Death in the Restraint Chair

Dayton City Paper | September 17, 2004
"It’s Spanish Inquisition technology with sort of a late 20th century advertising spin," said Stuart Katz, a lawyer who successfully sued the Sacramento County Sheriff’s Department for its use in 2000.

Katz was referring to the restraint chairs that are increasingly being used by jails, prisons, juvenile detention facilities, immigration detention facilities and psychiatric hospitals across the nation. Among these facilities is the local Montgomery County jail, which has three restraint chairs manufactured by the Iowa-based company, Emergency Restraint Chair, Inc. (ERC).

A troubling trend has developed at the jail in the last two years — the mixture of drugs, mental illness, violent altercations and use of the chair has resulted in the deaths of some of its inmates. Three of seven deaths within the Montgomery County Jail in the last two years have occurred after individuals were restrained in these chairs.

The Dayton Daily News reported on each death with a short article minus a reporter’s byline. After consulting with some of the paper’s staff, it became apparent that the daily merely rewrote the sheriff’s department press release and later followed up on the coroner’s results.

On October 22, 2002, Philip Anthony Banks, a county jail inmate arrested for public intoxication and disorderly conduct, died approximately four minutes after being placed in a restraint chair on the same night he was booked.

According to the county coroner's office, Banks’ direct cause of death was an overdose of Wellbutrin, a known anti-depressant. Besides death, an overdose of Wellbutrin can also cause seizures, hallucinations, and loss of consciousness. Banks also had a bag of partially dissolved Paxil tablets in his stomach, as well as other prescription and non-prescription medications (Darvon, Phenergan, Primatene and Sudafed) in his blood.

His autopsy also indicated a "bilateral fracture of the superior horn of the thyroid cartilage of the larynx (…) with acute hemorrhage (in) the adjacent soft tissue," which likely resulted from the multiple altercations he was involved with inside the jail.

According to the jail’s incident reports filed by participating corrections officers (COs), the following occurred. Banks physically fought with other inmates and officers. Sergeant James Waitzman decided that Banks should be placed in a restraint chair for the safety of all. Then, COs forcibly put Banks in a restraint chair.

CO Brian Wilson gave the following report: “I observed Inmate Banks for several minutes after his placement into the chair due to his bizarre behavior. He would act as if he were asleep, then open his eyes and growl while pulling against the chair restraints. He eventually calmed and stopped breathing a few minutes after calming.”

Banks was checked by a medic on duty and then removed from the chair and hooked up to an automated external defibrillator (AED). A medic and corrections officer gave CPR to Banks, but to no avail.

On October 24, 2003, Brian Mandich, a schizophrenic who had been booked on a domestic violence charge against his mother four days earlier, died in the county jail approximately 10 minutes after he was put in a restraint chair.

According to his autopsy report, Mandich’s direct cause of death was “fatal cardiac dysrhythmia due to excited delirium due to complications from schizophrenia.” The report indicated that the physical struggle with the COs, as well as hypertension and cardiovascular disease, were contributing factors in his death. In addition, the coroner indicated that Mandich had stopped taking his psychotropic medication.

According to COs’ incident reports, the following occurred. Mandich was beating on the Plexiglas of his cell with his head and/or his hands. Another inmate was threatening Mandich and three COs decided that Mandich should be removed from the cell for his own safety. After COs forced open the door to Mandich’s cell, he began slapping CO Chad Rother in the face.

On the floor grappling with Mandich, Rother reported, “I immediately gained control of inmate Mandich’s upper body and head, while he began clawing my face, biting my chest, and attempting to choke me. While keeping control of his head, I delivered several close-fisted strikes to his nose, eyes, and neck area but gained no compliance. He began to bleed from his nose but would not comply with any verbal commands to stop resisting.”

CO John-Paul Wilson reported, “In attempt to control inmate, I secured his legs once on the ground, but the inmate was very uncontrollable. He began kicking very violently. He kicked out my arms two or three times and began screaming about his dog and how he would let us pet it.”

Mandich was placed in handcuffs. Sergeant Waitzman ordered that he be put in a restraint chair. EMT Medic Nicole Weaver reported, “The officers used restraint tactics to place him in the chair. As the inmate was placed in the chair, he was screaming and moaning. While the restraint straps were being placed on the inmate, he began to urinate.”

Later, while checking Mandich's restraints, Weaver and others reported that Mandich's skin color began to change and that he stopped breathing.

However, the chronology of events and what actually happened appear to be somewhat conflicting between some of the jail’s incident reports and statements taken by witnesses. Sgt. Waitzman reported, “Within 10 seconds of entering the cell, Weaver began to check the restraints on the inmate. It was at that time I noticed the inmate had become pale and was not moving. I also looked and could not see him breathing. At that moment, he took a gasping breath. Seconds later, I still could not see Mandich breathing.”

