SUNDAY EDITION | Video of Kentucky inmate death highlights contr - WDRB 41 Louisville News

SUNDAY EDITION | Video of Kentucky inmate death highlights controversy over restraints

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LOUISVILLE, Ky. (WDRB) -- He was strapped face down on a mattress in a Kentucky State Reformatory cell by four prison officers, his hands cuffed behind his back and ankles shackled to a bed frame.

Within an hour Steven Lee McStoots was dead.

The 30-year-old’s final moments in the La Grange prison on Jan. 16, 2013, were captured on video and became the focus of multiple investigations and lawsuits, as well as a debate on whether Kentucky prisons should employ the controversial “five-point restraints” used on McStoots.

The restraints, according to prison staffers, were for his own good -- to protect the mentally ill man from hurting himself.

But others have argued that McStoots had gone limp before officers began putting restraints on him and was not a risk to anyone.

“He had settled down and was not a danger to himself or others at the time he was carried into the cell where he died,” said Sam Carl, an attorney who represents McStoots’ mother. “I don’t know that I’ve seen a case where a person has died on videotape under questionable circumstances and use of restraints (that are) sometimes characterized as cruel and outdated.”

McStoots’ mother filed a wrongful death lawsuit in Oldham County last November, claiming her son suffocated because of the five-point restraint, in which a person is tied face down with straps to a bed by the ankles, wrists and around the chest.  

A nurse present at the time, Teresa Garrard, filed a federal whistleblower lawsuit against the prison’s health care provider, claiming she was fired for speaking out about mistakes made in McStoots’ death.

And earlier this month, after a lengthy investigation, the Kentucky Department of Protection and Public Advocacy, which represents indigent and mentally ill inmates, presented a report on its findings and recommendations to the state Department of Corrections.

The report questioned why McStoots was put in five-point restraints, when it seemed he had calmed down, and whether the state should even be using that type of restraint anymore.

In addition, McStoots’ death has reignited a debate on how the mentally ill are treated in Kentucky’s prisons.

“There are more people with mental illnesses being incarcerated than ever before,” said Jeff Edwards, director of the state’s protection and advocacy division. He estimated that about 25 percent to 30 percent of the state’s inmates have a mental disability.

 Mentally ill inmates are not getting “true psychiatric treatment because that’s not what Department of Corrections is assigned to do,” Edwards said. “They are not there to provide psychiatric treatment. They are not a hospital.”

Because restraints were involved, a hand-held camera was used by a staffer to video the incident, as prison policy requires.

The 30-minute video of the incident, obtained by WDRB, does not appear to show McStoots fighting or struggling with officers during the time he was first handcuffed and taken from one cell to another to be restrained.  For most of the video, McStoots appears to lie limp and motionless as guards strap him to the bed.

A Department of Corrections incident report described it another way, saying McStoots was “very fatigued” in the minutes before he was put in restraints.

Click here to watch a 3-minute version of the raw video

An Oldham County Deputy Coroner labeled the cause of McStoots death “undetermined,” ruling he could not say if the restraints or actions by the officers contributed to the death.

A Kentucky State Police Detective tried to determine whether McStoots suffocated but was unsuccessful.

For her part, nurse Garrard told the Kentucky State Police that McStoots “suffocated by accident” and the prison was “covering it up,” according to police records.

Police and prosecutors concluded there was no criminal culpability, but most everyone involved acknowledged mistakes were made.

The Department of Corrections concluded in a critical incident review that the training for putting someone in five-point restraints is “very poor.”  The officers involved had not been trained in using the restraints, which hadn’t been done at the La Grange prison in years.  

“It was evident … that the cell entry team was not prepared for this particular situation and the staff appeared to be lacking in confidence,” the incident report found.

The state review recommended formal training if that type of restraint was going to be used again and that inmates should be placed in the prone position or face up in the future.  

Still, the assessment concluded that the use of force was consistent with policy and procedures for an inmate who continues to harm himself.

The state’s department of protection and advocacy concluded that McStoots did not resist or struggle with officers during the incident, unable to even walk.

“It is of concern why the restraint was not called off since Mr. McStoots did not resist the officers,” according to a draft of the investigation obtained by WDRB.

The public advocacy investigation concluded that three minutes passed between a corrections officer first stating that McStoots had stopped breathing and a psychiatrist coming into assess his condition. And staffers interviewed said they could not recall the last time five-point restraints were used.

