Many of the injuries and deaths are a result of restraints that are used more often to punish than to protect staff and patient. Following is an excerpt from an article titled "Deadly Restraint."
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.
Duct tape is like the force; it has a light side and a dark side and it holds the universe together.
--Jedi Knight school drop out.
