The Brisbane Report, Nancy D. Feldman, J.D. for New Jersey Protection and Advocacy, Inc.
PART 5 -- KELLY YOUNG'S DEATH AND
ITS AFTERMATH AT BRISBANE
Tragic Death Highlights Serious and Enduring Problems
Kelly Young, aged 17, died on January 5, 1998, following an incident at Brisbane during which she was physically restrained with a basket hold. This was the first death in Brisbane's history.
While Kelly Young's tragic death at Brisbane is the only death that has occurred there, in many ways it is not an isolated incident. Her death in the course of a disciplinary procedure highlights critical and long-standing issues at Brisbane, including the over-reliance on physical restraint instead of verbal de-escalation techniques; injuries resulting from the pervasive pattern of rough treatment of patients during restraints; lack of proper staffing and supervision in the living units; verbal harassment of patients leading to poor behavior; and the callous, impersonal attitude of some staff members toward patients.
The Period Before Kelly's Death:
Restraint Issues and Rising Troubles
Staff Becomes More Dependent on Basket Hold as Use of
Mechanical Restraint is Limited
Until a recent change following Kelly Young's death, the basket hold was the physical restraint or holding technique used on patients at Brisbane. In performing this hold, a staff member crosses the patient's arms around the front of the patient’s body and holds the patient’s wrists from behind. The Instructor Manual written in 1984 for the physical restraint technique that has replaced the basket hold at Brisbane, Handle with Care, notes that the basket hold can be effective with small children, but that it is extremely difficult, if not impossible, to apply without cooperation from the patient.
The Brisbane Policy on Physical Restraint/Holding (effective 2/21/91, revised 3/94) characterizes physical restraint as an extreme measure that should only be used in extreme situations to:
1. prevent imminent harm to the patient or other persons when other methods of control have been proven ineffective or are inappropriate; or
2. prevent serious disruption of the treatment program or significant damage to the physical environment.
The policy emphasizes that physical restraint must never be used when less restrictive measures are adequate. All available resources and methods must be used to avoid the necessity of physically restraining a patient. "In particular, procedures taught in the Crisis Recognition Prevention and Intervention program are to be appropriately utilized." When a physical restraint is to be used, the Policy provides "guidelines" to minimize injury, including notifying a registered nurse, who should take a leadership role, and when possible, involve two staff members in performing the procedure.
In the fall, 1996, Brisbane staff began to rely more heavily on the use of physical restraint, using the basket hold to control patients' behavior because the hospital was informed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that the use of mechanical restraints in the cottages was in violation of patients' rights to privacy. Brisbane was required to end the use of mechanical restraints in the cottages by June 1997, in order to continue to receive federal Medicaid funding. In preparation for this change, the Brisbane Quality Bulletin 4.4, October 1996, reported that because the Main House Coed Unit would maintain the capacity to use mechanical restraints, it would become a "Crisis Stabilization Unit." Patients who in the staff’s judgment required this type of intervention would be assigned there.
With Increased Reliance on Basket Hold, Increased Complaints of Abusive Staff
As Brisbane staff was forced to rely on the basket hold instead of mechanical restraints to control the behavior of the patients, the care and treatment of the adolescents began to deteriorate. State officials have acknowledged that without the option of using mechanical restraints, Brisbane staff members feared that they would not be able to assert control when a patient became agitated. Staff became edgier and more quick to respond physically to patients' behavior. DYFS Institutional Abuse Reports from Brisbane centered mainly on incidents occurring during physical restraints.
During late 1996 and 1997, NJP&A staff also tracked an increase in complaints regarding physical and verbal abuse of patients, which appeared to be a serious and systematic problem. Brisbane staff members were reported as being physically rough with and disrespectful and cruelly insulting to the adolescents. In a common pattern, a staff member would verbally harass a patient, who would become angry and belligerent. The staff member would then physically respond to this angry outburst, escalating the confrontation and instigating even more aggressive behavior on the part of the patient. Subsequently, the patient would wind up in a physical restraint, alleging physical abuse.
Such incidents echoed the 1989 report of Dr. Barry Nurcombe, the Public Advocate's expert in the Slocum v. Perselay litigation, who documented that staff members verbally intimidated and hectored patients. According to Dr. Nurcombe, staff members were especially provocative with more difficult patients, possibly seeking to set up a physical response that would allow them to assert their dominance.
Complaints about the treatment and care of adolescents at Brisbane during this period were also documented in other sources. In March 1997, two staff members from Brisbane sent a letter to Governor Whitman protesting the verbal and physical abuse of patients by certain staff members and the lack of investigation by DYFS. In September 1997, the state Medicaid examiners, while commending Brisbane for medical, nursing and social services, noted frequent complaints by patients that the non-professional staff was too rough, too quick to use physical restraint and too distrustful and disrespectful. In the spring 1997, nurses filed a health and safety grievance that alleged that nursing levels were so low that patients were put in danger.
