Report finds abuse, neglect in death of boy who died at Elmcrest
Malificynt
Report finds abuse, neglect in death of boy who died at Elmcrest
Associated Press, 05/07/98
HARTFORD, Conn. (AP) - The restraint hold that resulted in the death of an
11-year-old boy at a private psychiatric hospital, was not necessary and
physically abusive, the State Department of Children and Families concluded in
a report released Thursday.
But a second investigation, conducted by an independent panel, did not go as
far, calling the death of Andrew McClain accidental but preventable.
The special Child Fatality Review Panel found that Andrew's death at Elmcrest
Hospital in Portland reflects outdated staff training, inadequate management
and a lack of state policies that regulate child restraints.
A regulatory investigation by the state health department found numerous
violations at Elmcrest. As a result of that probe, Elmcrest and its parent
company, St. Francis Care, agreed to give $100,000 to the state's Children's
Trust Fund to be used for child abuse prevention programs. They also will allow
the state a greater role in monitoring Elmcrest policies.
A criminal investigation into the Bridgeport boy's death is ongoing. No charges
have been filed. The state medical examiner said the boy was crushed and ruled
the death an accident.
Andrew, who had a history of behavioral problems, died March 22 in a time-out
room, three days after being admitted.
Reports from the DCF review and independent panel inquiry gave similar account
of his final hours:
Andrew was put in the room after making a threatening gesture to another boy at
breakfast. When he resisted attempts to put him in a corner, he was restrained
face down with an aide on top of him. A second worker, hearing the ruckus,
entered the room and helped hold him down.
The DCF report concluded that Andrew was not demonstrating behavior that would
warrant any hold. The actions of the first aide, the report concluded, amounted
to physical abuse. Both workers and the hospital were deemed to be negligent.
When McClain began to struggle for his life, the aides treated it as a
behavioral problem and would not release him. Even after he was unresponsive,
the restraint continued until a worker noticed the child had wet himself and
then tried to rouse him. Attempts by a nurse to revive him failed. He was taken
by private ambulance to Middlesex Hospital, where he was pronounced dead.
Neither aide had proper first aid training and the nurse's training credentials
in cardiopulmonary resuscitation had lapsed.
Both aides have been placed on leave pending the results of a police
investigation.
While the DCF found neglect and abuse, the independent investigation did not go
as far.
``It does not appear in this particular case that the staff was properly
trained in de-escalating situations, so the question really remains whether
Andrew should have ended up in a restraint in the first place,'' said Linda
Pearce Prestley, the state's child advocate, who set up the Child Fatality
Review Panel.
That report also concluded that the state must develop new regulations for
mental health workers who deal with children.
One of the aides involved had been trained in restraint holds just days before
the incident, Prestley said. But the staff was using 14-year-old training
procedures and had never been trained in the current industry standards or by
anyone who worked outside of Elmcrest, the reports said.
``The people at Elmcrest did not know they were not meeting a standard, because
no standard existed,'' said Gary Fitzherbert, the Executive Director of the
Glenholme School, another residential facility, and a member of the independent
fatality review panel.
That panel found that only six states even mention the restraint of children in
their mental health regulations and only one state, California, specifically
limits the use of restraints on children.
Tom Gilman, DCF deputy commissioner, said the department has begun using the
recommendations from the independent review. He said a review panel of mental
health officials, law enforcement officials will decide on any new regulations
and whether legislation should be proposed.
``Unfortunately it sometimes takes a tragedy like this to look at policies and
analyze them across the board,'' he said.
In a written statement, Elmcrest said it has already made a number of policy
changes. Those include banning the type of hold used on McClain and requiring
all staff who deal with children to be trained in life-saving techniques.
The independent panel also said DCF should have been more aware of potential
problems involving restraint, especially after the similar death of a New Haven
boy in Massachusetts.
Robert Rollins, 12, died after being restrained at the Devereaux School, a
private facility for children with behavioral problems. He had been placed
there by Connecticut's child welfare agency.
``In terms of children dying in this state, you don't need to wait for a second
child to die in order to undertake an extensive review of the circumstances
surrounding a child's death,'' Prestley said.
However, DCF's Gilman said a review of the Rollins death also found abuse and
resulted in policy changes.
The independent panel also found that when Andrew was involuntarily committed
to Elmcrest, neither the hospital nor DCF informed the McClain family that they
had a right to challenge that admission.
The McClain family and their attorney have scheduled a news conference for
Friday morning to discuss the reports.
A second report from the Child Fatality Review Panel, dealing with issues that
arose during an examination of McClain's case history, will be released in
June, Prestley said.