Many if not most of the restraint catastrophes are happening at facilities who need but are not trained how to properly restrain a person on the floor.  In Michigan, educators can restrain a student face down, but the state will not allow them to be trained how to restrain a student face down.  This legislation was enacted despite the fact that Michigan had a fatality because of this very policy.  

School A had a standing only restraint policy and program.  One day a student acted out in class.  The student was too violent and dangerous to be contained safely in a standing hold.  Two teachers had to contain the child on the floor, but were never trained how to do so safely.  The teachers -- not having had any training on the subject -- had to make up their own floor restraint, and did so badly by placing their full weight directly on top of the child’s back and failing to monitor the child. 

Michigan recognized that banning prone restraint would violate the professional judgment standard enunciated by the Supreme Court, not to mention the 5th and 14 Amendments of the Constitution granting each person a fundamental right to protect themselves and others.  A teacher for instance cannot be told that she cannot use prone restraint to protect herself or another.  Especially when school resource officers, parents, other students and strangers on the street would be allowed to protect themselves by using the same restraint.  Instead, Michigan illegally enacted legislation prohibiting vendors, martial arts schools, and other similar self-defense programs from teaching safe restraint to educators.   This policy smells like censorship.  

An affiiciate of the County Commissioners Association of Pennsylvania (CCAP) also agrees that the elimination of prone restraint is illegal.  CCAP further states that "[t]he research that does exist clearly identifies factors such as pre-existing medical conditions, intoxication or illegal drugs, psychotrophic drugs, obesity or inappropriate administration of holds [most of which were not intended to be prone holds, and lack of training] [as the cause of death]. . . .  There is no research to support the proposition that a prone hold is a dangerous procedure when executed properly."  CCAP also states that their 29 organizations perform 2,200 total restrictive procedures per year, including prone restraint without a single fatality due to any restraint procedure including prone. 

Michigan is already on notice that it is not always possible to contain a student in a standing or seated position.  The answer is not to censor information, but to educate.  CCAP agrees stating ". . . we believe a focus on training and education in the proper use of prone restraint is the best solution."  What happened in Michigan is not an isolated incident.  Below are stories of standing and seated restraints that went to the floor.  It is what happens when staff is kept in the dark and not properly trained.

Standing Restraints / Failure to Train

Standing Restraint / Failure to Train.

Officials acknowledged that Chase Moody died due to restraint, but stated "our staff was not trying to take this [child] to the floor in a prone position, but they ended up falling to the ground in the course of things. . . .  When they went to the ground, they did fall foward.  This young man was a pretty big fellow: He's 6'1 and weighted 180 pounds.  From our own looking into things and knowing how our staff resonded, we know hat they did the best job that they could to respond appropriately.

Note: prior to going to a standing hold only policy.  The Brown School had seated and standing holds including the basket hold.  The grand jury in the basket hold case held there was "inadequate training of the staff administering the hold."  So Brown Schools went to standing restraint only instead of training their staff how to safely administer and monitor their clients on the floor.

Just because they changed the policy, does not mean it was not a failure to train.  Brown Schools knew that it was a foreseeable likelihood that the children they cared for would not be able to be safey maintained in a standing hold, and that the staff and child may very well wind up on the floor. 

The attorney for the defendant agrees stating "I'm not going to call them victims, but they were put in circumstances without the proper tools or skills to handle the situation."

Compression of the windpipe. 

There's not much information on this fatality.  We could only find one story that gave an actual description of what caused the death, and that article said the preliminary autopsy report says compression of the windpipe.  This sounds like a choke hold or undue compression of the neck.

Basket hold / Strangulation.

Press reports state that hree staff restrained a girl in the basket hold.  However, the autopsy found hemoraging of the eyes which according to medical experts is more indicative of strangulation.  The autopsy also found bruising on the girl's neck.

Basket hold.

Stephanie Duffield died after she was restrained at the Shiloh Residential Treatment Center. The restraint used was a basket hold.  The baskethold in the prone position was found to be a dangerous restraint by the GAO in 1999. 

Basket hold/Enlarged Heart/Heart attack

Randy Steele was sent to the Brown Schools to help correct his behavioral problems.  On this occassion orderlies restained Randy when he launched into a toy-tossin gtemper tantrum after refusing to take a bath.  He was placed in a basket hold.   He died the next day.  A medical examiner found that the boy suffered a heart attack during the restraint.

A grand jury issued a report citing "the inadequate training of the staff administering the hold."

Basket hold/Tranquilizer

Roshelle Clayborne flew into a rage and swiped at a staff member with a fistful of pencils.  Workers restrained her in a basket hold and put her in a prone basket hold position.  Roshelle complained that she could not breathe, so staff injected her with throazine, a tranquilizer and she fell silent and stopped moving. 

Basket hold.

From the description it is unclear whether she was in a prone or seated basket hold.  Reports say that a worker knelt to the floor and pressed the girl's head between her knees.  This position would indicate that she was in a seated bent forward basket hold where weight and pressure was placed on her back and chest.