Kelly Young's Death (3)
In the late afternoon of Sunday, January 4, 1998, Kelly Young was assigned to the Main House Coed Unit. There were four Brisbane employees assigned to this unit in accordance with the established staff: patient ratio of 1:4 -- Youth Worker Williams, Youth Worker Stoll, Head Nurse Simpson and a Human Services Assistant. However, during this late afternoon period, Head Nurse Simpson left to get medication that Kelly requested for menstrual cramps, and Youth Worker Stoll left to get his dinner, leaving Williams and the Human Services Assistant alone on the Unit.
Following a telephone conversation with her grandmother, Kelly became upset. After seeming to calm herself, she became more upset. She then requested permission to make another telephone call to a family member, but Williams refused permission because he felt Kelly was too upset. Kelly responded by becoming more upset, kicking a chair and then hitting and kicking the locked door near the nurse's station.
Without calling for back-up or trying to talk to Kelly to calm her down, Williams ordered Kelly to sit down. When Kelly refused, Williams grabbed her from behind to force her to sit down. Kelly responded by becoming more agitated, swinging and kicking at Williams as he tried to force her away from the door to the nurse's station. As Williams attempted to apply a basket hold, Kelly fell to the floor by the wall. With Kelly sitting on the floor, facing the wall, Williams secured her in a basket hold.
While maintaining this physical restraint, he dragged Kelly from the wall over to her assigned seat, approximately 10 to 12 feet away. Struggling to maintain the basket hold, Williams tried to move Kelly from the floor to her chair, but she slumped back to the floor. At this point, Youth Worker Stoll returned. Observing the struggle between Williams and Kelly, he called the Shift Administrator's Office for Nurse Simpson and other staff to come to the Coed Unit.
Stoll went over to assist Williams, who was still struggling with Kelly on the floor. Stoll wrapped his arms around Kelly's legs to prevent her from kicking Williams as Williams grappled with Kelly, trying to establish a more secure hold. Within three to seven minutes, Kelly stopped struggling. Williams and Stoll continued to hold Kelly for two more minutes once she was calm. Stoll called again for Nurse Simpson, and then went to assist with the other patients in the Unit. Once the hold was released, Williams left Kelly motionless on the floor, without any assessment of her condition.
Nurse Simpson returned to the Unit, saw Kelly lying on the floor, but did not receive any information from Williams about what had happened. She went to the medication room to call the Shift Administrator's Office to report the incident and to request a doctor, then she approached Kelly to administer medication. Kelly was unresponsive. Turning Kelly's head, Nurse Simpson saw that her face and lips were turning blue. She could not feel Kelly's pulse.
Nurse Simpson began emergency procedures. An ambulance arrived to take Kelly to Jersey Shore Medical Center. Kelly Young was pronounced dead the next afternoon after being taken off life support. The autopsy indicated that the cause of death was asphyxia.
The Monmouth County Prosecutor presented the facts surrounding Kelly's death to the Monmouth County Grand Jury. Following two days of testimony, the Grand Jury voted against any indictments, ending the criminal investigation.
Administrative Report Finds Improper Use and Application of Restraint Leading to Kelly’s Death
The State conducted an Administrative Investigation as a collaborative effort involving staff from the Division of Mental Health Services' Patient Service Compliance Unit and Brisbane. Their investigation included a review of Brisbane documents and staff statements taken by the Monmouth County Prosecutor's Office. The investigative team also conducted its own interviews of Brisbane staff.
The Administrative Investigation concluded that Nelson Williams had been provided with training in crisis intervention and hospital policies and procedures. However, the Report concluded that Williams failed to follow Brisbane's policies and procedures by:
The Report concluded that there was no evidence of intent or malice on Williams' part, but Williams' actions or inactions contributed to Kelly's death. Following this Report, Williams' employment at Brisbane was terminated in March 1998.
Circumstances of Kelly’s Death Parallels
Recent Connecticut Tragedy
In March 1998, a 12-year-old boy, Andrew McClain, died while being physically restrained at Elmhurst Psychiatric Hospital, a private hospital in Portland, Connecticut. The circumstances of this tragic incident echo the events leading up to Kelly's death. As reported in the New York Times, (4) Andrew was taken to the time-out room for misbehavior. Once there, he refused to move from one end of the room to the other. When a worker tried to move him to the corner, he became extremely agitated. This worker, with the assistance of a second worker, struggled to physically restrain Andrew. All three ended on the floor, with one worker applying pressure to Andrew's side and the other holding his legs. After a few minutes, Andrew stopped breathing. When the workers smelled urine, they tried to rouse him and realized that he did not have a pulse. Connecticut's chief medical examiner found that Andrew was crushed to death during the restraint.
