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Deadly Restraint
1998
The Hartford Courant


A Nationwide Pattern of Death

By ERIC M. WEISS
With reporting by Dave Altimari, Dwight F. Blint and Kathleen Megan
This story ran in The Courant on October 11, 1998
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.

They died pinned down on the floor by hospital aides until the breath of life was crushed from their lungs. They died strapped to beds and chairs with thick leather belts, ignored until they strangled or their hearts gave out.

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, [LA]. [LA] 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 [LA], 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, [LA], knew the routine well, too.

For six years, [LA], 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, [LA]  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, [LA] 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," [LA] said.

But [LA] was one of the lucky ones.

She survived.

Additional research was contributed by Sandy Mehlhorn, Jerry LePore and John Springer

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