.


Andrew McClain
December 6, 1986  - March 22, 1998
Find A Grave Memorial
One month after 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 centers, 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.

Death Occurred in the state of Connecticut

If you do not like what you see printed on this page, please see my DISCLAIMER statement. THANK YOU!







For information about how to report child abuse, please click the link below and you will be taken to a page that has an alphabetical, state by state listing of how to report child abuse for which state you are looking for and for some other countries.



Visit my child abuse quilt to see other places about preventing child abuse.

This page will open up in a new window so you won't lose your place while
visiting the Angels on my site.


 
Call this number to report child abuse ANY WHERE in the United States!

1-800-4-A-Child  1-800-422-4453




Child Abuse Intro
Child Abuse Links 1
It Is A Human Life

7 Steps To Prevention
Child Abuse Links 2
Child Abuse Poetry
Child Abuse Songs
Report Abuse
Child Abuse Links 3
Child Abuse Quilt