David Gudridge, a Cleo Wallace teacher who helped hold Casey down, later told police that he and the other staff members soon believed Casey was beginning to calm down. Then they felt Casey shudder. "It was just like an earthquake went through his body," Gudridge said. The six men took the unusual movement to mean that Casey was getting out of control again. They continued to hold him down. A second, massive tremor went through his body, and then he became still, Gudridge told police. (Gudridge, who according to a roommate no longer works at Cleo Wallace, did not return phone calls seeking comment.)

The staffers, who intended to take Casey to the quiet room, got up and took off his shoes, then searched his pockets to make sure he wasn't carrying anything he could use to hurt himself or others. Only then, they told police, did they notice that he had stopped breathing and that his face lay in a small puddle of vomit. That Casey would throw up during the restraint didn't come as a surprise to Smith. "He vomited the time we managed him before, also," he told police. "If I am not mistaken, I was told that he does it every time he gets managed." None of the six employees however, remembered seeing Casey throw up as they held him, police reported.

The staff members immediately called center nurses to perform CPR. The nurses wrote in their reports that the "copious amounts" of vomit present in Casey's nose and mouth hindered their attempts. The staff called paramedics, but they couldn't help, either. Rose received a phone call at approximately 2:30 p.m. asking her to come to the school. Only after she arrived did anyone tell her that Casey was dead.

The official cause of death, according to the coroner's report, was "acute cardio-respiratory failure related to mechanical [positional] asphyxiation due to the compromised mechanics of respiration." In other words, Casey was physically unable to breathe because he was being crushed.

Mike Montgomery says he's limited in what he can say about Casey's death because of state confidentiality laws and because the Colliers are considering suing the center. But, says Montgomery, the staffers who handled Casey were well trained in restraint techniques; two of them even had training as emergency medical technicians and "extensive experience in monitoring a patient's physical well-being."

"That," Montgomery says, "is one reason why this is such a freak and tragic accident." The incident so traumatized the people involved, he adds, that they received time off with pay to deal with their grief. None of the six staffers was disciplined, Montgomery says.

Montgomery and Gayle Collins, who heads Cleo Wallace's human resources department and once worked as the center's director of training, both say that the Colorado Department of Social Services has approved the facility's restraint techniques. But an official with the social services department, which licenses Cleo Wallace and similar facilities, contradicts that assertion. The state doesn't approve or disapprove restraint techniques, says licensing administrator Dana Andrews. Instead, the state requires only that treatment centers make available a written description of the restraint methods they use.

Montgomery refers to the restraint technique used on Casey at the center as the "Illinois System," and notes that it was adapted from a method used by the Illinois Department of Mental Health. Spokeswomen for that department, however, say they know of no techniques that call for adults to lie across a patient's body.

"It doesn't sound like any technique we use here," says Ginny Conlee, training administrator for the Illinois Department of Mental Health. "The whole point to these techniques is that you use ones that are safe for staff and patients and are not based on inflicting harm or pain."
"It sounds so dangerous," adds public information director Jo Warfield. "I'd be interested in knowing how our name got attached to it."
William Schiller, who heads the Family Clinic Institute on Disability and Human Development at the University of Illinois at Chicago--and who authored the "aggression management training series" used by the state's mental health department--has the same question. "I don't know where they got this `Illinois' thing," he says. "I can't think of anything where you'd have six people, with three of them laying on someone."

The proper boundaries for the use of physical restraint still stir debate in the psychiatric community, notes Schiller. And, he adds, not only does he not teach face-down restraints, "we try to emphasize not using restraint" at all.

The Westminster Police Department and the Cleo Wallace Center itself launched investigations after Casey's death. Gayle Collins told Detective Lynch that she considered the restraint technique used on Casey appropriate and within the center's policies and procedures. The employees, she noted, had first required Casey to sit out, and then asked him to go to the quiet room before placing their hands on him.

Lynch handed over his investigation into possible charges of criminally negligent homicide to the district attorney's office last month. After reviewing the report, says chief deputy DA Mark Pautler, he and others in his office decided that the Cleo Wallace staffers had "taken the action they felt was necessary at the time." No charges were filed.

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