Andrew McClain
April 11, 2002 - March 22, 1998
Only one short month after the death of her son, Lucinda
McClain was still waiting for someone to explain to her how and why it
could have happened. Andrew had died of Asphyxia while he was restrained
by
staff at the Elmcrest Psychiatric Center where he
was a living, in Portland, Connecticut.
Andrew's mother knows that he had a history of behavior
problems and was taken away from her and put into the custody of the state,
two years before his death. Lucinda also knows that her son died as a result
of being crushed on March 22, 1998, while being held down by health care
workers who were using what is known as the "Basket
Hold" to restrain him. Lucinda has two other sons,
age nine and ten and six year old twin girls who were taken away at the
same time as their brother Andrew, but, have since been returned to her.
Andrew was supposed to go home in June of 1998:
"How can I explain to my other children what
happened to their brother when I don't even
know. Andrew was under five feet tall and
weighed less than 90 pounds, so I don't
understand why it took two adults sitting
on him from behind to restrain him''
An investigation was being done by the Department
Of Children And Families, The Department Of Public Health and the Portland
Police Department. None of these departments identified the two health
care workers responsible for the death of Andrew, they were placed on medical
leave according to Michael Suchopar, the Vice President of operations at
Elmcrest.
Michael Suchopar said that Elmcrest was still working
through the details of what had happened to Andrew that day.
The facility
was also in the process of training all of the staff in cardiopulmonary
resuscitation. This is not something that had been required by the state.
Michael said that staff will continue to use the "Basket Hold",
though they were going to better monitor all restraint
holds in the future:
''We do not know all of the details of what
happened to Andrew McClain. But the entire
Elmcrest staff is saddened by this loss, and
we share in the grief of the family.
Because the police and the medical examiner's
investigations are incomplete,
we have not had access to those investigations,
and, on the advice of their
attorneys, the staff members involved have
not been able to talk with us
beyond brief interviews given on the day of
the tragedy''
The Department Of Children And Families and the Department
Of Public Health had begun to investigate the conditions at Elmcrest. The
Center was under 24 hour monitoring and agreed to stop taking in new patients
until the results of the investigation into the death of Andrew is complete.
State officials have said that the same hold that was used on Andrew, killed
another boy, 12 year old Robert Rollins, the previous year. The "Basket
Hold" is described as the person being held face down on the floor with
their arms wrapped around their chest and their wrists being held by someone
who is above them. The state decided to ban the "Basket Hold" in ALL
state center, due to the two deaths, that order came from Kristine Ragaglia,
the commissioner of the states Department Of Children And families.
Two panels, one appointed by Kristine and the other
headed by the states new child advocate, Linda Pearce Prestley, were reviewing
the circumstances surrounding the deaths of the two children as well as
the policy, procedures and training given regarding restraining holds and
if these holds put children at greater risk:
''We've got to get some answers and come up
with a statewide policy on therapeutic restraint holds,
and quickly''
At the time of Andrew's death, there was no official
state policy in regard to therapeutic holding. It was suggested that the
reason these two boys died because of this hold was because it was improperly
done in both cases. The hold has been used thousands of times with- out
any problem. Kristine says she is sure that the "Basket Hold" will
never be approved again, in Connecticut:
''Whether an aberration or not, when you have
the deaths of two children, you have to
question the wisdom of using that particular
hold when there are so many other
ways to restrain someone. I wish I could say
that restraint holds were never needed,
but the truth is that when children, and even
adults, are out of control and are
in a position to harm themselves and others,
as a last resort the holds must be used''
The head of the Child Fatality Review Panel, Linda
Prestley, said that her panel was investigating the death of Andrew. The
panel includes the Chief State's Attorney, John Bailey, the Chief State
Medical examiner, Wayne Carver and the Farmington Police Chief, Leroy Bangham.
