OPA: JB Investigation Report

Executive Summary


Investigation Report

On the Death of JB

State of Connecticut

Office of Protection and Advocacy for Persons with Disabilities

James D. McGaughey, Executive Director

Susan Werboff, Program Director
Protection and Advocacy for Individuals with Mental Illness (PAIMI) Program

Anne Broadhurst, Principal Investigator

April 11, 2003

Message from James D. McGaughey, Executive Director

The Investigation Report on the Death of JB  reflects the results of an investigation conducted by our Office’s Protection and Advocacy for Individuals with Mental Illness (PAIMI) program into the circumstances surrounding the death of J.B., a patient at the Whiting Forensic Division of Connecticut Valley Hospital. 

 J.B. died of cardiorespiratory arrest associated with being restrained.  The investigation found that signs he was experiencing a medical emergency were interpreted by facility staff as evidence of attempts at behavioral manipulation on his part, and, further, that legal requirements and policy safeguards surrounding the use of restraints were not observed.  It also found that other aspects of J.B.’s treatment reflected misunderstandings of his identity and needs.

 Our Office shares this report with the hope that those engaged in the work of behavioral health care will consider ways to prevent similar tragedies from   occurring.                                     







On April 3, 2002, “JB”, a thirty-nine year old patient at the Whiting Forensic Division of Connecticut Valley Hospital, died while being restrained in handcuffs and leg irons on the floor of a hallway of his treatment unit.  Preliminary indications were that he had simply suffered a heart attack while struggling with hospital staff.  JB had a lengthy history of psychiatric hospitalizations.  He presented many of the classic risk factors for heart disease: he smoked heavily, seldom exercised and, at 346 pounds, was described as “morbidly obese”.  CPR had been administered and 911 called, but, unfortunately, resuscitative efforts had proven futile.

However, as investigations into the circumstances surrounding his death proceeded, it became apparent that there was more to the story.  Witnesses reported that JB had ceased to struggle, and was manifesting signs of acute distress well prior to the time that those in charge recognized and declared a medical emergency.  Concerns had been voiced about dilated pupils and lack of response to “sternum rubs”, but these were dismissed.  As JB lay motionless on the floor, one of the psychiatrists present heard him make a “stertorous” exhalation- a “raspy, gurgling exhalation”.  “His chest compressed with the exhalation, but he did not inhale.”  Yet, shortly after making this observation, that psychiatrist departed the scene having neither intervened nor brought this observation to the attention of other doctors present.  Ironically, JB’s continuing passivity and the strange “snorting” sounds he periodically emitted were interpreted as evidence that he was “faking” and “playing possum”.   Instead of receiving evaluation and life-saving medical intervention, he remained in shackles while staff searched for smelling salts, and debated where and how he should be moved, and whether and how the restraint should continue.  Ultimately, his limp body was rolled onto a blanket and dragged into a restraint room where the supervising psychiatrist insisted that Whiting police officers keep him in handcuffs and leg irons.   Following another hallway conference, a large dose of Thorazine was ordered and injected into his buttocks.  Only after all this had happened did a proper check of vital signs reveal that JB was pulse-less and not breathing. 

As required by law, JB’s death was reported to the Chief State Medical Examiner and to a number of oversight and law enforcement agencies including the Office of Protection and Advocacy for Persons with Disabilities (OPA).  Acting pursuant to its authority under the federal Protection and Advocacy for Individuals with Mental Illness Act (PAIMI), OPA commenced an investigation.  Evidence gathered by other investigating agencies was reviewed, treatment records examined, and witnesses interviewed. FOOTNOTE:  [In keeping with DMHAS policy, CVH staff conducted a “Critical Incident Review” of the circumstances surrounding JB’s death.  OPA requested copies of all information related to this review, but the request was denied by DMHAS, which indicated that the review was part of a peer review process, and was therefore protected from disclosure under federal PAIMI requirements.  OPA disagrees with this determination and has filed an action in Federal District Court to compel disclosure of this and other information OPA needs in order to ascertain the nature and extent of the facility’s efforts to respond to this incident and protect other patients from harm.]