An inmate, James Jordan, Jr., gave the following statement to an investigating officer. “As they were putting the inmate in the chair, he was handcuffed from behind. (They were) having a hard time placing him in the seat with the handcuffs behind his back. Then, (Mandich) was wiggling about in the chair, so the guards pressed his head down between his legs. He became very still and quiet. They strapped his legs and around his waist and began to wheel him toward me. I was in the cell right in the pathway to place him in the cell next to me. His head was on his left shoulder and blood was in and around his left nostril. I had a very good view, so much of a view that it looked like he was dead before they wheeled him into the cell.”

In any case, Mandich was taken out of the restraint chair and placed on the floor so that he could be administered CPR. An ambulance arrived and took Mandich to the Miami Valley Hospital, where he was pronounced dead.

Jail incident reports indicate that, in addition to the “several closed-fist strikes to the nose, eyes and neck” delivered by Rother, Mandich absorbed two closed-fist strikes to his side, a pressure point applied to the armpit, a pressure point applied to the inner thigh, a hypoglossal pressure point, and a hypoglossal hold. DCP has, as of yet, been unable to determine if a hypoglossal hold is the same thing as a choke hold.

On Jan. 1, 2004, Michael Ellis, who had been arrested for possession of crack on Dec. 31, died approximately 15 minutes after being placed in a restraint chair.

The coroner’s office reported that Ellis’ direct cause of death was “complications of acute and chronic cocaine abuse, with physical struggle during excited physiological state contributing.” Jail incident reports indicate that Ellis absorbed one balance-displacement takedown, two armstrikes to left side, four closed hand hammer strikes to left rib cage, one knee strike to left shoulder, and three abdomen strikes.

Dayton Police had originally taken him to Miami Valley Hospital to do an “emergency committal” due to him having homicidal thoughts, but a suspected crack rock fell out of one of his socks, and they instead whisked him to jail. Officers reported they had been called to check out Ellis because he was sleeping on top of a van, but when they arrived, Ellis was “yelling as he was walking in the middle of the street.” When questioned by the officers, Ellis admitted that he had been drinking and smoking crack and responded that, “he was being hunted down by people, (and that) he was going to kill them first before they had a chance to kill him.”

County jail incident reports tell the following story. A CO opened the door to Ellis’ cell and he came out insisting, “Let me out of here. I want out of here.” The officer ordered Ellis back into his cell, but he refused. Ellis began pushing the officer. With the help of two other COs, he was wrestled to the ground and handcuffed. Ellis was then placed in a restraint chair and his feet were shackled.

A report from one CO stated that Ellis would not respond to verbal commands and “was highly agitated.” After Ellis was fully restrained, he was checked periodically. One medic came to check on Ellis and reported that he was “non-responsive” and “went into respiratory arrest.” Ellis was ordered removed from the restraint chair and was hooked up to an AED while a medic attempted to assist him with breathing. He died after efforts to resuscitate him failed.

DCP sent copies of the autopsy reports of all three inmates to be reviewed by an independent doctor at Miami Valley Hospital. He could find no inconsistencies in them and stated that the coroner’s conclusions seemed reasonable. One thing he did point out, however, was that he could not understand why Mandich’s body contained Lidocaine, an anesthetic used for surgery, and wondered why the jail would have administered it. We have not yet been able to get an answer to this question from the Sheriff's Dept.

“There are general safety questions about restraint chairs when someone is put in them if they're in some kind of psychotic state or under the influence of drugs,” said Anne-Marie Cusac, a journalist for The Progressive magazine who has investigated the use of the restraint chair throughout the U.S. "Also, the chair fully immobilizes you, and if you cannot move your legs and arms, there is that danger that the blood will pool and congeal and form clots that can then travel to your heart or lungs.”

The restraint chair has been linked to deaths within the jail and prison systems across the country, a fact that led the human rights organization Amnesty International to call for a national inquiry into its use in 2002. The U.S. Department of Justice did not respond.

In 2002, Amnesty documented 11 cases where the restraint chair was a factor in inmate deaths. Today, Amnesty has documented 19 restraint chair-related deaths in the past decade.

In its request for an investigation, Amnesty cited the 2001 deaths of the following inmates (all died after they were placed in a restraint chair): Charles Agster, a mentally disabled inmate in the Madison Street Jail (Arizona), on Aug. 6; Kevin Coleman, an inmate who was restrained for three days in the David Wade Correctional Center (Louisiana), on July 6; Albert Lee Cothran, a homeless man who was arrested on loitering and resisting arrest charges, on June 26; and Hazel Virginia Beyer, who died from being asphyxiated by the restraining straps of a chair in the Johnson City Jail (Tennessee) on March 7.