Kristine said that the recommendations of the panel would be used in the
review process of her own panel:
''This was a terrible tragedy that raises
many questions about restraint holds: how they are used,
what kind of training is being provided and
who should be legally entrusted to use them''
Ms. Prestley
Included in her comments, Linda said that she was
in support of the decision made by Kristine Ragaglia to ban the basket
hold, though she was concerned that health care workers might not know
how to react in other situations where restraint might be necessary:
"When a child is so out of control that he
or she is about to hurt themselves or someone
else, it can be just as dangerous, even more
dangerous, not to use some kind of
restraint method. You can't completely ban
the holds, because that would endanger
far more children's lives than the few who
have tragically died as a result
of their use''
There are no national surveys or statistic available
on the number of children or adults who have been injured or even die as
a result of these holds. Policies regarding the methods are lacking and
the deaths of the two boys at this facility prove that it IS time
to develop national and state standards regarding restraining patients.
Dr Betty Spivak, a child abuse expert and also a
member of the review panel said that she expects the panel to review the
entire process which lead up to Andrew being taken to Elmcrest, when he
got there and when he was to be returned to his family:
''We're going to have to define how and
when holds are used and develop strict training
guidelines that clearly delineate who can
use these holds and under what specific
circumstances and conditions. The restraint
issue is of course a very crucial one.
But it would be a mistake and negligent of
us to only focus on the final 10 or 15
minutes of this little boy's life. We must
determine how and why he came to be
at Elmcrest, who made those decisions and
whether they were the best decisions
for him"
Dr Marijke Kehrhahn who was the facilitator of the
50 member panel appointed by Kristine, commented that her group is studying
a wide range of the states restraint policies and procedures. Reviewing
the policies and procedures at psychiatric facilities would help to develop
new statewide policy and better protocol:
''We're facing a very daunting and ambitious
30-day task, but we've got to develop real
boundaries regarding the use of therapeutic
holds because something is clearly
going wrong"
The attorney for the McClain family, vincent Trantolo
said:
''This was as shocking a death as the
state has ever seen, and I am appalled as
both a citizen and parent. I can't imagine
any situation that would require an
adult sitting on a child and holding him face
down while crushing his chest and
interfering with his ability to breath. The
family just wants to find out what
happened to Andrew and make sure this method
is never used on a child again''
Changes were made at Elmcrest and lives were saved
due to training and policy changes. CPR was used to save the life of an
adult who was having a heart attack. Due to improved record keeping and
the monitoring required, workers were able to treat a child who was close
to dying from dehydration. Six months after Andrew's death, the records
of the monitors showed major staff and policy changes.
Though she was glad that changes were being made,
Lucinda wished it had been that way for Andrew:
"None of this is going to bring him back"
In many facilities, few changes had been made, yet.
At some, there were even practices continuing that were called questionable.
Linda Prestley hopes that the improvements made at Elmcrest will spread
over the entire state of Connecticut. Records indicate that Elmcrest has
cut back on their use of restraint hold and that
employees now use a nationally accepted restraint
technique. Regular specialized training has also been started.
Elmcrest has also increased the number of employees
who work in each ward and reduced the number of patients. A policy has
also been put in place to call 911 immediately in an emergency. Several
months after the death of Andrew, no other facility in the state had been
asked to take the same level of care, though there were two other comprehensive
reforms were in the works. Kristine Ragaglia had recommended last year
that the stated use the same restraint practices in all facilities. A proposal
was drafted and was being reviewed by several agencies.
The Department Of Children And Families banned facilities
from using any restraint hold that would cause a child to be face down
while being restrained.
The two women who had been restraining Andrew when
he died were both cleared in the case and not prosecuted. Later one of
them would have trouble getting a job and find out that she was placed
on a list, that was not known about until then, that said she was a danger
to children.
For information about preventing
child abuse in the state of Connecticut, click the links below. If they
can't help you, ask for someone who can. NEVER give up looking for
help for an abused child!
Call this number
to report child abuse ANY WHERE in the United States!
1-800-4-A-Child
1-800-422-4453
   
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