OPA’s inquiry focused initially on the restraint techniques employed and the apparent failure of procedural safeguards that should have protected JB from harm.  But underlying questions began to surface: Why were the signs of JB’s physical distress disregarded for so long?  How could so many trained health care professionals - doctors and nurses, all working in a hospital setting - have misinterpreted clear evidence of an evolving medical emergency, deferring whatever individual doubts they may have had to an institutional presumption about non-compliant patient behavior? 

The picture that ultimately emerges strongly suggests that the fatal events of April 3 were a result of more than procedural failures and faulty medical judgment: subtle, erroneous assumptions and missed cues about JB’s identity and needs were also major contributing factors.  In fact, evidence from his treatment records indicates that the misinterpretation of his respiratory distress on the day he died was but one example of fundamental and tragic misunderstandings that characterized much of his treatment experience at the hospital.

A narration of the events of April 3, 2002, and details about JB’s history and treatment are contained in the main body of OPA’s report.  The details are important not only to clearly understand the sequence of events that preceded JB’s death, but also because they help explain how fundamental misinterpretation of his needs and ill-fitting programmatic responses contributed to the tragic outcome.  While it is not possible to do full justice to this important information in a condensed summary, a brief description of the events of April 3 and an outline of  OPA’s findings and recommendations are listed below:  


On the day he died, JB awoke to find his “activity sheet” missing from the foot of his bed.  For patients at Whiting, the weekly activity sheet represents both a schedule and a record of activities attended.  The sheets are turned in to staff at the end of each day for scoring.  “Positive points” are awarded for appropriate behaviors, while “response costs” are assessed for negative ones.  The sheets are returned to each individual the next morning.  Applying a somewhat complicated computational formula to the data reflected on the sheets, patients are assigned to one of five “levels”.  These, in turn, determine the availability of certain individual privileges. 

Unit records indicate that JB was very upset that his activity sheet was missing.  He accused staff of taking it, and, throughout the early morning, was loud, argumentative and threatening.  In response to his agitation, staff encouraged him to voluntarily enter “quiet time” (unlocked, voluntary seclusion), which he did.  He soon emerged from the seclusion room, however, and due to his verbally threatening behavior, was placed into “timeout” (involuntary, locked seclusion) for approximately fifteen minutes.  At a “debriefing” meeting held after his release from locked seclusion, his behavior and other possible approaches were discussed with JB.  The unit psychiatrist who led the meeting reported that although the discussion produced no resolution, by the end of the meeting JB had calmed down.

The morning’s events set the stage for further conflict later in the day.  In addition to being upset about the missing activity sheet, JB’s records also indicate that he had run out of cigarettes several days earlier, and that he had no money to purchase more.  (JB was a heavy smoker who periodically ran out of cigarettes.)   After lunch that day, JB was observed smoking a cigarette outside the unit, in the courtyard.  As it was known that he had none of his own, this meant he had “bummed” the cigarette from another resident – a violation of facility rules.  He was summoned to another meeting with the unit psychiatrist.  That meeting that did not go well.  According to the psychiatrist’s progress notes, JB, who came directly from the courtyard still wearing his winter jacket, left the meeting “in a huff.”  Due to his loud and threatening behavior, unit staff was ordered to bring him to locked seclusion.  As he was being escorted down the hall to the seclusion room, JB reportedly attempted to strike out at one of the “four or five” staff surrounding him.  He was immediately brought to the floor, and a psychiatric code was called.  The time was approximately 2:30 PM. 

