Name Age Sex State Date Method Institution Type Notes on death Cause of death

Campos, Edith 15 F AZ 2/2/98 P Desert Hills Center R Restrained after not giving staff a family photo. Asphyxiation

Ward, Charles 45 M CA 2/14/92 M Brotman Memorial Hospital H Medicated and restrained for 11 hours. No autopsy; a doctor signed the death certificate stating Ward died of heart failure

Jadeed, Zouhair 22 M CA 3/15/92 M Napa State Hospital H Strapped face down on a mattress after eight hours of restraint. Napa County sheriff's coroner listed cause of death as "undetermined"

Kiefer, Marc 38 M CA 2/3/93 M East Bay Hospital H Restrained to bed with straps, belts and cuffs for 18 hours. Psychiatric drug overdose, according to lawsuit

T., Laurajean 47 F CA 7/13/94 M John George Psychiatric Pavilion H Face down on bed and placed in five-point restraints. Asphyxiation from positioning in restraints

Webb, Barry 36 M CA 11/19/94 M Valley Medical Center H Placed in restraints for more than seven hours. Cardiac arrest

unidentified 33 M CA 4/1/95 M Napa State Hospital H Died after being restrained overnight in a chair with waistbelt. Cerebral and cerebellar hypoxia

Jackson, Robert 42 M CA 4/5/96 M East Bay Hospital H Strapped to bed and given anti-psychotic drug cocktail. Overdose of clomipramine

Diaz, Joseph Richard 40 M CA 4/30/96 P Fairview Developmental Center R Restrained face down on bed. Undetermined

Kanda, Jimmy 6 M CA 9/20/97 M Crow's Nest Family Care Home R Strangled in restraint; 911 operator had to talk staff through CPR. Asphyxiation

unidentified 20 M CA N/A M N/A H Restrained face down to a hospital bed; found dead later. N/A

unidentified 17 M CA N/A M N/A N/A N/A N/A

unidentified N/A M CA N/A N/A CPC Fremont Hospital H Died while face down in restraints. N/A

Collier, Casey 17 M CO 12/21/93 P Cleo Wallace Center R 6-foot-5-inch boy restrained. Asphyxiation

Small, Marcia 78 F CO 5/8/98 M North Suburban Medical Center H Hung partially out of bed with vest restraint around her neck. Strangulation by ligature

Jacob, Richard 40 M CT 3/25/90 P Timothy Terrace CLA R Face down, arms in front of chest; aide on top. Cardiac arrhythmia

Zentai, Katalin 43 F CT 12/26/96 M Connecticut Valley Hospital H Placed in a restraint chair for 30 of last 36 hours; died of blood clots. Bilateral pulmonary emboli

McClain, Andrew 11 M CT 3/22/98 P Elmcrest Hospital H Face-down restraint with arms crossed over chest. Asphyxiation

Crumpler, Mardee 31 F DE 9/6/93 M Stockley Center H Rolled in gym mat and suffocated. Asphyxiation

Thomas, Emory 42 M FL 1996 M Manatee Glens H Tied to bed with five-point restraints. Heart attack

unidentified N/A F FL 12/4/95 P Gulf Coast Center H One of four employees straddled her. Anoxic encephalopathy due to mechanical asphyxia due to restraint; ruled a homicide

Rawls, Robert Lee 29 M FL 1/11/97 P South Florida State Hospital H Placed in a choke hold while struggling with aides. Asphyxiation leading to brain damage

Payne, Gerry A. 35 M GA 4/17/98 P Central State Hospital H Attacked employee, then restrained by staff members. Sudden, unexpected death associated with psychotic episode; contributing factor: cardiomegaly

Campbell, Chris 13 M IA 11/2/97 P Iowa Juvenile Home R Restrained four times in last 24 hours. Undetermined

Sleeth, Ed 66 M IA 2/3/98 M Woodward State Hospital H Supposed to be restrained to wheelchair. Blunt trauma to head

Clark, Robin Lee 39 M IA 6/4/98 M,P Woodward State Hospital H Clark tied up, physically restrained after swallowing part of toothbrush Complications from swallowing a toothbrush

unidentified N/A M ID early '90s N/A Idaho State Hospital South H Patient went into convulsions; restrained. No autopsy performed

Wallace, Wauketta 12 M IL 7/11/89 P Maryville Academy R Restrained on back or stomach. Postural asphyxia and stress due to restraint

Cook, Larry 50 M IL 1/2/97 M Roseland Community Hospital H Tried to burn restraints off with lighter. Cook and another patient died. Smoke inhalation, burns.

