Featured Article: Boy suffocated during school punishment: Coroner's Report

Graeme Hamilton, National Post, With Files From Canwest News Service
Published: Friday, June 20, 2008
Photos By John Kenney, Canwest News Service



















MONTREAL - After nine-year-old Gabriel Poirier was discovered lifeless in his classroom last April 17, his parents were told their autistic son had stopped breathing after hiding under a heavy therapeutic blanket.

Now a coroner has revealed that Gabriel's teachers had tightly wrapped him in the buckwheat-stuffed blanket, leaving only the tips of his ears sticking out, as punishment when he became disruptive. They left him unsupervised in a corner for 20 minutes, returning when a timer sounded.

Gabriel was unconscious and blue in the face. He was rushed to hospital, where he died the following night surrounded by his family.

In a report published yesterday, Coroner Catherine Rudel-Tessier concluded the child suffocated. She said the teachers at the special-needs school in Saint-Jean-sur-Richelieu, Que., failed to follow guidelines for the blankets, which are used commonly to calm autistic children.

"He was only 53 pounds, he was so small," Gilles Poirier, the boy's father said at a news conference yesterday. "How can they wrap him up like that in a 40-pound blanket? How can this treatment be tolerated?"

Ms. Rudel-Tessier said proper use of the blanket called for a child to be rolled at most once and for his head to be left uncovered. The blanket was to be used as a relaxation therapy, not as a punishment, and teachers were supposed to keep an eye on children using the blankets.

"A child rolled 'at least four times' in such a heavy blanket is under restraint," the coroner wrote.

Jean-Pierre Menard, a lawyer representing Gabriel's parents, is calling for changes to legislation to control the use of restraints in schools. The parents are also planning to sue the Hautes-Rivieres school board.

The coroner said use of the blankets should be ceased until clear guidelines are established. Basic rules would include ensuring the blanket is not too heavy for the child, never covering the child's head, ensuring that vital signs can always be observed, never rolling the child in the blanket and ensuring the child can get out if he wants to.

Kathleen Provost, executive director of the Autism Society of Canada, said weighted blankets can be calming for autistic children when used under the guidance of an occupational therapist.

"They have a therapeutic use and can be relaxing," she said.

Mr. Menard said the parents were surprised to learn Gabriel had been placed in the blanket as a punishment. The school board had initially said it was a natural death and that Gabriel had gone under the blanket on his own.

"The principal said they found Gabriel under the blanket and he wasn't breathing. The parents thought that something had happened while he was sleeping and that was how he died," Mr. Menard said. He said the school board later told the media that Gabriel had hidden under the blanket.

Mr. Poirier said he cannot understand why his child was placed in a restraint. "He was a very gentle boy," he said. "Sometimes he was loud, but he was never aggressive or violent. I just don't understand how this happened," he said, tears streaming down his face.

ghamilton@nationalpost.com

Restraint called common at school; Youths describe practices at facility where boy died

This is another instance of a restraint death, this time at a private school in 2007:

By Greg Garland and Annie Linskey
Baltimore Sun
February 2, 2007

As authorities continued to investigate the death of a youth who was being restrained at the Bowling Brook Preparatory School, four young men held there said the school's staff routinely restrained students - sometimes for hours and for minor infractions.

The accounts by the four youths, all juvenile offenders, describe practices that conflict with what state policies and experts say are the proper and widely accepted methods of physically controlling unruly youths. The use of physical restraint should be brief and done only as a last resort to keep a youth from injuring himself or someone else, state officials say.

In separate interviews with The Sun, one youth said he was held to the ground by Bowling Brook staff for four hours as punishment for talking during a meal.

Another said he was restrained four times in his 18 months at the school. A third described the restraint of students as "a regular occurrence" and estimated that he saw it happen once a week.
Three of the four complained that when they were restrained, they had had trouble breathing while being held down.

Officials at Bowling Brook, a privately run residential program for juvenile offenders, declined to comment yesterday on the youths' allegations.

The young men were interviewed outside Baltimore's juvenile court as they were released to home detention.

The four were among at least 40 youths who have been removed from Bowling Brook at the request of the Maryland public defender's office since the death last week of Isaiah Simmons, 17, who lost consciousness after being restrained by staff for more than three hours.

