Death by Restraint at KidsPeace

GAO Case Study on Seclusions and Restraints

Two staff members trained in the use of restraints pinned 14-year-old Mark Draheim face-down on the floor for 20 minutes after he tried to attack a counselor.

The student was Mark Draheim, a 14 year old male. He was living in KidsPeace, a private, non-profit, residential treatment center for troubled children in Pennsylvania, and attending a private school operated by the center when he died in 1998 as a result of being physically restrained.

He had been placed in the custody of the non-profit by the New Jersey Department of Youth and Family Services in 1995.

According to a report by the District Attorney, on December 10, 1998, following a fight with a fellow student at a school on the treatment center's campus, the 14 year old returned to his dormitory room.

A 195 pound male counselor entered the room to counsel the 125 pound boy about the fight.

The boy was agitated and attempted to stab the counselor at least three times with a pen. To prevent further attack, the counselor applied a prone restraint in which the boy ended up face down on the floor with the counselor's left knee on the left side of his body and the counselor's right leg across his back.

At this point, the boy no longer had the pen in his hand. The counselor locked the boy's arms behind his back.

A female counselor heard the boy say, "I'm sorry I hit you" and "I hate you all." While being physically restrained on the floor, the boy continued to yell, kick, and struggle.

A 155 pound male counselor also entered the room and placed a vinyl mat under the boy's head to prevent injury.

The treatment center's records reveal that the boy had previously been physically restrained 17 times. The treatment center would not release the boy's treatment plan.

After approximately 12 minutes, the 195 pound counselor became tired and the 155 pound counselor took his place, locking the boy's arms behind the boy's back and positioning his body so that it lay off to the left side of the boy.

The 155 pound counselor physically restrained the boy for approximately 8 minutes during which time the boy continued to struggle and scream "Get the [expletive] off me, get off me."

Another child reported hearing the boy yell, "Stop it, I can't breathe." The 195 pound counselor responded, "You'll be able to breathe if you stop struggling."

After approximately 20 minutes of physical restraint, the student lost consciousness, and CPR was administered.

The boy was taken to the hospital where he died a day later. The autopsy determined the cause of death as hypoxic encephalopathy due to compressional asphyxia, a brain injury sustained as a result of lack of oxygen due to the compression of the student's chest.

Each of the counselors who applied the restraint that led to the boy's death were trained and certified in applying physical restraints. According to an instruction manual, employees at the center were trained in applying multiple restraints, two of which required the student to remain face down on the floor in a prone position.

In his report, the District Attorney concluded that the treatment center's policy did not appear to have any inherent flaw in the technique and that the policy was well designed and appeared to have been followed by all the counselors involved. The coroner ruled that the death was accidental and the District Attorney did not file charges against the counselors.

In May 1999, the boy's mother sued the treatment center and two of the counselors who applied the restraint that led to the boy's death, alleging negligence. She claimed that the counselors used excessive force, and that the treatment center did not adequately train their counselors to deal with respiratory distress during a physical restraint.

The defendants denied these allegations and said the restraint was employed for the protection of everyone involved in the situation. The counselors further stated that they acted with due care and safety of the boy.

In May 2006, before the case went to trial, the boy's mother, the treatment center, and the two counselors reached a settlement. According to the terms of the settlement, the boy's mother would be paid over $1 million.

The treatment center and the two counselors did not admit any liability in the boy's death as part of this settlement. The two counselors who physically restrained the boy did not have criminal histories. They no longer work at the treatment center, but we were unable to determine whether they currently counsel children.

In October 1999, less than a year after the boy's death, the Pennsylvania Department of Public Welfare enacted regulations that prohibit child residential facilities and day treatment centers from administering restraints that apply pressure or weight on a child's respiratory system.

Consequently, we requested the treatment center provide its current policies and training manuals regarding restraints. In response, the treatment center sent us a letter stating it no longer uses prone restraints.

In addition, it provided us a copy of its policy allowing physical restraints in residential treatment facilities and education programs and a workbook used to obtain certification in physical restraints.

The center's policy states trained staff members are authorized to use physical restraint methods. According to the workbook, staff can apply physical force that reduces or restricts mobility while an individual is in an upright or seated position, lying face up, or in the transport of an individual from one location to another.