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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