After a preliminary examination of the facts in this case, the Child Advocate, in her role as Chairperson of the Panel, convened a Fatality Review Panel meeting on March 26, 1998 to review the circumstances surrounding the death of Andrew M., a child who was legally committed to the care and custody of the Department of Children and Families (DCF) when he died at the "Facility" on March 22, 1998.

The purpose of this review is twofold: In Part I, the Panel seeks to identify the immediate circumstances surrounding, and particularly to isolate those factors playing the most prominent role in, the death of this child, with apposite recommendations. In Part II, the Panel assesses the less immediate circumstances surrounding the death of this child, such as the predicates for state involvement in Andrew’s case, the services and interventions provided, and the social work and therapeutic management of his case, and again provides relevant recommendations. Not only does this review of the broader circumstances put the first tier of inquiry into context, but also facilitates a better understanding of how this child might have been better served and protected by the system as a whole.

Part I includes an examination of the events which led up to the untimely death of this child; the institution’s policies and procedures on behavior management, including the use of therapeutic holds; and the clinical responses to this incident. It also addresses the role of state agencies in the protection of children in care in mental health and other facilities across the state. Part II, which will be released by the Fatality Review Panel on or before June 22, 1998, will include a consideration of the issues raised by Andrew's social, psychological and medical history; his history with DCF, Connecticut's child protection agency; and the efficacy of the therapeutic and medical management of his case.

Summary of Facts

Andrew M. was born on December 6,1986, and first came to the attention of DCF (then known as the Department of Children and Youth Services) prior to his third birthday, as a result of medical neglect referrals. His family has had sporadic involvement with DCF since that time over concerns of chronic abuse as well as medical, physical and educational neglect. While in the care of his mother and grandmother, Andrew suffered three separate eye injuries resulting in the complete blinding of his left eye at the age of three.

At the time of his admission into the Facility, Andrew was eleven years old and had experienced three changes in his legal guardianship, a host of serious injuries and illnesses, a period of commitment and extensions of commitment to DCF, repeated inpatient psychiatric hospitalizations, placement in three traditional foster homes, placement in one therapeutic foster home, a day treatment program, and partial hospitalization programs. Andrew was a child described by many as "sweet" and "endearing," who was eager to please and wanted to learn to read. He was also a child who had an extensive history of acting out, sometimes violently, and of planning harm to others, of acting on those plans on at least one occasion, of threatening suicide, of having to be physically restrained in school and in psychiatric facilities (on at least twelve and four occasions respectively), and of running away. He had been diagnosed on several occasions with "oppositional defiant disorder," "conduct disorder: and "intermittent explosive disorder," disorders in which strongly imposed authority is frequently met with aggressive behavior and uncontrollable rage.

On March, 19, 1998, Andrew was admitted to the Facility under a Physician’s Emergency Certificate (PEC) from Hospital A, after he exhibited threatening behaviors against another child in Foster Home A. At the Facility, Andrew was examined by a psychiatrist and admitted to the inpatient program on the S Unit. A staff therapist was assigned to Andrew's case, and he began to gather background information on Andrew. The therapist worked with Andrew two times in group therapy, but had not engaged in individual therapy with Andrew up to the time of his death.

On the morning of Sunday, March 22, 1998, Andrew became involved in a series of escalating exchanges with Mental Health Worker 1 (MHW 1) which led to Andrew’s removal to the time-out room. Once in the time-out room, another series of escalating confrontations took place leading to Andrew being placed in a physical restraint by MHW 1, who was then assisted by MHW 2. This physical intervention resulted in Andrew’s untimely death.

Summary of Findings

• The death of Andrew M. on March 22, 1998 was the result of traumatic asphyxia, which has been ruled accidental.
• Under no circumstances, should the physical restraint of a child include compression of the child’s thorax by the weight of an adult.
• Staff response at the Facility in which Andrew died reflected an inadequate behavior management program.
• The Facility utilized an outdated physical restraint training program that did not conform to currently-accepted standards established by contemporary training programs.
• Although not necessarily a contributing factor to Andrew’s death, the Facility’s staff response to this medical emergency was inadequate.
• Although not a contributing factor to Andrew’s death, the treatment plan at the Facility lacked sufficient direction regarding the use of physical restraints on medically compromised children.
• The Department of Children and Families should have conducted an assessment of behavior management programs and physical restraint policies affecting children under DCF’s care, after the death of Robert R.
• The Department of Children and Families should promulgate regulations and policies that address the development of appropriate physical restraint policies for use in the facilities that they license and in the facilities in which children who are under the care and custody of DCF are placed.
• The Department of Public Health should promulgate regulations designed to develop standards for behavior management programs and physical restraint policies in the children’s facilities that they license.
• Neither the Facility nor the Department of Children and Families ensured that Andrew was advised of his right to a hearing and his right to an attorney upon involuntary admission to a psychiatric facility.