The department recommended the state eliminate the five-point restraint and the practice of putting mentally ill inmates in segregation units where they spend 23 to 24 hours a day alone in a cell. McStoots was one of these inmates, leaving his cell only on the days he took a shower.

“We are using segregation, we are using isolation for people and people are decompensating,” Edwards said in an interview. “People have committed suicide. People have died while in restraint.”

Edwards would not specifically discuss the report on McStoots, since it had just recently been turned over to the Department of Corrections.

In her lawsuit, Garrard said she warned that the face-down restraint should not be used “due to risk of suffocation.”

“In the whole entire time I worked there, an inmate was (never) strapped down like that,” Gerrard said in a deposition. “I told them that, you know, even in nursing school you learn not to strap people down like that because they die of suffocation.”

"He's not breathing"

He started drinking and smoking marijuana at 13 and was having hallucinations by age 16. Four years later, Steven McStoots was in a psychiatric hospital.

And in the final months of his life, he seemed to be unraveling. Interviews, court documents and prison records reveal a pattern of delusional and dangerous behavior.

In October 2012, he punched himself in the face, bloodying his nose. He said he heard God’s voice, at one point telling a psychologist he could not use his sink or toilet because “I will receive the mark of the beast if I do.”

McStoots had been incarcerated in La Grange since September 2011 and had been granted parole, but had not yet been released from a five-year prison sentence for a 2nd degree arson conviction. He also was charged with hitting a corrections officer.

For most of his time in La Grange, McStoots was in the Correctional Psychiatric Treatment Unit at KSR as doctors tried to find proper medications for him. He remained in the jail’s psychiatric unit because he continued to try and hurt himself

By December, McStoots was repeatedly placed in a restraint chair to prevent him from harming himself.

Just a week before his death, he had been put in a restraint chair, but still managed to hurt himself.  

On Jan. 16, 2013, after a period of “bizarre behavior,” in which he was banging his head and jumping around his cell, possibly hallucinating, McStoots was deemed a danger to himself. Warden Clark Taylor gave the order to put McStoots in five-point restraints because the restraint chair had been ineffective.

At the beginning of the video, as nurses try to get his attention, McStoots seems unaware that anyone is trying to talk with him, sometimes slowly rocking back and forth on a mattress on the floor, other times jumping around his cell. A nurse says he doesn’t seem “as agitated” as he was but points out that he has been hitting his head.

As guards approach, one staffer encouraged a nurse not to watch them restrain McStoots, according to the video.

The guards storm in, grabbing and quickly taking McStoots down, handcuffing his arms and legs, the video shows. McStoots is lifted up and then asked to walk. He walks briefly and then falls to his knees, his eyes barely open.

He was carried “with little resistance” to a different cell, according to court records.  McStoots was described as being “very fatigued” as he was moved from one cell to the other.

At the second cell, McStoots was placed face down and guards began the five-point restraints process, “although no one on the cell entry team had been training in the application of the restraints,” according to the investigation by the Department of Corrections. A supervisor who had been trained to do five-point restraints watched over the guards, providing assistance at times.

In the investigation by the Department of Public Advocacy, a staffer told them a KSR unit administrator had said McStoots needed to be placed in five-point restraints “to teach him a lesson because the restraint chair was not working.”

It had been about seven years since the prison had last put an inmate in five-point restraints, an officer later testified.  Others said it had been at least five years.

In the video, McStoots groans as he is placed face down on a bed, with several officers placing the restraints on him, blocking the camera’s view of McStoots. He appears to offer no resistance. At first, McStoots is breathing heavily, but he soon goes silent.

A few minutes after guards start restraining McStoots, one officer shouts, “Hold on y’all. Whoa, sh--, he’s not breathing.” Others in the cell disagree, saying they observe McStoots breathing, and the men continue.

About three minutes later, someone in the cell tries to get a response from McStoots. When he does not respond, the person asks for an ammonia capsule to try and revive McStoots.

More than six minutes after the first report that McStoots was not breathing, officers are ordered by a psychiatrist to take McStoots out of the restraints.

“He’s not responding, I think we need to go ahead and call EMS,” a woman in the video says as she rushes out of the cell.

Other inmates in the background start banging on their cell windows, some shouting, “Y’all killed him!”

In the next few minutes, as McStoots was released from the restraints and turned over, a medical assessment determined he was not breathing

An Emergency Resuscitation bag grabbed from the nurse’s station did not contain the necessary equipment to provide oxygen during CPR. It took another four to five minutes to track down the AMBU bag, a breathing apparatus that helps to manually administer oxygen, according to the report by the state department of public advocacy.