At CVH, a psychiatric code alerts all available clinical staff to respond to a psychiatric emergency.  By calling the code, unit staff was signaling that the scope of the emergency was beyond their ability to handle without additional help from outside of the unit.   Interviews with hospital staff and statements made to facility police indicate that at least twenty people responded, among them four agency police officers, four nurses, two psychiatrists, the unit medical director (a doctor of internal medicine), and nine Forensic Treatment Specialists.  One of the participants – a nurse supervisor from another unit put the number of responders at closer to thirty-five.  In fact, so many people became involved in holding JB to the floor, or crowded around him, that many of those who responded could not see who he was, or ascertain what was happening.

OPA/PAIMI’s full investigation report describes the events that followed in considerable detail.   The investigation findings, summarized  below, outline these events and identify factors that contributed to JB’s death. 


  1. On the morning he died, JB’s treatment staff missed a significant opportunity to help him build trust in them, and insight into the direction of his own recovery.  They focused on confronting his inappropriate behavior rather than engaging him in a discussion about the underlying reason he was agitated.  In the weeks prior to his death, JB had begun to participate more and to achieve higher levels of success in the Unit 2 program.  The missing activity sheet reflected the positive points he earned by participating.  His concern for its whereabouts stood in marked contrast to his long-standing posture of indifference.  For most of the time he lived on the unit he had avoided activities and even refused to carry the sheet with him.  This expression of concern offered an opportunity to acknowledge what succeeding in the unit’s program had come to mean for JB, and, perhaps, to offer concrete, trust-building assistance in looking for or re-constructing the missing sheet.  Instead, he was placed in time out and counseled regarding what he needed to do differently when upset.

  2. Throughout the course of the morning, and prior to the implementation of the restraint procedure in the afternoon, JB was not offered the opportunity to engage in any of the “personal safety preferences” he had identified as preferred ways for dealing with behavioral and/or emotional difficulties – activities such as writing in his diary and drawing.

  3. Nicotine withdrawal undoubtedly contributed both to JB’s agitation on April 3, and to his overall problem following unit rules.  Indeed, a treatment plan summary (dated 1/16/02) reported that JB’s persistent violation of unit rules around cigarettes was his single largest issue.  Yet there is no evidence that the effects of withdrawal were taken into consideration, or that his addiction to tobacco was being addressed.  (Following its investigation, the Department of Public Health cited CVH for failure to develop a program to address JB’s nicotine addiction.)

  4. The level and type of force utilized by hospital staff members during the restraint on April 3 failed to take into account JB’s known limitations and the increased medical risk associated with his physical condition.  JB’s records note that he had gained approximately 100 pounds since his 1998 admission to CVH, and, at 346 pounds, was considered “morbidly obese”.  He rarely exercised, smoked heavily, perspired noticeably and was frequently out of breath after walking short distances.  More significantly, JB had complained of shortness of breath on several occasions – most notably when lying flat on his back during periods of restraint.  Because of this the hospital had used a wedge under the mattress to elevate his head on occasions when he was restrained.  Yet, on the day he died, he was held down flat on his back, placed in manacles, and maintained in a supine position for approximately 20 minutes.

  5. The unit psychiatrist in charge of supervising the restraint failed to properly monitor JB’s physical condition throughout the restraint procedure.  Despite expressions of concern by nurses and an EMT-trained agency police officer, the unit psychiatrist made no assessment of JB’s status during the approximately 20 minutes he was being restrained.  Nor was an assessment performed prior to administration of an intramuscular injection of major tranquilizing medication.  Instead, the unit psychiatrist attributed JB’s “snoring” exhalations and non-responsiveness to  “playing possum.”  (Despite staff reports that JB would sometime feign sleep to avoid scheduled activities, a review of JB’s progress notes covering the three and one-quarter year period he was hospitalized revealed only two entries that allude to this behavior.  Neither of those incidents involved restraints, seclusion or physical resistance of any type.)

  6. A psychiatrist responding to the emergency code from another unit heard JB give a “stertorous exhalation, a raspy, gurgling exhalation” and observed “his chest compress with the exhalation, but not inhale.”  Despite this alarming observation, the psychiatrist left the scene of the incident without ensuring that a formal assessment of JB’s respiratory status was completed.  He stated that the unit psychiatrist who was supervising the restraint “signaled” to him that “everything was under control.”