One worker told her that if she could talk she could breathe.  While this maybe true, her last breath might be "I can't breathe."  Apparently this was the case here as her body suddenly convulsed, then went limp. 

Side Restraint.

Willie Wright was a 14 year old 250 pound boy that was banging his head against the wall.  Psychiatric attendants were attempting to restrain him so he would not continue to hurt himself and could be sedated at the request of two physicians.  After holding Wright on his side for about 15 minutes, Wright stopped struggling and workers noticed he was no longer breathing.  They administered CPR but neither the workers nor an emergency crew could revive him.

Strangulation.

We could not find any original sources for this incident.  All we could find was the Hartford Courant Report.  According to the Hartford Courant D.J. lost consciously due to a type of restraint that caused strangulation. 

Baskethold and Thorazine.

A death of a mentaly disturbed 12-year-old boy was declared an accident by Dr. Robert Steing, Cook County medical examiner.  But Stein criticized the method of restraint used at the facilty.  Stein said that up to six staffers, up to four at any given time, kept Wauketta Wallace either on his back or his stomach wiht his arms folded across his chest. 

Stein also said that the boy suffered from mental illness and residence in a state mental faciltiy would have been more appropriate for him.  Maryville took th eboy at the request of DCFS after local mental health centers refused to accept him. 

In 2002, Illinois held that corporate foster care facilities are not entitled to parental immunity.  This is so even though according to David Schneidman, spokesman for DCFS said that the State department prescribes the restraint provisions these private entities must follow.

Basket hold.

Timoth Roberts was restrained in the basket hold after he acted up.  Grandfather used Cornell's crisis intervention training for its employees at the time. 

We note: that while Cornell did train the basket hold in a seated position.  It did not train staff to use the basket hold on a child or client in a face down position.  Though there is no indication from the media reports that the hold was used while the child was face down, and the tragedy may well have occured while the child was seated. 

Avery County commissioners unanimously passed a resolution Monday asking state lawmakers to ban the basket hold restraint.  

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Basket hold.

Two staff members restraint a nine year old boy, Earl after a verbal altercation that was about to escalate into a physical fight.  The executive director stated that the basket hold had been used on Earl before, and was part of training to handle unruly children.  Here Earl was placed face down in the hold, even though the facility admits that their restraint training vendor, Cornell-TCI, policy is that with a basket hold the child should never be taken to a hard surface and put on his stomach. 

Basket hold.

The hold used with 11 year old Andrew McClain is called a two-person therapeutic hold. It was taught to all nurses, mental health workers and others with significant patient contact at the hospital.

A staff member crosses the patient’s arms across his chest from behind and grasps both wrists. The patient is then lowered as gently as possible to the floor where he lies face down across his own arms. The worker holding the wrists may need to apply slight-to-moderate pressure to prevent the patient from rolling over, but should never apply heavy pressure.

A second worker crosses the patient’s legs at the ankles to prevent the patient from kicking. The Portland Police Department investigation later found that, in Andrew’s case, the hold had been done correctly. The theory of the hold itself was at fault.

After this fatality and the publishing of the Hartford Courant's expose on restraint, Connecticut's former Commissioner of the Department of Children and Families stated that it was doubtful that the use of the basket hold would ever be sanctioned in Connecticut again.

Basket hold.

New York State-Office of Mental Health (OMH) has a history of forcing its facilties to use badly designed training programs.  The restraint protocol at Elmcrest Psychiatric Center (EPC) is no different.  Here NYS endorsed a restraint hold that the GAO found dangerous for use at all its child and adult private and publicly owned facilities. 

Basket hold.

Not much was reported about this fatality except that he too died as a result of being restrained face down in a basket hold.

Headlock.

Investigators have been told that 16-year-old Mark Soarez died after being placed in a headlock by staff members trying to subdue the youth at a group home for troubled teenagers in Marlborough.

Richardson said Soarez received permission from a staff member to go to the "quiet room" -- a space with padded walls -- to work out his anger through shadowboxing.

But, Richardson said, he heard the counselor in question go into the room and challenge Soarez to fight. Richardson told police the counselor had Soarez in a headlock when Richardson went into the room after hearing Soarez scream: "I can't breathe."

"It appears he was restrained too tightly around the neck." Under usual circumstances, a headlock is impermissible as a restraint and using such a hold can result in sanctions, state officials said.   The Hartford Courant lists the cause of death as a caridac arrest.

Standing Restraint/Failure to Train

A student at a school district serving special education students died as a result of a floor restraint.  Details of the actual restraint are unclear as the school was put on virtual lock down and only basic and minimal information was released to the press. 

By press accounts, the school district contracted for a standing only restraint program.  Apparently the teachers could not contain the student standing up, and took the student down to the floor.  The teachers were never taught how to properly restrain or manage a student on the floor which proved to be fatal.

