part 2 of 2
In February 1992 Casey went to live at another Utah-based program, Sorenson's Ranch School in Koosharem. At Sorenson's, Casey lived in a rustic cabin set in a high mountain valley. Like every youth there, he received a horse in order to learn responsibility. It would have been an idyllic place to many troubled youths. But Casey wasn't happy.
"He was not an easy child," recalls ranch owner Burnell Sorenson. "He was one of the harder kids we've ever had here." If Casey couldn't go on a trip or participate in a special event, says Sorenson, he could get violent. "He would sometimes lose it and swing at people," Sorenson says. "Then again, he could be the softest, kindest person in the world."
Staff members sometimes had to wrestle Casey to the ground and restrain him when he became threatening or violent, says Sorenson. One person would grab each arm, and another would grab his legs. A fourth person would talk to Casey and calm him. Employees took great care in performing these takedowns, says Sorenson: "We always worried about him because of his asthma."
Whenever Casey got angry about the rules or frustrated with a Sorenson staffer, he would tell his mother more "stories," says Rose. Once he told her that the school's staff forced him to march backward for hours at a time. And more than once, Casey's tales of mistreatment or deprivation caused her to phone the school with complaints or to race the 600 miles to be by his side. "I interfered so much that Sorenson didn't want to see my face anymore," she admits.
Burnell Sorenson agrees that Rose's repeated intervention was one reason ranch directors decided they could no longer keep Casey. But the decision to cut Casey loose was not an easy one for Sorenson or others at the facility.
"If he'd spent another six months here, I think he could have made exceptional strides," says one staffer who asked that his name not be used. "I feel sad and blame myself for letting him go on when he hadn't finished."
Casey returned home in mid-October 1992, less than a year after he'd left. His next--and final--placement would be in the Cleo Wallace Center.
The private, not-for-profit Cleo Wallace Center was founded in 1943 by its namesake, a Denver speech and language specialist who started by holding classes in her basement for children "with special needs." In 1958 the center moved to its present home, a 33-acre site in Westminster. The campuslike setting, which features mountain vistas and expanses of green lawn, has grown to include two hospital units, a gym, a central dining commons, an administration building, classrooms and housing for the residential patients. There is no barbed wire. "This is not a detention center," says chief operating officer Mike Montgomery.
But the rules are as strict as any jail's. Behavior is closely monitored, and even the slightest transgression can result in punishment--usually isolation of one form or another. "Glaring," using profane language and interfering with staff are only a few of the items on a long list of "aggressive and intimidating behaviors" that can result in punishment.
The staff also frequently "physically manages" patients it deems a danger to themselves or others. One director told detectives after Casey's death that staff members manually restrained patients 430 times between June and December of 1993.
Patients are referred to Cleo Wallace by doctors, social service agencies, schools, hospitals and the courts. On any given day, says Montgomery, the center has 160 youths ages 5 to 21 in treatment, not counting those who receive outpatient counseling. Despite its hefty fees--residential patients pay $240 a day, though social service agencies pay less--Cleo Wallace has become one of the largest such treatment centers in the state.
After Casey came home from Utah, the Colliers agreed to enter him in Cleo Wallace's day-treatment program. He would attend classes there during the day and return home at night and on weekends. This time, says Rose, she was determined not to interfere with the staff.
One morning, not long after his enrollment, Casey refused to go to school. It was a holiday, Mike says, but the center remained open, and Casey resented the idea that he would have to attend class. He grabbed a butcher knife from the kitchen and ran out of the house and down the alley.
A notation in Casey's medical history says that Casey threatened his mother with the knife, an accusation Rose vehemently denies. In addition, his medical records from Cleo Wallace indicate that his parents told a staffer they considered the boy dangerous. But Rose insists Casey never threatened her or made her feel afraid. "They're liars," she says. "I never said he was violent."
Nevertheless, Rose did phone police after Casey bolted from the house with the knife. "I didn't want the cops to shoot him because of seeing this big kid with a knife," she says. Rose says that Casey returned home without incident after having lunch with one of her sons, who works nearby.
Rose sent Casey back to Cleo Wallace. This time, however, he would have to live there full-time.
The Colliers wondered whether the center's rigid set of rules was the best way to handle their son, but Mike chose not to challenge the center on it. "I figured, maybe what Casey needs to learn is to follow the rules," he says.
Rose found the regulations more bothersome. For example, water had always terrified Casey--in part, she believes, because of his experience as a youngster being held in a toilet. In addition, she says, swimming aggravated his asthma. "But they told him, `You will swim or else.'"
Forcing him to stay alone in his room or placing him in isolation areas known as "quiet rooms" became a common method for dealing with Casey. His treatment program required that repeated misbehavior be followed by periods of "complete social isolation," meaning he was not permitted any contact--including verbal or written communication--with his peers. Copies of his logs from Cleo Wallace show that center staff confined Casey to his room for days on end.