  7. Despite the fact that a large number of medically trained personnel clustered around JB throughout the application of the restraint procedure, no one present properly monitored his physical condition, even though significant changes were reported and observed.  Although they had concerns that “something was wrong,” and that the sounds that JB was emitting were “odd,” staff members present deferred to the unit psychiatrist’s assessment of the situation and his judgment of JB’s behavior.   

  8. According to interview statements and written reports, staff members present expressed confusion regarding outcome expectations.  During the course of the incident, staff disagreed amongst themselves regarding whether they were going to transport JB to the time out room or restraint room, the manner in which they were going to move him, and when to remove the handcuffs and leg irons.

  9. Well past the point when JB had ceased to struggle, the unit psychiatrist insisted that JB remain in shackles and receive an IM injection of Thorazine. 

  10. According to the CVH police department Case Report, two police officers confirmed that a unit nurse had twice informed the unit psychiatrist that JB’s pupils were dilated prior to the injection of Thorazine.  Yet, no further assessment of JB was either ordered or completed by the unit psychiatrist.  According to the unit psychiatrist, the Thorazine was administered because “there was concern that if we tried to remove the cuffs he would strike out, even though he was not responding to us and was flaccid at that time.”  This rationale for continued use of mechanical restraints, and introduction of chemical restraint stands in clear violation of legal requirements necessary to justify their use.

  11. After administration of the Thorazine, it was determined that JB’s pupils were fixed and dilated and no pulse could be found.  An emergency medical code was called.   According to the DPH report, the primary care physician for the Whiting Division of CVH, an internist, who had arrived on the scene after JB had been brought to the time out room, reported that “he did not assess JB when his level of consciousness was questioned because there were many people in the room with JB, including the unit psychiatrist.”  The internist was the only one present with a flashlight, which he handed to staff to appropriately check JB’s pupils.

  12. As indicated in the DPH report, current DMHAS policies regarding the use of physical restraints for behavioral management do not identify the role of agency police officers in psychiatric emergencies, including criteria for the initiation of police response, providing assistance to nursing staff, and guidelines for specific interventions or restraints used.  Agency police officers are the only DMHAS staff authorized to use handcuffs and leg irons, but their use on JB was a direct result of requests from a unit nurse.

  13. Although modifications to the current restraint and seclusion room doorway widths have been proposed, the current doorway widths on the unit did not permit staff members to safely escort JB to the seclusion room in an upright position.  This necessitated dragging JB through the doorway in a supine position.

  14. Staff members attending to JB did not have immediate access to medical supplies that were necessary to properly monitor JB’s physical condition during the restraint procedure and to respond to a life-threatening emergency once a medical code was called.  Items not readily available to staff on Unit 2 included ammonia inhalants, which were located on the emergency cart housed on another unit, a flashlight, and an emergency cart equipped with battery-operated equipment, such as a defibrillator and suction machine.  (Neither the restraint nor the seclusion rooms are equipped with electrical outlets, which hampered the ability of hospital personnel to effectively utilize the emergency medical equipment that was obtained once the medical code had been called.  Staff members had to access an electrical outlet one or two doors down from the time out room in order to plug in the suction machine.)


  1.  In addition to the specific findings listed above, the OPA/PAIMI investigation identified several more subtle issues of concern.  These include:

  2. Failure to adequately consider the potential impact of JB’s identified cognitive limitations and limited literacy and math skills on his ability to understand and benefit from the complex behavioral program implemented for him.

  3. Failure to consider alternative treatment approaches or seek outside consultation despite strong evidence that, for most of his stay, JB derived little benefit from conventional hospital programming.

  4. Failure to adequately review and monitor the effectiveness of the multiple psychotropic medications given to JB, and to consider their potential contribution to the 100 pound weight gain he experienced while hospitalized.