At least four youths who witnessed the attack have said staff members "sat on" Simmons while he was held facedown on the ground, according to the Maryland public defender. Two witnesses have told The Sun that Simmons complained during the incident that he couldn't breathe.

The school has said in a written statement that its handling of Simmons was proper.

An expert who teaches restraint techniques to state workers said the training emphasizes that "no weight should be applied" to a youth held facedown in a prone position. "No program will say sit or kneel on them," said Danny Martinez of Jireh Consulting and Training in Albuquerque, N.M. He said most incidents of restraint last one to five minutes.

His firm has been teaching the Maryland Department of Juvenile Services employees who train workers at state-run facilities for about five years but is not involved with any training program at the privately run Bowling Brook.

Youths who were interviewed yesterday described witnessing or being subjected to lengthy periods of restraint.

Maurice Holmes, 18, said he was held to the ground for four hours the first time he was restrained. "It felt like I was going to die," he said. "I'm blowing snot out my nose. I'm saying, 'I can't breathe, I can't breathe.'"

Raymond Aur, 17, said he saw people restrained almost every day during his 10 months at Bowling Brook.

He said he was restrained in a seated position three times and on the ground four times. In July, he said, he was restrained for four hours because he disobeyed orders and spoke during a meal.
He said workers took him outside and pressed his face into fresh-cut grass. His face was covered with bruises and cuts, he said, and at one point he urinated on himself.

Aur said that three staff members held him down and that the men worked in shifts so that when one got tired, another would take his place. After they released him, Aur said, the guards told him that he had been restrained for four hours - and now "owed" the school four hours of work.

He said he had pain in his arms that continued until the next day, when the staff took him to the hospital. His mother, Sheila Aur, showed a reporter a hospital bill for $386 that was sent to her.

The description is for "services for Raymond D. Aur rendered at Carroll Hospital Center" on July 17.

Sheila Aur said that when she visited her son that weekend, he "looked like he'd been beaten by 10 people. ... They said that Ray had been restrained for a long time."

While the state Department of Juvenile Services allows workers at its state-run facilities to use facedown restraint, some programs prohibit that because of the potential to cause harm.

Staff at the Glen Mills Schools, a well-regarded program for juvenile offenders in Pennsylvania, are told not to put a youth facedown, said Jack Rachko, who oversees training there.

"We tell them to do everything possible to keep him faceup," he said. "We never want them facedown, always faceup - and you always monitor their breathing."

He said it is rare for a youth at Glen Mills to be physically restrained for longer than 10 minutes, and it would be brought to the attention of high-level supervisors if a restraint went on for much longer than that.

"You gain control and it's over, usually within 10 minutes," Rachko said. "We don't have extended restraints going on and on and on."

Maryland's policies say physical force - including restraint - is to be used as a last resort and that "only the minimum amount of physical force necessary to control the youth may be used."

But Nichelle Vandervall said her son, who is 16, was restrained with such force that on one occasion, his elbow was dislocated and a blood vessel in his eye burst. "It scared him to death," she said. "He hasn't been restrained since then."

But Vandervall has mixed feelings about the facility. She's noticed a positive change in her son's attitude. "He's not as aggressive as he was," she said.

"Bowling Brook, what they stand for, the opportunity is excellent," she said. "My son is much better than what he was when he got there. He sees that he can be something other than a drug dealer."

Investigators with the Department of Juvenile Services inspect private facilities like Bowling Brook several times a year, according to department spokesman Edward Hopkins. The most recent visit to Bowling Brook was Jan. 12, less than two weeks before Simmons' death. "There were no negatives, no deficiencies or things like that" found in the unscheduled visit, Hopkins said.

Autopsy: restraint killed student at Killeen school

July 17, 2008: We just became aware of this article and wanted to share his story. Staff withheld food as punishment from a child they knew to have been deprived food as a baby. When he attempted to leave the classroom in search of food, staff restrained him. Another child died at the hands of educators who should have known better...

Monday, March 25, 2002

KILLEEN, Texas (AP) - A 14-year-old boy who died after being restrained in a classroom by his teachers perished from an excessive amount of pressure to his chest, a preliminary autopsy shows.