Gray, Roxanna 17 F IN 7/6/89 P Family and Children's Center R Restrained face down on a pillow. Suffocation

Dahlke, David 39 M KS 1/10/89 P Winfield State Hospital H Restrained face down on mat. Records closed to public

Mapes, Thomas 17 M KS 7/8/94 M,P Youth Center at Topeka R Handcuffed and brought face down to floor. Asphyxiation

Bogrett, Jeffrey 9 M MA 12/1/95 M New England Center for Autism R New Hampshire boy died in restraints at a Massachusetts group home. Sudden death during restraint

Rollins, Robert 12 M MA 4/21/97 P Devereaux School R Restrained face down with arms crossed over chest. Positional asphyxiation during restraint

Galligan, James 59 M MA 12/1/97 P Pembroke Hospital H Suffered a heart attack while being restrained by staff. Heart disease; diabetes and bipolar disorder contributed

Soares, Mark 16 M MA 4/29/98 P Wayside Union Academy R Aides thought teen was faking unconsciousness Cardiac arrest

Isaacson, Kent 37 M ME 8/6/88 M Augusta Mental Health Institute H Restrained to bed for long periods of time before his death. N/A

Smith, Earl 9 M MI 1/11/95 P Children's Village R Restrained face down by staffer who thought his distress was a ruse. Asphyxiation due to chest compression

Halfacre, Benjamin 37 M MI 5/6/97 P Hummer Lake Group Home R Held him down from behind and took him to floor. Respiratory and cardiac arrest

Thomas, Bobby Sue 17 F MN 8/16/96 P Northwood Children's Home R Face down restraint. Acute cardiac arrhythmia

Pettit, Sherilee 35 F MN 5/18/97 P Cambridge Regional Human Services Center R Face down restraint for 4.5 minutes. Positional asphyxia secondary to restraint hold

Andrews, Buddy Earl 39 M MO 4/24/95 P Fulton State Hospital H Broke neck while being taken down. Broken neck

Schumacher, Richard 44 M MO 11/17/95 P St. Louis State Hospital H Refused to be discharged, taken down by security. Sudden death, marked agitation and physical restraint

Harris, Robin 25 F NC 4/7/90 M Dorothea Dix Hospital H Incident in which young female patient died after restraint. Heart condition (natural causes)

Sovern, Tristan 16 M NC 3/4/98 P Charter Greensboro H Face down on floor, towel in mouth. Asphyxiation

Young, Kelly 17 F NJ 1/5/98 P Brisbane Child Treatment Center R Placed in basket hold and taken to floor. Asphyxiation

unidentified 50s F NV 1995 S Unidentified private hospital H In locked seclusion; set fire to room; died of fumes. Smoke inhalation

F.H. 30 M NV 9/25/95 P Nevada Mental Health Institute H Six aides restrained him face down, one on buttocks. Heart disease, congenital defect of the heart

W.D. N/A F NV 8/15/96 M University Medical Center H Cardiorespiratory arrest in four-point restraint. Thermal brain injury due to hypoxia due to cardiorespiratory arrest

Ramon Luz (pseudonym) 33 M NY 1988 M Rockland Psychiatric Center H Violent behavior led to camisole restraint for four hours. Acute respiratory arrest due to drug intoxication due to multiple drug synergism

9012192 N/A M NY 1990 S Creedmoor Psychiatric Center R Suffered severe burns in fire he started in seclusion room Undetermined

9207042 60 F NY 1992 N/A Brunswick Hall R Became unresponsive while nursing staff placed her in bed. No deficiencies cited. Sudden cardiac event

9711011 72 F NY 1997 M Cabrini Medical Center H Wrist restraints ordered to enhance hydration, nutrition; safety measure. Cardio-pulmonary arrest

8801252 N/A F NY 1/16/88 N/A Elmhurst Hospital Medical Center H Death's circumstances did not suggest any deficiencies in care Convulsive disorder

8802016 39 M NY 2/7/88 P Hudson River Psychiatric Center H Patient physically restrained while face down; became unresponsive. Probable asphyxia

8803972 N/A N/A NY 3/15/88 N/A Bellevue Hospital Medical Center H No deficiencies in care found Chronic ethanolism and narcotism, cirrhosis of the liver

8806172 26 F NY 6/17/88 M South Beach Psychiatric Center H Died after release from 4-point restraint Cardiac arrhythmia following administration of antipsychotic medications

8808030 76 M NY 8/7/88 M County Hospital of Western Suffolk H On Aug. 6, patient was found on floor, with restraint attached. Shock, dehydration and urosepsis.