  5. Failure to recognize and capitalize on JB’s strongly positive responses to individualized instruction in music.

  6. Failure to allow holiday visits by family members by ensuring that they remained eligible to visit subsequent to JB’s intra-facility transfer. 

  7. A global need to study the potential effect of client race on perceptions of dangerousness and patterns of restraint use in human service settings.


The OPA/PAIMI investigation concludes by making the following recommendations to DMHAS:

  1. Review current policies and procedures regarding the emergency application of physical and chemical restraints in order to ensure that both conform to accepted medical standards and do not place individuals at risk of injury or death.  It should be clear that in both physical and chemical restraint situations, their use is authorized for only as long as a critical situation persists; that individuals being restrained are continuously monitored by medical professionals who are alert to the potential of a medical emergency and qualified to respond appropriately should one arise; that emergency medications are only administered after a medical assessment of the individual’s physical condition occurs; and that genuine attempts are made to de-escalate a situation prior to employing emergency interventions.  DMHAS staff should identify individual de-escalation strategies and put this in writing in residents’ charts.  As individualized de-escalation strategies may be subject to change for individuals who are hospitalized for long periods of time, they should be re-evaluated on a regular basis to ensure that they are still effective.  In addition, the manner and type of physical or chemical restraint administered should take into account any physical or emotional limitations that place individuals at greater risk.  Strategies for calming individuals down, identified risk factors, and approved restraint techniques should be included in individual treatment plans.

  2. DMHAS should ensure that agency policies and procedures regarding the emergency application of physical and chemical interventions specifically address the role and responsibility of facility police officers, including conditions for their involvement and regulations for types of interventions used.

  3. DMHAS needs to ensure that medical staff members are adequately prepared to recognize what constitutes a medical emergency and to effectively take charge when such situations occur.

  4. DMHAS should establish a protocol for assigning objective supervision to manage the application of emergency physical and chemical restraint procedures.  This protocol should include the designation of a staff person who has not been involved in the development of a particular intervention to act as an objective evaluator of the situation and provide guidance to staff, as needed, in order to ensure that appropriate and safe approaches are followed.

  5. DMHAS should ensure that emergency medical equipment and supplies are readily accessible to hospital personnel and in good working order.  DMHAS should also ensure that environmental issues that were problematic during the emergency restraint procedure, such as the narrow doorways leading into the restraint and time out rooms, are effectively remedied.

  6. DMHAS should ensure that the unit psychiatrist be disciplined and/or receive training regarding his failure to promptly and appropriately assess JB’s changing medical condition during the application of emergency restraint, and for his failure to adequately assess his medical condition prior to the administration of emergency medication. 

  7. DMHAS should establish a protocol to ensure that when unprofessional acts and/or omissions by health care professionals are suspected, they are reported to appropriate licensing agencies for review.

  8. DMHAS should ensure that all staff members receive ongoing education in such areas as: alternatives to the use of physical and chemical restraint; how their own attitudes and behaviors shape the responses of others; how to recognize signs and symptoms of physical distress when applying emergency restraint procedures; how to assist individuals in meeting criteria for release from restraint as soon as possible; diversity training, which includes an honest discussion of cultural and racial issues; and how to support themselves for their own responses to the often intense nature of their work.

  9. DMHAS should develop a formal mechanism to initiate multi-disciplinary, external review and consultation regarding the treatment of individuals whose behaviors are proving to be particularly challenging despite efforts of clinical staff of a particular facility.  Particular attention should be paid to those individuals who do not respond to conventional behavioral therapies and/or chemical interventions.

  10. DMHAS should review current policies and procedures associated with outside individuals securing approved visitor status within secured facilities to ensure that visitors are not subjected to unnecessary re-authorization procedures once they have been approved.

End of Executive Summary

Content Last Modified on 7/30/2007 8:27:41 AM