Cedrick Napoleon, a special-education student at Manor Middle School, died March 7 about an hour after being restrained. School officials said he was causing problems in his behavior management class.

A female teacher and two aides remain on leave from the school, and police said the case is likely to be referred to a grand jury.

The autopsy revealed Friday that Napoleon died from "mechanical compression of the trunk," which forensics officials say is a form of suffocation.

Killeen police said the investigation is ongoing. The school district, which has been working with police, also is conducting an internal investigation.

Police said the teacher and a male aide attempted to restrain Cedrick, who was 4-foot-11 and weighed 129 pounds, in the classroom. Another aide was in the room with about a dozen students, police said.

The teen's foster parents, Wilbert and Toni Price, said classroom staff had restricted Cedrick's food as punishment for his misbehavior.

"But for him, that was a very bad punishment, because when he was a little baby, he was deprived of food," Wilbert Price said. "He liked food. It was like a security blanket for him. And they were aware of this."

Cedrick was trying to leave the classroom in search of food when he was restrained, Toni Price said.

She said Cedrick's classmates told her that he told the person holding him down, "I can't breathe. I can't breathe. I give."

Toni Price said Cedrick was a peaceful boy who loved football and basketball and someday wanted to open his own doughnut shop.

"Cedrick always had a big smile," she said, noting Cedrick had been in their care for 16 months.

"On that day, Cedrick wasn't doing anything violent. He wasn't fighting anyone. He wasn't hurting anyone.

"And for him to have had to lost his life like that is a crime, and somebody should pay for that."

Charles Patterson, Killeen Independent School District superintendent, said in a news release Friday that he would like "to convey that the heartfelt thoughts of personnel in the district continues for the family in the loss of Cedrick."

Boy suffocated during school punishment - UPDATE

Coroner's Report
Graeme Hamilton, National Post, With Files From Canwest News Service
Published: Friday, June 20, 2008

MONTREAL - After nine-year-old Gabriel Poirier was discovered lifeless in his classroom last April 17, his parents were told their autistic son had stopped breathing after hiding under a heavy therapeutic blanket.

Now a coroner has revealed that Gabriel's teachers had tightly wrapped him in the buckwheat-stuffed blanket, leaving only the tips of his ears sticking out, as punishment when he became disruptive. They left him unsupervised in a corner for 20 minutes, returning when a timer sounded.

Gabriel was unconscious and blue in the face. He was rushed to hospital, where he died the following night surrounded by his family.

In a report published yesterday, Coroner Catherine Rudel-Tessier concluded the child suffocated. She said the teachers at the special-needs school in Saint-Jean-sur-Richelieu, Que., failed to follow guidelines for the blankets, which are used commonly to calm autistic children.

"He was only 53 pounds, he was so small," Gilles Poirier, the boy's father said at a news conference yesterday. "How can they wrap him up like that in a 40-pound blanket? How can this treatment be tolerated?"

Ms. Rudel-Tessier said proper use of the blanket called for a child to be rolled at most once and for his head to be left uncovered. The blanket was to be used as a relaxation therapy, not as a punishment, and teachers were supposed to keep an eye on children using the blankets.

"A child rolled 'at least four times' in such a heavy blanket is under restraint," the coroner wrote.

Jean-Pierre Menard, a lawyer representing Gabriel's parents, is calling for changes to legislation to control the use of restraints in schools. The parents are also planning to sue the Hautes-Rivieres school board.

The coroner said use of the blankets should be ceased until clear guidelines are established. Basic rules would include ensuring the blanket is not too heavy for the child, never covering the child's head, ensuring that vital signs can always be observed, never rolling the child in the blanket and ensuring the child can get out if he wants to.

Kathleen Provost, executive director of the Autism Society of Canada, said weighted blankets can be calming for autistic children when used under the guidance of an occupational therapist. "They have a therapeutic use and can be relaxing," she said.

Mr. Menard said the parents were surprised to learn Gabriel had been placed in the blanket as a punishment. The school board had initially said it was a natural death and that Gabriel had gone under the blanket on his own.