Basket hold / Failure to Train.

There were many many situations at this facility that led to its ultimate closing in 1999.  The first was a seated basket hold restraint that broke a girl's back.

The second was a restraint fatality.  There are no adequate press reports as it is unclear whether the staff performing the restraint were trained in the use of floor restraint.  The parent program of Desert Hills, Youth and Family-Centered Services of TX states in their literature that they use Cornell's-TCI program. We cannot confirm for 100% certaintly whether they used the program in 1998-1999.

The third incident was actually a failure to train.  According to much of the restraint literature - much of which is based on junk science and non-expert opinions -  all physical interventions are failures.  In this case, staff did not intervene and a boy was beaten in the head with a baseball bat causing him severe damage.  We wonder whether the boy that was beaten would feel that had staff intervened and stopped the other boys from breaking his face whether he would agree with these restraint experts and similarly feel that staff "failed" when they saved him from a brutal beating.

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Cleo Wallace Center / Devereux

Medical / Face down. Medically counter indicated by individual treatment plan, facility policy and obesity.

Parker's plan restricted the use of facedown prone restraint because of her obesity; she weighed 270 pounds. In addition, the Behavioral Support Plan was the only place this restriction was noted, though it also should have been included in daily progress notes under Special Treatment Procedure. Further, the Behavioral Support Plan is part of the patient's treatment plan and should have been reviewed monthly. "Had the BSP been appropriately disseminated and implemented," the report concludes, "the appropriate restraint technique may have been utilized." The training manual used by Devereux Cleo Wallace stated that a facedown prone restraint should not be used on a child 30 percent over recommended body weight. Orlena Parker's weight exceeded that percentage.

Devereux Cleo Wallace failed "to include pertinent physical monitoring information for the restraint process" in their Seclusion and Restraint Policy as required by state quality standards. The policy "did not address how the facility monitors the physical well-being of the child during and after the restraint, including but not limited to breathing, pulse, color and signs of choking or respiratory distress." El Paso County DHS' initial report indicated that staff said they had moved away from the child and came back to check on her, even though a CPI trainer said they were trained "not to leave the side of a patient who is lying still after a restraint."

The manual states that up to four, even five staff can be used, "but presents no conditions for more than five staff." If five staff members are used, three should be on the lower body and one on each arm. In Parker's case, according to the report at least six staff members -- possibly seven, depending on conflicting reports --held her down with two adults on each arm.

Cleo Wallace Center/Devereux

Medical / Three man pile-on - medically diagnosed asthmatic.

Here also there should have been a medical and treatment plan in place regarding restraining Casey Collier face down with three staff members laying across his back.  As Casey was asthmatic.

On the afternoon of December 21, Cleo Wallace employees became convinced that Casey had lost control. Two staffers grabbed him, intending to escort him to an isolation room. When he began struggling, four other employees joined in. Using a controversial method of restraint that Cleo Wallace staffers refer to as "the Illinois system," six men pressed Casey face down on the floor. One man held his head, another his arms, another his legs. Three staffers laid across his back, a procedure that, according to the autopsy report, literally prevented the asthmatic Casey from drawing air into his lungs.

Basket hold.

According to the Hartford Courant, Timothy was restrained in the basket hold face down with his arms crossed in front of his chest with staff members laying on-top of him.

Choke hold.

According to the Hartford Courant, Robert Lee Rawls was placed in a choke hold while struggling with aides.

Suffocation

According to the Hartford Courant, Roxanna Gray was restrained face down on a pillow causing her to suffocate because the pillow prevented her from breathing. 

Choke hold.

According to the Hartford Courant, Robert Rawls was placed in a choke hold while struggling with aides resulting in asphyxia leading to brain damage.

Basket hold.

According to the Hartford Courant, and confirmed by NJ State officials, Kelly Young died while placed face down in a basket hold.

Basket hold.

At the time of the Hartford Courant investigation all NYS owned and lmost icensed OMH, OCFS and OMR-DD facilities were using the basket hold as its restraint hold.  OCFS facilities approved using only the basket hold in the seated position.  NYS OMH and OMR-DD authorized the use of the basket hold in the prone position.

Basket hold.

Pursuant to a FOIL request and subsequent GAO report describing the holds used at NYS-OMH and OMR-DD facilities as a face down basket hold, this fatality is another BH related fatality.

Basket hold.

Letchworth is a facility which according to NYS and a GAO report used the basket hold and the basket hold in its face down position as its holding method.

Basket hold.

Taconic DDSO is a facility that according to NYS and a GAO report used the basket hold and the basket hold in its face down position as its holding method.

Basket hold / choking

Finger Lakes DDSO is a facility that according to NYS and a GAO report used the basket hold and the basket hold in its face down position as its holding method.

Basket hold.

Broome Dev. Center is a facility that according to NYS and a GAO report used the basket hold.  It appears that the basket hold was used in a seated position here that went unstable and fell to the side.