In 2003, Amnesty made another request for a national inquiry after certain police departments pointed out several individual cases worthy of investigation. This request was also ignored.

Some organizations, such as the UN Committee Against Torture, have called for an outright ban on restraint chairs since 2000 on the grounds that “their use led to breaches of the Convention Against Torture and Other Cruel, Inhuman, or Degrading Treatment.”

Amnesty advocates that, at the very least, a “rigorous national or international inquiry (investigation) into the use of restraint chairs should be completed.”

Gerald Le Melle, Deputy Director of Amnesty International, cites the absence of “independent studies done on the medical effects” and the lack of federal oversight in questioning the safety of restraint chairs for people under the influence of drugs or who are mentally ill.

“If somebody is under the influence of drugs, it cannot necessarily be detected,” he said. “There is also some medical testimony that the chair is a contributing factor of death for people who are going through withdrawal, for example. There are hundreds of thousands of police officers who would bring somebody in those conditions to a hospital, rather than put them in a restraint chair. If someone is schizophrenic, you might not detect that at all and, if you put them in a restraint chair, you may be contributing to their ultimate demise.”

The emergent national pattern is that it is mentally ill and drug-addled inmates who perish after violent struggles to get them in the restraint chairs.

According to Amnesty, two recent chair-related deaths in the U.S. took place in Gwinnet County Jail in Georgia in June and September 2003. The first inmate had a history of mental illness and was placed in the restraint chair after being shocked with a stun gun six times and administered psychotropic drugs. The autopsy report concluded that he died of a heart attack, but the cause of the heart attack was not determined.

The second inmate, who was reported to be “acting crazy” was also shocked before being placed in a restraint chair and died hours later. Amnesty is currently investigating how the combination of both methods of force — use of the stun gun and restraint chair — could contribute to the cause of death when involving inmates in an agitated delirium.

As of press time, DCP has been unable to determine if the Montgomery County Jail permits mixing the two forms of restraint.

The ACLU Prison Project has investigated cases where the restraint chair was a factor in the cause of death in the U.S. jail and prison systems. In March 1997, they investigated the death of Michael Valent, a schizophrenic inmate at the Utah State Prison who died after being strapped to the restraint chair for 16 hours.

The deceased’s family filed a lawsuit against the state of Utah and received a settlement of $200,000. The medical examiner reported that a blood clot formed in his leg while he was restrained, and, when he started walking, it traveled to his lung and killed him. According to the Salt Lake Tribune, the litigation caused Utah State Prison to restrict use of the chair.

“The restraint chair should only be used when there is an immediate threat to the safety of the individual, the staff or other prisoners who are at risk,” said Kara Gotsch, a spokesperson for the ACLU National Prison Project. “(But) when the risk ends, the person should be released from the chair. We see incidents where people are kept in restraint chairs for 47 hours.”

In the Montgomery County jail, however, Mandich, Ellis and Banks died after being in the chair for relatively short amounts of time. As two of the autopsy reports hinted, it may have been the violent fights to get them in the chair that contributed more to their deaths than the chair itself.

In "The Devil's Chair," Cusac’s April 2000 article in The Progressive, a series of cases in which use of the restraint chair had resulted in death, serious injury and torture, were reported. Cusac interviewed prisoners, lawyers and restraint chair manufacturers and investigated cases where “the restraint chair was being used in an improper and sometimes sadistic manner.”

According to Cusac, in July 1999, a 30-year-old schizophrenic man in Texas’ Tarrant County Jail was placed in a restraint chair by jail authorities and died within eight hours. In December 1996, in Florida’s St. Lucie County Jail, a man died after being strapped into a restraint chair. He had notified the police that he had swallowed a large amount of cocaine, but was ignored. In April 1995, a man died in California’s Sacramento County Jail of “probable acute cardiac arrhythmia due to restraint anxiety and severe physical exertion,” due to “apparent manic psychotic episode." The county coroner's office concluded that his death was an accident.

One of the most horrific restraint chair-torture stories happened in 1996 in Maricopa County Jail in Arizona. Inmate Scott Norberg, after being placed in a restraint chair for acting strangely, was killed by COs after they put him in the chair, gagged him and repeatedly shocked him with a stun gun even after he was already dead. A medical examiner found burn spots and bruises covering his body, but blamed the death on accidental "positional asphyxia."

The county settled a suit filed by Norberg’s family for $8 million. A subsequent federal investigation into his death resulted in a nationwide trend to significantly restrict the use of stun guns in concert with the restraint chair.

Today, Cusac says that the use of restraint chairs should be further investigated in order to avoid instances where people are neglected and harmed when being restrained.

"The devices seem susceptible to abuse," she posited. "So, as long as our prisons and jails are using them, the public needs to keep a close eye on how they are used so that needless ill treatment and deaths don’t occur."