8808099 N/A F NY 8/24/88 N/A Kings Park Psychiatric Center H Physician failed to stabilize; hospital privileges revoked Chronic bronchitis due to bronchial asthma

8810187 48 F NY 10/23/88 M Franklin General Hospital H 4-point mechanical restraint; not checked as required. Acute pulmonary thromboembolism; deep leg vein thrombosis

8901095 28 N/A NY 1/18/89 M Mid-Hudson Psychiatric Center H Death after camisole restraint; no deficiencies cited. Acute cardiac failure, hypertensive arteriosclerotic cardiovascular disease

8902015 N/A M NY 2/1/89 N/A Metropolitan Hospital Medical Center H No deficiencies in care cited Probably cocaine intoxication

8903013 39 M NY 3/4/89 P Hudson River Psychiatric Center H During restraint, peers reportedly struck and sat on patient's abdomen. Acute asphyxia secondary to aspiration of gastric contents

8907036 N/A N/A NY 7/11/89 P Association for the Help of Retarded Children R Police did overlaying restraint; ruled homicide; no facility citations Asphyxia due to chest compression, due to overlaying during restraint by police officers

8908106 22 F NY 8/24/89 M Mid-Hudson Psychiatric Center H During first four days was in almost constant restraints. Suicide; asphyxia due to strangulation with sheeting material wrapped around neck

8908100 36 M NY 8/25/89 P Eliot House R Police restrained patient after he became agitated, displaying paranoia. Cardiac arrest secondary to release of catecholamines and toxic levels of medication

8910009 74 M NY 10/4/89 M Erie County Medical Center H Patient was placed in a jacket-vest and given Haldol. Chronic obstructive pulmonary disease, congestive heart failure

8911010 31 M NY 11/5/89 M Capital District Psychiatric Center H After Ativan and Prolixin injections, patient became unresponsive Severe coronary artery sclerosis; ischemic damage to colon, stomach, kidney, brain, liver

9001042 41 M NY 1/9/90 P Stony Lodge Hospital H Patient collapsed during restraint attempt; no deficiencies cited. Exhaustive psychosis

9002105 N/A N/A NY 2/17/90 N/A The Bridge Inc. R No deficiencies cited in record No autopsy performed

9005103 N/A M NY 5/17/90 M Queens Hospital Center H Patient was placed in restraints twice in three days prior to death Therapeutic complications arising from the use of certain medications

unidentified N/A N/A NY 5/24/90 N/A Builders for Family and Youth R No deficiencies cited in record N/A

9007150 37 F NY 7/27/90 S Mohawk Valley Psychiatric Center H Locked in seclusion for 4 hours; released; no vital signs 2.5 hours later. Undetermined

9008107 16 M NY 8/19/90 P Nassau County Medical Center H Patient unmanageable, restrained by staff. No deficiencies cited Congenital heart defect

9010014 N/A M NY 10/2/90 P Manhattan Psychiatric Center H Some staffers didn't have refresher training on restraint use since 1987 Fatal injuries sustained while being restrained

9103068 N/A M NY 3/8/91 M Kings County Hospital Center H Became unresponsive while being transported. No deficiencies cited. Acute and chronic substance abuse

9103075 28 M NY 3/15/91 S Mid-Hudson Psychiatric Center H While in seclusion, patient put sock in airway. No deficiencies cited. Suicide by impaction of sock into throat and asphyxiation

9103128 39 M NY 3/26/91 M Elmhurst City Hospital H Emergency communication problems cited. N/A

9107093 N/A F NY 7/4/91 N/A St. Barnabas Hospital H Admitted the previous day. No deficiencies cited. Death due to dilated hytrophic cardiomyopathy

9107081 28 M NY 7/22/91 P Creedmoor Psychiatric Center R Restraint followed by seizure-like movement; no deficiencies cited. Hyperthermia (body temperature at 108 degrees)

9107132 N/A N/A NY 7/22/91 N/A Harlem Valley Psychiatric Center H No deficiencies in care cited N/A

9108127 73 M NY 8/31/91 M Erie County Medical Center H No autopsy; other findings of fault in care. Myocardial infarction

9110071 11 M NY 10/21/91 M Our Lady of Victory Infant Home R Patient left unattended in Tumble Form seat on waterbed. Cardio-respiratory arrest

9111165 N/A N/A NY 11/4/91 N/A Metropolitan Hospital Center H Dept. of Health cited deficiencies in care N/A

9201152 N/A M NY 1/29/92 M Harlem Hospital Center H Cited for state law violations; restrained several hours without MD orders Cause not cited