"The principal said they found Gabriel under the blanket and he wasn't breathing. The parents thought that something had happened while he was sleeping and that was how he died," Mr. Menard said. He said the school board later told the media that Gabriel had hidden under the blanket.

Mr. Poirier said he cannot understand why his child was placed in a restraint. "He was a very gentle boy," he said. "Sometimes he was loud, but he was never aggressive or violent. I just don't understand how this happened," he said, tears streaming down his face.

ghamilton@nationalpost.com

Autistic boy likely suffocated: coroner's report

Brett Bundale , The Gazette
June 19, 2008

A coroner's report released today revealed suffocation as the probable cause of the death of a nine-year-old autistic boy.

The boy's parents described the reports findings as a "shock" because the school told them he had passed away "naturally and calmly."

The boy, Gabriel Poirier, attended a specialized school in Saint-Jean-sur-Richelieu, in the Montérégie region of Quebec.

On April 17, Gabriel began to disturb his class with loud sounds. After being told repeatedly to calm down by a teacher, he was rolled in a weighted blanket. With his arms by his side, he was left on his stomach for over 20 minutes with only his toes exposed.

When the teacher went to check on him, he was "listless and blue in the face," the Coroner's report said. The teacher called 911 but the boy was already in a deep coma and passed away the next day in the Sainte-Justine hospital.

"He was a very gentle boy. Sometimes he was loud, but he was never aggressive or violent," Gilles Poirier, the boy's father, said today.

The parents' lawyer, Jean-Pierre Ménard, said vulnerable children like Gabriel need better protection.

"We're asking Minister Courchesne to implement a legal framework to regulate how these children are handled," Ménard said.

Weighted blankets are custom-made blankets filled with a specific material that gives the blanket added weight. They are considered an effective tool for helping calm down high-energy children, especially autistic children who respond well to sensory therapy.

"They have a therapeutic use and can be relaxing," said Kathleen Provost, executive director of the Autism Society of Canada.

But occupational therapists have developed a set of rules and protocols that must be followed when using a weighted blanket, Provost said.

bbundale@thegazette.canwest.com

Boy with autism died 'while care workers brought drinks and shopping'

Boy with autism died 'while care workers brought drinks and shopping'

NISKAYUNA, New York State, USA: A 13-year-old boy with autism died on February 15 after police say two care workers for the disabled drove him around for 90 minutes - running errands, buying beverages and shopping - when he stopped breathing in their van.

The men, one of whom allegedly used an improper physical restraint on the boy, Jonathan Carey, were both charged with manslaughter.

Colonie Police said the workers did not seek or offer medical help during the drive on February 15. Instead, the employees of the O.D. Heck Developmental Center in Niskayuna allegedly stopped to buy beverages, then a computer game and then dropped the game off at one man's home.

Edwin Tirado, 35, of 1634 6th Ave., Schenectady, and Nadeem Mall, 32, of 9 Plaske Drive, Schenectady, reported the boy needed medical attention only once they had finally returned to the O.D. Heck Center where the child, who was also mentally retarded, lived, police said.

The child, identified by police as Jonathan Carey, had been with the Niskayuna centre since his parents moved him from a Dutchess County facility they believed had abused him.

We are devastated," sobbed Mike Carey as he and his wife, Lisa, waited for an plane to bring them home. "He was such a special human being."

The Glenmont couple was on a long-awaited vacation together, having left their younger son with friends. It was to be a respite from the constant advocacy for Jonathan.

"We can't believe it," they sobbed from the St. Thomas airport in the Virgin Islands. "We are in total shock."

The accused O.D. Heck employees are being held in Albany County jail without bail.

Police said Mall was driving a van to take Jonathan Carey and a 14-year-old client, whose identity has not been made public, from O.D. Heck to Crossgates Mall, Colonie Police Chief Steven Heider said in a news conference on February 16.

Along the drive, Mall stopped for cash from an ATM and when he returned to the van, according to Heider, Tirado had the boy in the illegal hold. "The two adults rendered no aid and they did not return to O.D. Heck for an hour and a half," Heider said.

Efforts were made to revive the boy at the centre, and he was taken to St. Claire's Hospital in Schenectady, where he was pronounced dead. Police cannot say the boy died in the van because a person is not ruled dead until pronounced so by a hospital or medical examiner, the chief said. An autopsy is set for today.

