The medical examiner links Jacob's death to the struggle during his restraint at a Windsor group home for the mentally retarded.

...but conclusion is contradictory

With the above opinions in hand, the state Department of Mental Retardation reached a much different conclusion. In its official findings, the department suggested the death "could have been caused by the lithium.'' Neither the chief state medical examiner's office nor Columbus found lithium played a role.

[The following "SIDEBAR" article is one I'd not known of

October 11, 1998
Page: A12
Section: MAIN


Connecticut's patient advocate said The Courant's investigation of the Jacob and Zentai cases proves the need for major changes in his organization.

"We're going to get some help up here and learn from these situations ourselves,'' said James McGaughey, the exective director of Connecticut Protection and Advocacy. McGaughey said he has asked the National Association of Protection and Advocacy Systems to come to Connecticut and help his department retool. He said the process should begin later this month.

"We need to establish a very good system of monitoring that makes sure departments are conducting good quality assurance,'' McGaughey said. "And if it looks like a whitewash we're going to investigate.''

[The following TEXT headed the October 11 1998 Day One article file that I obtained in MARCH, 2005. It doesn't appear in any of the 2002 hard copies I have of this series. So, I thought I'd just stick it in HERE. The red font color is the Hartford Courant's.]


What we found

An investigation by The Courant has identified the following problems with restraint use and its oversight in psychiatric hospitals and facilities for people with mental retardation.:

PEOPLE ARE DYING. The Courant has confirmed 142 deaths during or shortly after restraint or seclusion in mental health or mental retardation facilities nationwide over the past 10 years. But because many cases go unreported, the actual number of deaths could be as high as 1,500 in the past decade, a statistical estimate shows.

NEED FOR STANDARDS GREATER THAN EVER. As more patients with mental disabilities are moved from public institutions into smaller, mostly private facilities, the need for stronger oversight and uniform standards is greater than ever.


What's to come


The aides who execute most restraints -- and provide most hands-on care -- are the least trained and lowest paid in their field. Our most vulnerable citizens -- children with mental disabilities -- are the most likely to bear the brunt of the overuse and misuse of restraints.


Oversight is haphazard, rife with conflicts of interest and ultimately ineffective. When it comes to the quality and safety of patient care, the public interest comes second to the interests of the health care industry.


A legal system designed to hold people and institutions accountable for their actions often collapses when it comes to restraint-related deaths. As a result, few are ever punished.


Dangerous restraint practices persist even though solutions are simple and straight-forward: better training, stronger oversight, uniform standards and the collection and sharing of information.


This series DEADLY RESTRAINT is available on The Courant's Web site, including a national database of restraint-related deaths, a discussion forum and more. [No longer offered without charge.]

Deadly Restraint: A Hartford Courant Investigative Report

DAY TWO; October 12: Little Training, Few Standards, Poor Staffing Put Lives At Risk

DAY THREE; October 13: Patients Suffer In A System Without Oversight

DAY FOUR; October 14: People Die And Nothing Is Done

DAY FIVE; October 15: From "Enforcer" To Counselor

Hartford Courant October 17th-published Related Article:

Hartford Courant October 24th-published Related Article:

Hartford Courant DECEMBER 16th-published Related Article:

How the Courant Conducted Its Investigation

"Glossary of Terms" used by the authors

Hartford Courant DEADLY RESTRAINT Investigation DATA BASE

To Return To Wherever You Came From

OR Use the Following Links:

Return to the Restraint Asphyxia LIBRARY

Go to the Restraint Asphyxia Newz Directory


Email Charly at:
(Those are hyphens/dashes between the "c" and "d" and "miller")