A report released by the Department of Children and Families and a separate report by the Child Fatality Review Panel noted that Andrew's behavior did not require physical restraint. Instead he could have been left alone in the timeout room. The Department of Children and Families also concluded that Andrew's intense agitation, which led to the physical restraint, was in reaction to the abusive way in which he was being treated by the hospital worker. The Child Fatality Review Panel’s report criticized the Department of Children and Families for failing to do an extensive study after the death of another child under similar circumstances in 1997, which could have led Connecticut to establish uniform rules on physical restraint of children.
Aftermath of Kelly Young's Death:
Crystallization of Complaints about Brisbane
News of Kelly Young's death intensified and publicized the growing concerns about the treatment of the children at Brisbane. Newspaper articles included details of the history of Brisbane, including the Public Advocate litigation, the 1989 highly critical white paper from the Mental Health Association of Monmouth County, as well as more recent complaints. (See footnote 3). Ginger Mulligan, executive director of the Mental Health Association of Monmouth County, noted that while conditions at Brisbane improved following the white paper, they had recently deteriorated, and that she had been receiving increased calls from parents describing abuse of their children. In addition, she reported concern that the staff was inadequately trained to deal with the problems of the children there, resulting in a "detention center mentality" and inappropriate reactions of staff to the patients' acting-out behavior. (5)
On March 29, 1998, Department of Human Services' Commissioner William Waldman held a meeting with advocates in the children's mental health community to discuss their complaints about Brisbane. Among those attending the meeting were Ginger Mulligan, staff from NJP&A, Mildred Boyd, Chair of the Brisbane Board of Trustees, and representatives from five families that had children at Brisbane, including Robert Freitag, who had expressed his disapproval of his child's treatment at Brisbane in the newspaper articles about Kelly. As summarized by the Department of Human Services, the complaints raised at this meeting focused on the harsh treatment of children, including verbal and physical abuse and restraint, as well as other issues including:
State Findings and Recommendations Leading to
May 1998 Action Plan
At the same time that complaints about the care and treatment of adolescents at Brisbane were being raised, a review of the operations at Brisbane was conducted by state officials, including Ginger Schnorbus, Chief of Staff, Department of Human Services; Gena Haranis, Special Assistant to the Chief of Staff, Department of Human Services; Lucy Keating, Assistant Director in the Division of Mental Health Services' Office of Children's Services; Raymond Grimaldi, Brisbane's Chief Executive Officer, and his staff; the Patient Services Compliance Unit; and staff from the Department of Human Services and the Division of Mental Health Services. The state review concluded that Brisbane is "neither a hospital in crisis nor are there serious shortcomings or inattention to the quality of care and safety issues. At the same time, some of the concerns expressed were found to have merit and corrective actions are required."(6)
Recommendations, developed to address the complaints about Brisbane and the Department's own findings, were incorporated into the Arthur Brisbane Child Treatment Center Action Plan, May 1998 ("May 1998 Action Plan"). These state findings and recommendations included:
The Department found Brisbane's investigations into complaints of abuse to be good, but recognized that Brisbane needed to have better follow-up with parents. The first report to parents was adequate, but then there was not sufficient additional information.
To address these problems, the Action Plan required the risk manager to have an expanded role and to keep families advised on the status and findings of investigations into allegations of patient abuse. The job of client services representative would be expanded to include the duties of family advocate.
According to the Action Plan, an experienced clinical therapist with expertise in treating adolescents who are victims of sexual abuse would be hired. Specialized groups for patients with substance abuse problems, such as Alcoholics Anonymous and Narcotics Anonymous, would be re-established.
The Action Plan called for increasing the number of families involved with family therapy by working with DYFS to address transportation and, if necessary, offering family therapy during the evening.
Other areas addressed in the Action Plan included commitment to change the table of organization, installation of surveillance cameras in the common areas to monitor staff-patient interactions, and upgrading the physical environment by painting and re-waxing the floors of the living units.
May 1998 Action Plan Fails to Address Deficiencies in the Physical Plant or the Large Numbers of Discharged Patients Waiting for Placement
The problems with the aged, unsuitable physical layout of the hospital were not dealt with in the May 1998 Action Plan, except for the minimal requirement for Brisbane staff to conduct a feasibility study, which would be reviewed and implemented if possible, for physical changes and improvements in the cottages to allow for handicap access and adequate space for clinical interventions. Although the Department acknowledged in its findings that there was a lack of placements for older adolescents ready to leave Brisbane, there was no attempt to tackle this issue or the overall issue of the lack of placements for Brisbane’s waiting CEPP population.