"The 13-year-old succumbed to what we're alleging were improper and wrongful holds placed on him," Heider said.

Niskayuna Police were called first, but their investigation indicated the boy had been suffocated while being driven around Colonie, he said. Police said the 14-year-old client is verbal and was able to give them a description of the events.

"The bottom line is the Niskayuna police and the first responders did a fantastic job here in being able to pick apart their story," said Albany County District Attorney David Soares. "You couldn't ask for anything better."

Soares said the case would be put to a grand jury for indictment as soon as results of the autopsy are received. Although current information supports the charges of manslaughter, Soares said, he would not rule out the possibility of increased charges.

"It's too early to tell," he said. "At this point in time, my thoughts are with the Carey family."

The state Office of Mental Retardation and Developmental Disabilities, which oversees the centre, issued a statement on February 16 expressing sadness over the boy's death.

"Officials have been and will continue to work closely with law enforcement as they piece together what happened," the statement said, adding the agency provides "intensive staff training, monitoring and follow-up of any use of behavioural interventions and, given the current situation, these protocols will once again be reviewed."

Spokeswoman Deborah Sturm Rausch said she was not sure if she could find information about what Mall and Tirado's exact job titles were, or whether they had to be, or were, licensed.

Tirado, who had worked at the agency for six years, was the person restraining the boy but Mall had an equal responsibility for failing to provide or get medical assistance, Heider said. He declined to specify what hold was used but said the boy suffocated.

A woman answering the door with an infant at Mall's Schenectady home declined to comment. There was no answer when a reporter approached Tirado's home.

Since 2004, the Carey family has fought for legislation to force state agencies to disclose information they said could prove abuse of patients like their son. In October that year, Mike said he found Jonathan, then 11, naked, covered in bruises and lying in his own urine in the Anderson School in Dutchess County. The father had popped in unexpectedly to visit his son and took him home the same day.

The Careys said they never knew what their son endured because Jonathan was non-verbal and could not tell them himself. He was moved to O.D. Heck where the Careys said in December he was doing well.

The Careys described the fawn-haired boy with huge cerulean eyes as a good son who loved his father and mother. "He loved to watch Jesus films," Mike said softly. "He loved people and wanted to be around people. He loved horses. There was just so much love in his heart."

Jonathan was a regular visitor of the New Horizons stable on Pearse Road. When he was riding horses, Jonathan seemed happy, his parents said.

The Careys sued Anderson School in 2005, in state Supreme Court in Albany, claiming the institution and its staff violated Jonathan's right to safety and nourishment.

In December, Mike Carey said, "No parent or guardian should ever have to go through what Lisa and I have had to endure just to get answers. We would have been arrested if what happened to Jonathan had happened at home."

Since then, the couple has fought to get sealed records opened that they believe could reveal who had physically abused the boy as well as who knew it but did nothing to prevent it or report it. He said he hoped his son's death would enable the family to get the law changed.

"This is what we had been concerned about, what we have been fighting for," Mike said, of his son's death. "We really felt compelled, like a God-given responsibility, to help other children, to get changes and reform to help prevent something like this from happening."

Jonathan's death is prompting county lawmakers to renew calls for the passage of Jonathan's Law. The Rensselaer County Legislature is now calling on state lawmakers to take action and pass the Bill. If it passes, the law would give parents the right to access their children's records. Right now, that information cannot be released and acts of abuse can be concealed from families.

Jonathan's family has been trying to get a law passed since 2004, after they said their son was being mistreated at a Dutchess County facility.

(Source: Albany Times Union, February 17, 2007)

Physical Education

When special-ed teachers seclude and restrain students, the state says no one needs to know
by Elizabeth Ulrich
Nashville Scene.com
January 24, 2008

Rob Zimmerman’s son Jack is the kind of smart, happy child who loved school. But two years ago, Jack’s dad says, that suddenly changed. When the now 11-year-old moved to another special-ed classroom at his Williamson County school, Zimmerman says Jack’s new teacher did not believe he was “as much autistic as he was ornery.”

