Two weeks after Stafford's funeral, a representative from Advocacy, Inc. contacted Walker. The representative gave Walker a portion of her father's medical records, including the autopsy report, which concluded that Stafford died of asphyxiation during a takedown, ruling his death an accident.
Walker had her first glimpse into the real circumstances behind her father's death. She was infuriated. Worse, she was left with unanswered questions about how her father died: Did he really die because he wanted his bedroom light on? What made him believe his life was in danger? Why didn't they get off him before it was too late? Most important, how could he have died at the hands of the very people Walker trusted to help him?
"The way [Advocacy] talked, he was fighting for his life," Walker says. "There's some lying going on."
Mental health advocates had complained about deadly restraints for years, but it wasn't until 1998 that their use became publicly scrutinized. That year, The Hartford Courant published a series of groundbreaking articles that uncovered 142 U.S. deaths in 10 years. The articles estimated the real number of restraint-related deaths each year to be much higher--anywhere from 50 to 150 people--but said that the actual number is untraceable because institutions weren't required to report them and privacy laws stymied outside investigative efforts.
The articles, however, confirmed many of the advocates' complaints, blaming many of the deaths on a lack of regulations governing how and when restraints should be used, as well as an absence of training requirements that emphasize "de-escalation" techniques proven to calm patients down before they need to be restrained.
The newspaper series led to the passage of new federal laws that recognize a patient's right to be free from unnecessary restraints and created public reporting requirements designed to document the problem. The legislation, which took effect in 1999 and 2000, established new rules prohibiting the use of restraints except during emergencies in federally funded institutions. In Texas, the state agencies that regulate those facilities have recently revised their own sets of rules, which mirror the federal standards and began to take effect last year.
Although mental health advocates welcome changes, they argue that the facilities still aren't doing enough to decrease the use of restraints, and as a result unnecessary deaths and injuries are still too common. Stafford's death, for example, is one of a dozen restraint-related deaths that Advocacy, Inc. has recorded in Texas since 1999.
"If [Terrell] had followed their own rules, this shouldn't have happened," Priddy says, adding the case goes beyond questions about rules and encompasses broader treatment practices used in state hospitals. "There is an atmosphere of animosity that does not contribute to a therapeutic alliance between the clients and the staff. Instead, it exacerbates the conflict, despite the rules."
Others who care for the mentally ill say the new regulations aren't an effective tool to prevent deaths and injury. Various professional medical lobbies complain that the regulations are so specific they strip doctors of their ability to exercise individual judgment while bogging them down with paperwork. Others worry the new public reporting requirements will lead to an increase in lawsuits, which will only drive up costs in a system that virtually everyone agrees is under-funded and already unable to keep good employees on the job.
Katie Stavinoha, a TDMHMR spokeswoman, says she can't comment on the Stafford lawsuit (nor would officials at the Texas Attorney General's Office, which is handling the litigation). Generally, Stavinoha and other state officials say they effectively regulate the use of restraints. They also say they had been training their employees in de-escalation techniques long before the law required it.
Indeed, there is no shortage of rules pertaining to how restraints are used. In addition to the federal regulations, each state regulatory agency in Texas now has numerous, complex rules. They cover virtually every aspect of restraints, from how long patients can be held to the exact amount of time a facility has to call a doctor and fill out all the appropriate paperwork.
What the rules don't do is effectively address what employees should do to prevent the use of restraints--beyond requiring them to receive training in what caregivers call de-escalation, says Nestor Presas, a staff investigator at the Dallas branch of Advocacy, Inc. The organization is the designated agency in Texas under the national Protection & Advocacy system, which Congress created in 1975 to guard the interests of physically and mentally disabled people.