Psych facility internal video shows patient dying from use of prone restraint

November 8, 2011

Investigators with CALL7 (channel 7 in Pueblo, Colorado) obtained an internal video showing Pueblo State Hospital officials forcing a patient on to a table, strapping him down as he struggles and suffocates, and then taking several minutes to unstrap him and attempt to provide medical care.

The video shows Troy Geske recoiling as attendants bring him into the isolation room.After hospital staff strap him down, Geske tries to lift himself to breath but eventually collapses and dies.

A worker notices he’s not moving, rushes in, and attempts to rouse him. The staff attempts to revive Geske with oxygen, but find the emergency tank empty. Attendants didn’t begin CPR until it was too late, the video shows. 

The state went to court to try to keep the video, which graphically shows the danger of prone restraint, away from the family and public.

The Colorado Department of Human Services, which runs CMHIP, banned the restraint after a CALL7 Investigation into Geske’s death.

“When I watched my son being put face down, leaned on by four huge men not allowing any part of his body to move... his head or anything, all I thought of was inhumane,” said Troy’s mother Linda Stephens. “One pressing his face to the table. One had his elbow in his back which would further deplete the lungs of his air. I can't imagine the fright, being so scared, what my son went through.”

CALL7 Investigator John Ferrugia showed the video to Dr. Harlan Lubin, who works for Denver Health and covers the Denver jail. Lubin has treated violent and dangerous patients, including adolescents in the youth corrections system. He said the face-down restraint is too dangerous to use.

“I don’t think there is any reason why prone restraint should be used as opposed to other types of restraints or other interventions,” he said. “You’re just bringing on a lot of added risks when you do prone restraint.”

But legislators earlier this year disagreed when they killed a bill that would have banned prone restraint at all mental health facilities -- not just state facilities. Lawmakers heard from directors and staff of adolescent and children’s residential treatment facilities that sometimes use prone restraint on patients many times per day.

“We utilize therapeutic crisis intervention and prone restraint is what we do,” testified Rebecca Hea, executive director at the Denver Children’s Home. “I’m unbelievably anxious that a law is going to go into effect that will limit my staff’s ability to keep kids safe.”

But Troy Geske’s mother said the techniques demonstrated in the legislative hearing were not prone restraint and said people should see what it’s really like.

“I wanted to jump up and go ‘seriously... do you really think that is a prone restraint?’” she said. “It's not! Prone restraint is violent.”

A grand jury found the state hospital responsible for Geske’s death but did not find criminal wrong doing.

Lubin said the procedure should not be used.

“Just inherent in the prone restraint is the risk that the person will have difficulty with breathing and unfortunately, in this case, die,” Lubin said.

CDHS is meeting with contractors, including those at youth residential treatment facilities, to explore new techniques that will eventually replace prone restraint. And there is an audit underway of deaths at the state hospital after a series of CALL7 investigations showed problems and mistakes at the hospital that led to the unnecessary deaths of patients.

Stephens says it is essential people see the videotape of the restraint that killed her son and hopes the video will prompt lawmakers to act.

“If I can watch a video of how my son died, then dammit you can watch one to hopefully speak out and help this from happening again,” she said. "I imagine my son (gasping for air) trying to breathe. For just a short period, (his) brain has to know I'm going to die, I can't breathe.

“I don't want him to die in vain,” she said. “And the only way we can do that is to keep it out there, to let people know what happened -- the reality of the prone restraint.”

Source: Arthur Kane and John Ferrugia, "Video Shows Struggling Mental Patient Die In Restraint; Prone Restraint Technique Was Banned In State Facilities After CALL7 Investigation Found It Fatal," ABC Channel 7 New, The Denver Station, November 7, 2011.


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