In 1996, Tom Hogan, then-sheriff of Crawford County, Iowa, founded ERC. The company sold three restraint chairs to the Montgomery County Jail in 1998.

Hogan believes that the restraint chairs manufactured by his company, if used properly, are a safe alternative to other forms of restraining inmates — such as padded cells, restraint boards or the use of sedatives like Thorazine. Until a more efficient technology for restraining prisoners from hurting themselves or others is developed, he argues that the restraint chair is the best option.

When placed in the restraint chair, the detainee sits in the chair while being handcuffed and put in leg irons. A leather strap is then attached to the handcuffs from the back of the chair and the person is strapped in the chair by the waist, wrists, shoulders and ankles with nylon belts. Of course, that is easier said than done in the case of an inmate fighting desperately to stay out of the chair.

According to the manual for the proper use of the Emergency Restraint Chair, the detainee must be monitored continuously and be in the restraint chair no more than two hours unless given direct supervision from a medical doctor or nurse. County jails are warned by ERC not to use the restraint chair as a form of punishment.

Dan Corcoran, president of AEDEC, Inc., another manufacturer of restraint chairs, believes that the restraint chair can save the lives of inmates or mental patients who are suicidal or are causing physical harm to themselves or others. Corcoran claims that the restraint chair is a safe alternative to other forms of restraint devices.

"If you keep people sitting upright, their air ways are cleared and they cannot do harm to themselves or other people," he said. "It keeps them from losing their life. If they are trying to take their own life, COs should not be diagnosing, they should be there to help keep them alive. It's not just a place to deposit them out of the way. It's something to prevent them from making the situation worse."

In a 2000 “Nightline” episode, Corcoran compared the chairs to restraining a puppy: "You take a little puppy, and he’s excited as all get out. You hold him for a little bit and his heart slows down. Prisoner, same way."

When questioned about the lack of medical studies (there aren’t any) in support of the chair, Corcoran responded, "It’s not a medical problem. It’s an incarceration. It’s a correction problem. And it’s not cruel or unusual because we restrain ourselves exactly the same way in our cars with the very same seat belts."

In response to cases of death involving the use of the restraint chair, Corcoran said that the chair is not solely responsible, but that the authorities of corrections facilities sometimes are at fault.

It is not just Amnesty International, the ACLU, and the United Nations Committee Against Torture that have issues with the use of restraint chairs. It is also law enforcement trainers like Steve Yerger, a 14-year professional who facilitates restraint chair training courses at 3 Tier Investigative Services.

His group says it knows about four COs being criminally charged and convicted, four serious, permanent injuries, and 28 deaths resulting from improper use of the chair.

Ever since he first witnessed a pattern of deaths, Yerger has specialized in training correctional facility staff on the formal policies and procedures involved when restraining inmates.

“Across the country and internationally, these chairs have been sold, but nobody has taken the time to do the research or obtain information as to why injuries occurred, why sudden in-custody deaths occurred and where chairs had been used,” Yerger claimed. “Cases of death that are linked to the restraint chair are sometimes sudden where the inmate has died the same day they were arrested. There are factors that are very common with sudden in-custody deaths. I've seen cases where people have died within minutes after being in the chair and cases where people are in the chair for hours and hours and they don’t die.”

From his experiences with training and witnessing the use of the restraint chair, Yerger posits that there are both sensitive physiological and psychological factors involved that make it difficult to judge whether an inmate should be restrained.

“We are not saying that the chair itself causes death, but there are incidences where somebody died while they were in a chair or right after they were released from a chair,” Yerger said.

Even though he’s critical, Yerger supports the use of the restraint chair if the proper procedures are implemented and applied.

“We feel that these chairs are needed for the type of population county jails are getting these days,” he said. “Our correctional facilities are getting a huge population of drug addicts. A lot of times, the correctional facility is dealing with a situation that is precarious from the start.”

Of the three deaths at the Montgomery County Jail, litigation is currently being pursued only in the case of Brian Mandich. Restraint chairs continue to be used throughout the country without any sign of a national inquiry or regulation other than in-department policies, which, it must be noted in the case of Montgomery County, are relatively progressive (at least on paper).

At the same time, suspiciously, videos that were taken by the jail of the three now dead inmates’ restraint chair sessions were not archived and are, therefore, “not available,” according to the Sheriff’s Department’s Kathy Duibley.

According to Larry Greger, a lawyer considering litigation against the county jail, Sheriff Dave Vore pledged to videotape all restraint chair sessions at the jail at a meeting between himself, Greger and Montgomery County Court Judge Jeffrey Froelich. As of press time, neither Vore nor Froelich have confirmed or denied Greger’s allegation.

When we get more information, we will follow up this story.

We requested restraint chair demonstrations from three local county jails — Montgomery, Greene and Clark. Over the last month, all of them refused or did not respond to our request.

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