Use of prone restraints linked to deaths

This article is excerpted from ENVOY, December 1993.

An inquest jury found no criminal negligence by Fircrest School staff in the July 19 death of John Mileck, a 45-year-old resident who stopped breathing on July 15 while Fircrest staff were restraining him in the prone position.

Although Fircrest staff testified at the October inquest that injury from this type of restraint is rare, on Oct. 8 an Oregon mental hospital patient also died after he suffered oxygen deprivation while in a prone restraint.

To restrain Mileck after he became agitated in the morning of July 15, four Fircrest staff placed him stomach-down on the floor of his residence and held his legs, arms, torso and head while he struggled.  When Mileck was turned over approximately twenty-two minutes later, he was visibly blue.  Staff started CPR and called 911, but Mileck died at Harborview Hospital on July 19.

According to King County Medical Examiner, Dr. Donald Reay, “positional restraint is viewed as a major cause of Mileck’s death.”  Doctors at Harborview hospital explained that Mileck died because of brain damage from lack of oxygen suffered during the prone restraint.

Reay testified at the early October inquest that, because this restraint could be dangerous if breathing was restricted, the person’s breathing must always be carefully monitored.

While Fircrest staff testified that they were careful to monitor Mileck’s breathing, the placement of towels around his head and hands may have obscured his lips, nose, ears and fingernails from view. The use of towels while performing a restraint procedure is not part of the procedure as it is taught to Fircrest staff.

Reay added that pressure or pushing on the back or chest could further restrict breathing. The prone restraint technique often requires two or more persons applying force to restrain someone who is struggling.

In the similar Oregon case, a patient at Dammasch State Hospital, Peter Lynn Gournea, 32, died after staff members held him in a prone position with a towel over his face.  While Gournea’s death, like Mileck’s, was ruled accidental, it was caused by the use of a prone restraint procedure.

Oregon state medical examiner, Dr. Larry Lewman, as quoted in The Oregonian, said Gournea suffered oxygen deprivation because his neck was hyperextended, the towel over his face partially blocked his nasal passages and he was on his stomach, making it hard for him to expand his chest cavity with air.

In their investigation of Mileck’s death, state surveyors cited Fircrest for failure to follow federal health Care Financing Administration (HCFA) regulations, specifically for the use of towels during the restraint procedure, for injuries Mileck sustained on his face from moving his head site to side while held down, and for their failure to ensure Mileck’s health and safety.

Other state investigations, however, found no wrongdoing.  DSHS, the agency that runs Fircrest, assembled an outside 3-person medical team to work under contract with DSHS to investigate Mileck’s overall treatment, but did not draw conclusions about the cause of his death.  DSHS’s Office of Special Investigations said that staff followed proper procedures when physically restraining Mileck on the floor after he became agitated, but did note that Fircrest needs to respond more quickly to medical emergencies.

While Fircrest School has restricted the use prone restraint, many are outraged that Mileck’s death has been excused.

Mileck, who had lived at Fircrest for 27 years, is survived by his father, Emil Mileck, of Vancouver, and mother, Joyce Black, of Ballard.

The statewide Coalition of County DD Advisory Boards, WPAS and many other disability organizations have written the U.S. Department of Justice, requesting a thorough investigation.  After investigation, WPAS will publish its report of this tragic death and the use of restraints at Fircrest School.

*Editor's Note: Disability Rights Washington was formerly known as Washington Protection and Advocacy System.


ENVOY Credits

ENVOY Editorial Staff:  Nicole Elger, Gillian Maguire, Mark Stroh
ENVOY Staff Contributors:  Laura Allen, Nicole Elger, John Macdonald, Gillian Maguire, Elizabeth Schwieterman , Michael Smith, Elizabeth Stanhope, Mark Stroh
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