May 1998 Action Plan Mirrors March 1990 Workplan
As though time had stood still in the intervening eight years, the earlier March 1990 Workplan, like the May 1998 Action Plan, addressed the need for expanded and improved substance abuse treatment, the need for family therapy and transportation for families, and changes in the table of organization. The 1990 Workplan also required that monthly parent meetings with the Brisbane administration be held to involve families and that a full-time family advocate be hired. However, in contrast to the May 1998 Action Plan, the March 1990 Workplan directly and broadly focused on Brisbane's appropriate role within the mental health system of care.
Implementation of Action Plan:
Continuing Concerns about Physical Restraint, Supervision, and Patient Care
By fall 1998, there was some progress in the implementation of the May 1998 Action Plan. Staff had been trained in and were utilizing the Handle with Care hold. There was a commitment to hire 14 new youth workers instead of 12, and eight new youth workers had already been hired. Although the title change was not implemented, all eight of the new employees had college degrees. Still pending was the hiring of a therapist with a master’s degree in social work who had expertise in treating adolescents with a history of sexual abuse.
Communication with parents appeared to have improved in some areas. At admission, parents were now being met by one of the top administrators. Several family advisory group meetings had been held. Although these meeting were viewed as an unusual opportunity for parents to be involved with their child's institution, attendance at the meetings had been very low. Still unresolved were issues of the communication with parents when their child alleged institutional abuse. The Office of Children's Services reported, however, that it was working with the Department on lowering the standard for making a finding of abuse, shortening the response time to parents, and changing the tone of letters to parents.
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During the months after Kelly Young’s death and as the May 1998 Action Plan was implemented, Brisbane was under special scrutiny. Nevertheless, problems persisted in the areas of physical restraint, supervision and patient care. Concerns about the safety of the Handle with Care hold escalated after a patient's arm was broken during the hold in the course of being moved. Other, more minor injuries during physical restraints were also alleged.
Supervision was also a persistent concern. In the late spring, a patient on two separate occasions tried to commit suicide in the shower. Another patient disappeared from the calming down room at school and from Brisbane's grounds and was not returned to Brisbane for almost four hours. Problems with supervision and patient safety did not appear to be limited to these incidents. Brisbane attempted to correct an acknowledged deficiency in supervision and staffing by making each unit semi-autonomous with a more unified core of assigned psychiatrists, nurses and youth workers.
The quality of the overall care of patients at Brisbane also continued to be uncertain. It was reported by the parent of the child whose arm was broken that staff at the psychiatric hospital was unable to provide the child with the proper care, requiring the parent to visit daily to attend to the child's needs.
The Brisbane administration’s reliance on the rigid standard for finding "child abuse" appears to have created an atmosphere that is tolerant of abusive, unacceptable staff behavior as long as it does not meet the strict legal definition of child abuse. If DYFS’s role in only scrutinizing "child abuse" is too limited to address patients’ and families’ serious, more general, complaints of inappropriate staff behavior, then the State should assign these investigations to another outside agency.
At Best, A Limited Action Plan Can Only Accomplish Limited Improvements
A decade before Kelly's death, Dr. Barry Nurcombe documented overwhelming problems with staff training and staff interactions with patients along with deficiencies in the areas of the physical plant, and the diagnostic, therapeutic and educational services. He also noted the lack of options for patients ready for discharge. During 1989 and 1990, these same issues were among those identified by the Mental Health Association of Monmouth County, by the State in the report of the Arthur Brisbane Management Team, and by Dr. Robert Friedman, the court-appointed expert in the Slocum v. Perselay litigation. In 1998, following Kelly's death, the same problems that were first noted by Dr. Nurcombe in 1988, were among those raised by advocates for children's mental health services and acknowledged by state officials in preparing the May 1998 Action Plan.
Although this most recent Action Plan may result in some improvements at Brisbane, it cannot accomplish any lasting and profound changes. It fails to confront the most significant problems at Brisbane: its isolation, its unsuitable physical plant, and the lack of placements for the adolescents when they are ready to leave. As long recognized, Brisbane’s physical plant is inappropriate for a psychiatric hospital and the physical isolation inhibits family involvement and possibly limits the recruitment of therapists and other staff. Even after the tragedy of Kelly Young’s death, these factors, exacerbated by the pressure brought by the addition of the juvenile justice population, will continue to kindle the persistent problem of poor, ev