During his intake interview, Stafford lamented that he was broke. He had no job, no sex drive. "And I'm back here," he added, referring to Terrell, where months earlier he had been a patient. "Ain't no way I'm getting out of here alive."
The doctor described Stafford's speech as "fluent and coherent" and observed that his physical health was good. His thought process was "organized," though the doctor noted he "exhibited a poverty of thought" and was at times "oppositional." He assessed Stafford as suffering from "melancholic type depression with nihilistic delusions" and switched his antidepressant prescription. Stafford was admitted to the hospital's K-2 acute care unit, where he was to remain for 90 days under a court order, which his daughter Katherlyn LaGale Walker had previously sought.
If Stafford was suicidal then, his demeanor had changed four weeks later when he placed three collect calls to Walker, asking her each time to come get him. It was his last call, on Thursday, December 9, that still haunts Walker.
"He said, 'I want to come home. They're trying to kill me,'" Walker recalls. "I said, 'Be patient. We'll be down there Saturday.'"
At the time, Walker says she couldn't get her 51-year-old father to explain what was wrong. Indeed, nothing out of the ordinary appears to have happened that day, according to the daily progress note staff entered in Stafford's file at 8 that night. "Client remains depressed; has been keeping to himself," it states. "No behavioral or management problems noted."
Shortly after 11 p.m., however, Stafford awoke in his bedroom and turned on his light. A nurse suggested he sit in the lobby if he couldn't sleep. Stafford sat in the lobby without incident for some time between 11:30 and midnight but eventually went back to his room and turned the light on again. He was told to turn it off. He walked back and forth between the lobby and his room, repeatedly turning on the light. Stafford was becoming combative.
The mental health workers at Terrell are trained to diffuse these situations so they don't have to physically restrain patients--using various body holds and, if necessary, tranquilizers, straps and seclusion--to prevent them from hurting themselves or others. The details of what happened to Stafford next are sketchy, but one thing is clear: The training didn't work.
Stafford began yelling. At one point, he lunged at or grabbed a staff member. They put Stafford in a two-man "basket hold," securing his arms behind his back. Stafford began kicking his legs, so they forced him facedown on the floor into a "prone" hold. More staff members (it's not clear how many) arrived and held his arms and feet down. Stafford began banging his head on the floor, prompting staff to grab his head. It is unknown how long Stafford was kept in this position, but at some point he was injected with two rounds of sedatives. Stafford went still.
When staff members rolled him over to check his breathing, they noticed a "faint smell of feces"--a common indication of asphyxiation. If the staff were adequately trained and equipped to resuscitate Stafford, by then it may have been too late: Stafford was likely dead. Some 45 minutes later he was brought by ambulance to a local hospital. His pupils were fixed and dilated, he had no vital signs, and his abdomen was "grossly" distended--he was dead on arrival.
That night, the telephone rang in Walker's Dallas home. "They called me and told me they thought he was having a heart attack," Walker says. The next day, Walker went to Terrell to get a detailed account of her father's death. She never got one. Instead, she left believing he died of a heart attack brought on by natural causes.
"They didn't tell me how he died, what's the cause of death, none of that," Walker says. "They never told us they had to restrain him."
Laurance Priddy, a staff attorney at the Dallas branch of Advocacy, Inc., a federally funded nonprofit watchdog empowered to investigate cases like this, does not believe there was any criminal intent behind Stafford's death. It was an accident, he thinks, but one that should have never happened. Trouble is, deaths like Stafford's are all too common. That's why Advocacy, Inc. is now suing the Texas Department of Mental Health and Mental Retardation (TDMHMR), the state agency that regulates Terrell hospital, hoping to force changes that will prevent deaths like Stafford's.
The litigation is part of an ongoing national campaign led by advocates of the mentally ill who argue that the use of physical restraints is a "medieval" practice that, while sometimes necessary, is relied on as a substitute for effective care, resulting in unnecessary death and injury of society's most vulnerable citizens. Worse, they say, the restraints are still used to discipline difficult patients or simply out of convenience--despite new laws strictly prohibiting that.