9203080 N/A M NY 3/21/92 N/A Columbia Presbyterian Medical Center H No deficiencies in care cited N/A

9207001 62 M NY 7/4/92 N/A Binghamton Psychiatric Center H No deficiencies in care cited. Natural causes cited; no further investigation

9207031 84 F NY 7/11/92 M St. John's Episcopal South Side H Found dead in bed; no deficiencies cited. Arteriosclerotic heart disease

9208036 N/A F NY 8/8/92 M Elmhurst City Hospital Center H Patient was agitated, requiring wrist and ankle restraints. No deficiencies cited. No autopsy performed

9200000 28 M NY 10/5/92 P Letchworth Village Developmental Center R Restrained on mat by staff; physician ordered 2.5 mg. of Valium. Seizure disorder

9210100 29 M NY 10/22/92 M Bronx Psychiatric Center H Secured to bed by a sheet across his chest; ruled homicide Asphyxia leading to anoxic encephalopathy

9211112 31 F NY 11/23/92 S Creedmoor Psychiatric Center H Center cited for "serious'' oversight and record-keeping problems Intoxication, due to combined effect of six drugs

9304162 N/A M NY 4/28/93 M Kings County Hospital Center H Transferred there in March because of immune system conditions. No deficiencies cited. Death attributed to AIDS

9305066 72 F NY 5/17/93 M Niagara Falls Memorial Medical Center H Found slumped in geri-chair with posey restraint pressing against neck. Cardiopulmonary arrest due to hypoxic cerebral encephalopathy

9308010 77 F NY 8/4/93 N/A Manhattan Psychiatric Center H No deficiencies in care; record-keeping deficiencies cited. Chronic obstructive pulmonary disease

9308054 74 M NY 8/16/93 M Elmira Psychiatric Center H Moved from geriatric to acute admission unit. No deficiencies cited. Sepsis

9310044 N/A M NY 10/14/93 P Letchworth Village Developmental Center R Put in day room for observation following final restraint. Spontaneous rupture of arteriovenous malformation

9312023 34 M NY 12/1/93 S Capital District Psychiatric Center H Patient found slumped over in quiet room. No deficiencies cited Acute cardiac failure, cardiomyopathy, severe hypertension; in seclusion

9402035 N/A M NY 2/2/94 M St. Luke's/Roosevelt Hospital Center H Restrained for approximately 38 hours prior to death Cardiac arrhythmia secondary to cardiac myopathy following release from prolonged restraint

9402013 38 M NY 2/4/94 M Kings Park Psychiatric Center H Found lethargic and verbally unresponsive in geri-chair. Complications of agitated psychosis (bipolar disorder) w/ rhabdomyolysis and acute pneumonia

9402144 N/A F NY 2/27/94 M Coney Island Hospital H Patient became assaultive, requiring Ativan and wrist and ankle restraints Pulmonary hypertension due to chronic bronchial asthma

9403047 37 M NY 3/14/94 P Wilton Developmental Center R Patient vomited during takedown restraint; no deficiencies cited. Hyperemia of tracheo-bronchial airways; pulmonary congestion

9404117 84 F NY 4/25/94 M Mid-Island Hospital H Death's circumstances did not suggest any deficiencies in care. Congestive heart failure

9408031 32 M NY 8/10/94 P Letchworth Village Developmental Center R Restrained face down; patient stopped struggling after 12 minutes. Asphyxiation due to aspiration of stomach contents

Griffiths, Jamar 15 M NY 10/18/94 P Allen Residential Center R Breathing was obstructed while being restrained. Traumatic asphyxia and brain death from lack of oxygen due to heart and lung failure

9604131 37 M NY 4/24/96 P Taconic DDSO R Placed in standing hold; went into lying hold for 20 minutes. Undetermined

9608047 N/A M NY 8/12/96 P East Leon Road IRA R Float staff unfamiliar with case placed him in hold. Traumatic asphyxia

9608105 N/A M NY 8/31/96 S Finger Lakes DDSO R Placed in timeout room; no deficiencies cited. Acute subdural hematoma

9702024 36 M NY 2/5/97 P Sunmount DDSO R Placed in lying hold; no deficiencies cited. Ventricular arrhythmia

9704018 23 M NY 4/3/97 M Interfaith Medical Center H Died during 4-point restraint; second of day. No deficiencies cited. Hypertensive cardiovascular disease

Hunt, Donald 39 M NY 4/25/97 P The Holliswood Hospital H Died during takedown in preparation for restraint. Cardiac arrest

Martoral, Maximo 40 M NY 6/24/97 P Finger Lakes DDSO R Died of choking and asphyxia during restraint Asphyxiation

