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National Review of Restraint Related Deaths of Children and Adults with Disabilities: The Lethal Consequences of Restraint

Authors: Equip for Equality


This report summarizes a study of 61 cases in which a person with disabilities died while being restrained. The cases were nominated for inclusion by the Protection and Advocacy organization in thirteen states (nominations were solicited from all 50 states with thirteen responding). Extensive reviews were done of each situation, and a detailed report was prepared reviewing what was learned then detailing a set of policy recommendations (click on the “Web Links” tab above to read the full report online). Below is a sample of the many interesting findings presented in the Executive Summary:

About those who died-
- The people who died ranged in age from 9 to 95 years old.

- Nearly one-third of those who died were over the age of 65, with 14 seniors over the age of 80 at the time of their deaths.

- The four youngest children to die in restraints were 9 years old.

- Almost three-quarters of those who died were male.

About the actual deaths-
- The deaths occurred in a variety of settings – nursing homes, schools, wilderness camps, residential treatment facilities, state institutions, emergency rooms, general hospital units and psychiatric hospitals.

- When people died while being restrained, trauma histories and pre-existing medical conditions had often not been considered

- Many deaths resulted from unlawful restraints

- The individuals who died were most frequently restrained in 4-, 5- and 6-point mechanical restraints (referring to the number of straps around the person’s limbs and body and attached to a bed or gurney).

- The second leading device involved in the deaths was a bed rail. This finding is particularly alarming given the recent change in the CMS regulations that excludes bed rails from the definition of restraint.

When a death had occurred -
- The most common physical restraint (27 of 32 cases) involved staff members physically holding the individual down on the floor.

- Only 7% of the cases involved the use of techniques deemed appropriate by standards for managing a person’s aggressive behavior.

- Most physical and mechanical restraints also involved chemical restraints

- There were significant failures to monitor individuals in restraints

- Staff responses to the individual’s distress were found to be particularly disturbing

Summary based on a review of the report as viewed online on 1/26/12 at http://www.equipforequality.org/publications/national-death-study.pdf

Contact Info:
Organization:Equip for Equality
Address:20 North Michigan Avenue, Suite 300
Chicago, IL 60602
Phone:(312) 341-0022-- TTY (800) 610-2779
Fax:(312) 341-0295

Web Links

View the full report

Home page of lead organization, Equip for Equality

This information was found at www.qualitymall.org