Hospital Restrained Dying Man April 16, 2003 By DWIGHT F. BLINT, Courant Staff Writer

James Bell, a 39-year-old psychiatric patient, was having a fatal heart attack while being restrained by staff members at Connecticut Valley Hospital in April 2002.

Although he was surrounded by about 25 members of the hospital's staff, which included doctors and nurses, no one noticed that Bell was stricken until it was too late, according to the findings of an investigation by a state advocate for the disabled.

The state Office of Protection and Advocacy for Persons with Disabilities concluded that workers at the Whiting Forensic Division at CVH dismissed Bell's signs of distress - some of the workers accused an unresponsive Bell of faking - and failed to properly follow policies and procedures surrounding the use of restraints.

The report also suggested a series of policy and procedural changes, such as improved monitoring of a patient's medical condition.

"This reinforces the fact that using restraints is a dangerous business," said James D. McGaughey, executive director of the office of protection and advocacy.

McGaughey said Bell's death continues to show that restraints should be used only during emergencies and that when used, it is important for workers to follow proper guidelines.

McGaughey said his investigation revealed that as in past restraint deaths, workers became so focused on gaining control that no one was monitoring the patient's overall condition and they continued to hold Bell even after he ceased struggling.

"Something happens that causes people to lose sight of the humanity of the person being restrained," McGaughey said.

Officials with the state Department of Mental Heath and Addiction Services accepted the bulk of McGaughey's finding, but dismissed the report as "late."

Hospital officials said they initiated an internal investigation shortly after Bell's death and months ago made a series of procedural, policy and structural changes to the hospital in an effort to avoid another similar incident.

McGaughey said he was not aware of the changes inside the hospital and is in the midst of an ongoing federal lawsuit against the state mental health agency in an effort to obtain a copy of their internal investigation.

Dr. Cynthia Conrad, chief of professional services at the hospital, said everyone, from line staff to managers, was very troubled by Bell's death.

"It was a tragic incident we all regret," Conrad said.

Hospital officials would not comment on whether any staff members were disciplined.

According to McGaughey's report, Bell was restrained after attempting to strike a staff member. About 25 workers responded to a call for assistance.

McGaughey said so many people were involved in the restraint that many of them could not see who Bell was or what was happening.

When concerns eventually were raised about Bell's dilated pupils and lack of responsiveness, workers dismissed them and accused him of "playing possum."

And when Bell, motionless on the floor, exhaled without inhaling, a psychiatrist who observed it walked away without intervening or bringing it to anyone else's attention.

In fact, as Bell lay shackled in handcuffs and leg irons, hospital staff searched for smelling salts and debated where and how he should be rolled onto a blanket and dragged into a seclusion room.

When the workers finally took Bell into the room, a supervising psychiatrist insisted that he remain shackled even though he was no longer resisting.

Following another hallway conference, Bell was injected with a large dose of a sedative, Thorazine. Only then did a check of his vital signs reveal that he had no pulse and had stopped breathing.

Among the changes initiated by the hospital management are enhanced training to help staff recognize when a patient is in distress during a restraint and to more clearly define the role of each participant involved in a restraint.

Management is also educating staff members about the role obesity and nicotine addiction can play in a patient's condition. Bell had many cardiac risk factors. He smoked heavily, seldom exercised and weighed nearly 350 pounds.

"It's unfortunate when lessons are learned from these tragedies such as the death of a patient," said Dr. Wayne Dailey, an agency spokesman. is Copyright 2003 by The Hartford Courant