The teacher told the family that Jack was “trying to trick her.” Jack’s behavior changed, as he began to dread school and act out—screaming and spiraling out of control.

Zimmerman and his wife were shocked to learn why: Jack’s teachers had taken him down the hall to a janitor’s closet, placed him inside and shut the door, leaving the boy to sit alone in the dark for up to three hours at a time on more than one occasion. “They said he liked it better when it was dark,” an animated Zimmerman told a group of state lawmakers Tuesday. “We’re talking about human life—my son’s life,” Zimmerman said.

And it wasn’t long before Jack told his parents that his teachers were also “umphing him,” describing the groaning sound his teachers made as they held him down for “ornery” behavior. In his own way, Jack alerted his parents to a growing problem in special-ed classrooms all over the state: the unreported, undocumented use of seclusion and restraint.

Jack’s case is rare in the sense that he was able to tell his parents he had been restrained and stuffed into a closet that his father says school employees called a “calming room.” Many autistic children are not as verbally developed as Jack and are therefore incapable of reporting abuse.

Often, these are children who, as Zimmerman puts it, are “set up for abuse.”

After reports like Zimmerman’s began to trickle in, the Disability Coalition on Education (DCE), a statewide organization of educators, advocacy groups and families, reviewed state law and found that there are no guidelines to regulate how—or if—schools should report such incidents or document how often they occur.

To push state lawmakers to draft legislation to require such oversight, representatives from several advocacy organizations for the disabled and mentally ill met Tuesday with a House-Senate study committee. They discussed the methods of restraint and seclusion now used with Tennessee special-ed students.

The committee also heard a tearful Gary Hassell talk about his son, a special-education student with autism at Oakmont Elementary in Dickson County, who had been physically restrained, face-down, on the classroom floor. School employees held his son down for an hour in what is called the “prone” position, a controversial hold that some experts say can result in asphyxia in as few as six minutes.

Similar methods of seclusion and restraint have led to the deaths of two teens at Chad Youth Enhancement Center, a residential treatment facility for troubled youth just outside of Clarksville (“Handle With Care,” Nov. 8) and have been key components in claims of abuse and neglect at Hermitage Hall, a Nashville private residential facility that treats male sex offenders (“Bad Medicine,” Dec. 13).

State records for Chad and Hermitage Hall, both of which are licensed by the state’s Department of Mental Health and Developmental Disabilities (DMHDD), describe hundreds of cases where young residents are physically restrained, often violently, by facility staff. Neither DMHDD nor the Department of Children’s Services finds anything out of the ordinary or troubling about these incidences, according to interviews with officials there, and Gov. Phil Bredesen’s office also has been unswayed by reports of abuses at these juvenile facilities, directing questions back to the departments.

But Tennessee public schools are not required to report incidents of seclusion and restraint to the state—or even to parents such as Zimmerman. Carol Westlake, the executive director of the Tennessee Disability Coalition, told the study committee that, while state law requires in-patient facilities and residential juvenile programs to report how often such incidents occur, public schools remain one of the only places in the state without that mandate.

And, while facilities such as Chad and Hermitage Hall purport to have stringent requirements for teaching workers how to properly administer restraint holds, schools are not legally required to train employees.

DCE Chair Holly Lu Conant Rees says her organization has repeatedly requested a copy of the Metro schools’ policy on seclusion and restraint but has received nothing.

Conant Rees tells the Scene that her organization has started to collect data from parents across the state to push state lawmakers to draft legislation.

Thirty families, several of whom have students in Metro public schools, completed a DCE survey saying that their children have experienced multiple incidents of restraint and seclusion in the classroom. DCE describes the findings as “uniformly disturbing.”

Of those families reporting incidents to DCE, 40 percent said school staffers injured their children, who showed signs of bruising, contusions, abrasions and nail and grip marks. And 60 percent of families reported that their children experienced significant psychological and behavioral setbacks after being restrained or secluded. The children had acted out with violent tantrums and experienced anxiety, night terrors and psychosis.

It’s a familiar story to parents like Zimmerman, who says it only takes one encounter with a “bad apple” in the special-education classroom to change a child’s life forever. “If you don’t have documentation, you don’t have accountability.”