Casey's stubborn streak led him to refuse his medication, as well. Doctors had prescribed lithium, Rose says, but Casey refused to take it.
In October or November some of the other patients accused him of "being sexual" with them. A Westminster police report says that detectives investigated allegations against Casey and indicates that he was charged with two counts of third-degree sexual assault. Rose says that no charges were filed, and that Casey had only been engaged in "horseplay."
On December 8 Casey became angry at a Cleo Wallace staff member and refused to "sit out," or take a sitting position and face the wall. He swore and ran out of the room. He began struggling when staffers tried to escort him to the quiet room. They had to perform a "takedown"--a physical hold in which a staffer falls backward onto the floor, forcing the patient to fall on top of him. The employee then holds the patient until he or she is calm. It took five people to subdue Casey that day, according to facility logs.
On December 17 Casey verbally threatened the staff. On December 20 he stood on a stair banister and yelled at staff members. The coroner's report noted both incidents. By this time he had become so difficult to manage that the center assigned a "one-on-one" counselor to stay with him all day, even sitting with him at mealtime.
Hours after Casey's death, his one-on-one couselor, Kevin Smith, talked to Westminster detective Mike Lynch about the events of December 21. Smith, who did not return phone calls from Westword, told the detective Casey was agitated all morning long. A staff member had denied Casey's request to go to the movies that day, which made Casey angry. "But [it was] nothing out of the ordinary," Smith told Lynch. "He is usually pissed off for one reason or another." Casey remained calm enough, however, to work on his school assignments in the library.
Shortly after 2 p.m., Smith told the detective, he went to use the telephone, and Casey seized the opportunity to leave the library and walk down the hall of the administration building. Teacher Tammie Brink spotted him wandering around.
When Brink confronted Casey, she told detectives, Casey became argumentative. She told him to sit out, facing the wall. He hestitated for a moment, then sat down on the floor near the library doorway. He continued to move around, though, which violated Cleo Wallace rules. Brink told him that if he did not perform his sit-out properly, he would have to go to the quiet room.
At that point, says Smith, Casey stood up. Brink then left to get teacher's aide Bruce Nipper, so he could "escort" Casey to the quiet room. "I don't give a fuck what you're going to do," Smith quoted Casey as saying, "but I am not going to the quiet room." Casey then pulled off his jacket "and was ready to fight, basically," Smith said.
According to a transcript of Smith's talk with Lynch, he was trying to calm Casey when Brink returned with Nipper. When Casey allegedly balled up his fists, Nipper grabbed one of his arms and Smith grabbed his legs. Nipper wrestled Casey to the floor as Cleo Wallace had taught him, but when they fell to the ground, Nipper found himself pinned to the wall. Casey then began pulling Nipper's hair and thrashing about. Four other staffers eventually joined in the fray as Casey continued to struggle. It became such a jumble of bodies that one female employee hung onto Nipper's feet, thinking they were Casey's.
"Casey was continually prompted to calm down, stop yelling and struggling so that staff could let up pressure on his arms and legs," Nipper wrote in a report of the incident. Several staff members told the police that at one point, Casey complained that he couldn't breathe. He then said that he was "chilling," or calming down.
Six staff members rolled Casey over onto his stomach and held him there. Three of them lay across his midsection. Nipper crouched over Casey's head; his face was touching Casey's. Smith had Casey's legs. Another man held an arm. It was "not a regular textbook management," teacher Matthew Dudek told police. At six-foot-five and 210 pounds, Casey was simply "too big" for that.
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.
The Colorado Department of Social Services is now conducting its own investigation into the case. The review so far has revealed that the center failed to document internal training for some staffers, and that some staffers had not yet read and signed a statement defining child abuse and outlining their personal responsibility to report incidents of abuse. In addition, some staff members' files did not include required documentation that their names do not appear on the state's child abuse registry.
State investigators also have asked that Cleo Wallace provide to them in writing details of the physical restraint techniques its employees use, and have re-emphasized that facilities must inform the state in writing about the death of a patient. (Cleo Wallace directors phoned in their report to the department of social services, state officials say.)
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But there is no indication in the state inspectors' report that staff members broke any rules regarding the use of physical restraint. That may be partly due to the fact that, when it comes to residential care centers for children and adolescents there virtually are none to break. The state is considering beefing up its restrictions surrounding the use of physical restraint at such centers, says Andrews. "I anticipate we'll have something fairly soon," she says. But for now, regulations on restraint forbid only the use of handcuffs or straps, and specify "holding" as the only method to be used.
New rules being considered might require the state to approve employee training regarding physical restraint, Andrews says, as well as a definition of "holding."
No matter how soon any changes come, however, they will come too late for Casey, whose ashes now rest atop a Japanese cabinet in his parents' home. Rose had planned to take the ashes and scatter them along a Utah trail that Casey loved. But she and Mike changed their minds. "He liked being home more than anything," Rose says of her son. "We're going to keep him home."
end of part 2