During the time it took to track down the AMBU bag, McStoots was not getting any air, according to the deposition of a nurse at the scene.

(Now, nurses check the emergency bag daily to make sure all of the necessary equipment is included, according to court records.)

Subsequent efforts to revive McStoots were unsuccessful.

McStoots was taken away in an ambulance – with his hands cuffed – and a short time later pronounced dead at a hospital. It had been about an hour since guards first began restraining McStoots.

At a meeting after McStoots’ death, Warden Taylor said proper protocol was followed and warned those in attendance to “keep silent about the incident,” according to Garrard’s lawsuit.

Prison staffers denied in depositions that Taylor tried to hide anything.

The Garrard lawsuit was settled with the prison’s health care provider earlier this year. The terms of the settlement were not made public. Her attorney said they could not comment because the settlement was confidential.

The Kentucky State Police investigated McStoots’ death and sent their findings to the Oldham County Commonwealth’s Attorney’s office, which declined to take the case before a grand jury on any criminal charges.

KSP Det. Michael Gonterman said he told Commonwealth’s Attorney Courtney Baxter that he didn’t believe anyone involved did anything criminally wrong.

The KSP investigation found that the prison was in the midst of revising its policy on five-point restraints.

Dr. Gary Weinstein, an expert witness on behalf of Garrard, concluded that McStoots did not receive proper psychiatric care and the prison staff was not trained in how to care for an out-of-control psychiatric patient, according to his deposition.

In addition, Weinstein testified that four-point restraints are to be used as a “last resort” and there was no documentation on the five-point restraints or why they were used.

Asked if he would have done anything differently, Danny Perry, administrator of the unit McStoots was in, said officers followed policy.

“Should I have used the five-point restraint? I don’t know,” he said in his deposition. “I don’t know. I can’t really say. I can’t predict that, what I would’ve done different.”

And Perry said the warden had a similar view after watching the video, telling staffers “there was no view that anybody had caused the death of inmate McStoots during this restraint.”

In interviews with the Department of Protection and Advocacy, some staff members expressed concern about the lack of training prior to using five-point restraints on McStoots.

“It bothered me training was not given before the restraint,” one staffer told the department, according to the final report. “It is never used, and then someone dies in the process.”

Restraints still "an acceptable practice"

McStoots was born in Merrillville, Indiana in 1982, the second of two children. He worked briefly as a nursing home aide and at a chicken factory but was in a psychiatric hospital by the age of 20. From 2007 until his death, he was mostly incarcerated or hospitalized.

He was diagnosed as having schizophrenia, being psychotic and depressed, among other things.

WDRB could not reach any of McStoots’ family members.

Dorothy Canary, McStoots’ mother, “speaks of her son Steven as being a good and kind son, one she loved greatly and one that had problems,” said attorney Carl. “He had a difficult life but in essence, he was a good man.”

McStoots suffered from depression, which could often be managed with medication, if McStoots took the medicine, Carl said. In prison, his mental health went downhill, Carl said.

Prison staff members said McStoots was unpredictable from day to day, but that he liked to read Christian books, loved his family and was not a bad person, according to staff interviews in records obtained by WDRB.

Carl said Canary wants to know what type of medications her son was receiving, whether they were changed if ineffective, why her son was put in five-point restraints and why the procedure was not stopped sooner after a staffer said McStoots was not breathing.

The Department of Protection and Public Advocacy has recommended the Department of Corrections eliminate five-point restraints.

Edwards, of Public Advocacy, said that “people have died,” especially when placed face down. “I question the therapeutic value of placing someone in those restraints.”

Public Advocacy’s report to the Department of Corrections recommends that the Correctional Psychiatric Treatment Unit be licensed as a psychiatric hospital to ensure the proper oversight and prevent overuse of restraint and isolation for inmates with mental illnesses.

That report highlights correspondence from former La Grange warden Larry Chandler in a letter in 2004 about the use of face-down restraints.

Chandler responded that no one had been placed face down in the short time he had been warden.

“The only reason a person would be placed restrained face down is to prevent that person from injuring his head,” the report quoted Chandler as writing. “I have recommended … that they no longer restrain inmates face down and that we look at the market for head protection gear to prevent any injuries.”

In an e-mail to WDRB, the Department of Corrections said the use of five-point restraints is “an acceptable practice within correction facilities.” Now, however, the use of restraints must be approved by the central office, instead of a warden at a prison. The department declined to comment further because of the pending wrongful death lawsuit.

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