Roberts, William 34 M NY 7/13/97 P Broome Developmental Center R After placed in hold, patient fell to side and vomited. Massive aspiration of gastric contents

Phelps, Dustin E. 14 M OH 3/1/98 M Lancaster foster home R Boy was wrapped in a blanket and mattress with straps Undetermined

Goldman, Kevin 24 M OK 12/21/93 P Pioneer Home R Collapsed after being restrained by five aides. Cardiac arrhythmia

Jang, Jung Sook 34 F OR 10/10/90 M Lane County Psychiatric Hospital H Strapped to bed and given three types of drugs Heart attack

Gorneau Jr., Peter Lynn 32 M OR 10/8/93 P Dammasch State Hospital H Towel over face while holding him on table Smothered while being restrained

Prinkey, Leroy 14 M PA 9/28/88 P Western Center R Aide used a "one-man body" slide that led to face-down restraint Cerebral anoxia caused by heart and lung failure due to forceful restraint

Tallman, Jason 12 M PA 5/12/93 P KidsPeace R Restrained face down on pillow Suffocation

Dorsey, Sakena 18 F PA 6/10/97 P Foundations Behavioral Health R Placed face down on the floor with staffer laying across back Suffocation

Arnold, Michael 19 M PA 7/15/97 P Keystone City Residence R Prone torso restraint after he tried to leave a day camp Asphyxiation due to chest compression

Knisley, Betty Jean 60 F PA 1/23/98 M Laurelton State Mental Retardation Ctr R Strangled in wheelchair restraints Asphyxia by mechanical restraint

D.S. N/A M PA Feb. 1995 P Hamburg State Mental Retardation Ctr R Staff took boy to floor N/A

Harris, Diane 17 F TX 4/11/90 P Seguin Community Living Center R Basket hold technique was used Asphyxiation

Jacques, Jorge 28 M TX 10/11/90 P Rio Grande State Center H Banging his head on floor; put a pillow under it; suffocated Suffocation

Green, Anthony 15 M TX 5/12/91 P Brookhaven Youth Ranch R Unruly resident restrained in face-down floor hold for 15 minutes Asphyxiation

Roberts, Eric 16 M TX 2/22/96 M Odyssey Harbor R Wrapped in a plastic and foam blanket with Velcro for one hour. Stopped breathing due to pressure on the chest, according to autopsy

Randolph, Bobby Jo 17 M TX 9/26/96 P Progressive Youth Center R Taken to floor and restrained by two aides Asphyxia due to compression of neck

Epps, Trake 26 M TX 12/1/96 P Corpus Christi State School R Found unconscious on floor, subdued by choking. Cardiac disrhythmia during restraint by bar/positional asphyxia

Clayborne, Roshelle 16 F TX 8/18/97 P Laurel Ridge R Pinned face down by aides, given tranquilizer. Cardiac arrhythmia or irregular beating of the heart

Mulkey, Christopher 26 M TX 8/19/97 P Corpus Christi State School R Mulkey placed in basket hold; later suffered a severe asthma attack. Asthma attack

Jeffries, Demetrius 17 M TX 8/26/97 P Crockett State School R Stopped breathing while being restrained. Strangulation

Gordon, Sandra 45 F UT 1/6/98 M Rosewood Terrace Care Center R Left unchecked in restraints for 10 hours. Strangulation and blunt trauma

Wilson, Elwin Darrick 23 M VA 5/27/93 M,P Central State Hospital H Restrained by more than a dozen staffers and left in seclusion room. Sudden cardiac death

Huntley, Gloria 31 F VA 6/29/96 M Central State Hospital H Restrained 300 hours in last month of life. Acute and chronic myocarditis (inflammation of the heart)

McGraw, Shinaul 12 M WA 6/5/94 M New Directions, Second Chance R Wrapped in bedsheet with gauze over mouth and restrained to bed. Hyperthermia

Malloy, Joseph 41 M WA 11/9/94 P Rainier School R Arms, legs held down by staff for 7 to 8 minutes. Hypoxic encephalopathy, broncho pneumonia

Weston, Loretta 61 F WA 12/01/95 M Rainier School R Restrained to toilet and left alone; lost consciousness, died 5 days later. N/A

Neyman, Melissa 19 F WA 7/24/97 M Private group home R Unmonitored in restraints; hung out window unnoticed for six hours. Strangled after climbing out window with restraints

Ferrarini, Joshua 13 M WI 1/8/89 P St. Aemelian-Lakeside Hospital R Face-down restraint. Suffocation

unidenified 49 M WI 3/9/96 M Winnebago Mental Health Institute H Patient put in "burrito'' restraint (body wrap), then vomited and aspirated. Aspiration