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Colorado Restraint Board Death Case Settled
by Bill Trine, esq.
A§ 1983 civil rights lawsuit and medical/healthcare negligence lawsuit was brought by the mother of 54 year old Michael Lewis, who died on May 7, 1998, after being placed on a "restrainer board" while incarcerated as a pre-trial detainee at the El Paso County Criminal Justice Center in Colorado Springs, Colorado.
The lawsuit was brought against Correctional Medical Services, Inc. (CMS) who had a contractual obligation to provide medical services for prisoners and detainees at the facility. The mother claimed that CMS and its employees condoned and participated in the use of excessive force in violation of the substantive due process clause of the 14th Amendment to the U.S. Constitution, and in violating the cruel and unusual punishment clause of the 8th Amendment through deliberate indifference to Michael Lewis' medical needs.
The mother's § 1983 claims against the El Paso County Sheriff's Office (EPCSO) were based on the same constitutional violations brought against CMS: (1) the use of excessive force by EPCSO employees; (2) deliberate indifference to medical needs; (3) the adoption of policies and procedures that violated §1983; (4) failing to enact policies and procedures to prevent Michael Lewis' death; and (5) failure to properly train employees resulting in deliberate indifference to Michael Lewis' medical needs.
Michael Lewis was arrested and jailed April 14, 1998, for sexual abuse of a minor. He had no previous criminal record; however, he did have a mental health record. Lewis was previously diagnosed with Attention Deficit Disorder (ADD) and "hyperaction" and a possible bi-polar disorder. He was disabled with ADD and depression and was on medication at the time of his arrest. Because of his condition, he had not been able to sustain steady employment and had received welfare type assistance.
On Monday, May 4, 1998, three days before his death, CMS employees and EPCSO employees noted that Lewis had become psychotic. Chart entries indicate that he was delusional and confused, was talking to himself and decompensating, was disheveled and disoriented. _ knowing only that he was in jail, and his name.
On May 5, Lewis' brother-in-law was so concerned he called the facility, but was reassured that the employees were aware of Lewis' condition, that he was being housed in the mental ward, and was under observation.
About 12:15 A.M. on May 7, Lewis was talking out loud to himself, which disturbed other prisoners, so he was removed from the mental ward, placed in a special detention cell and placed in soft restraints to prevent him from disturbing the sleep of the other mentally ill prisoners. The soft restraints simply accelerated his psychotic condition, so at 3 A.M. he was placed on the restrainer board where he was strapped down face first, with his head turned sideways and his torso and extremities strapped to the board so that he could not move. Restraints were placed across the head, upper back, upper arms, wrists, hips, thighs and ankles (11 restraints).
At 5:30 A.M. the deputies took him off of the board to allow him to eat breakfast and to return him to the mental ward where he went to bed.
At 9:20 A.M. on May 7, 1998, he was clearly psychotic. He was noticeably unsteady on his feet, and had once again begun talking loudly to the walls and pipes. He was again removed from the mental ward and taken to the isolation room where he was placed in soft restraints.
Again, the use of soft restraints aggravated his psychotic condition, causing him to yell incoherently and fight the restraints. Because of his psychotic outbursts, he was again placed on the restrainer board at 11 A.M. While on the board Lewis was incoherent, strenuously fighting the restraints and yelling. Three hours and 20 minutes later, when a transport team arrived to transfer him to the State Mental Hospital in another city, he was shaking as if experiencing a series of seizures. When he was released from the board, he was unresponsive. Code Blue was called and CMS nursing personnel arrived and started CPR. The fire department and ambulance service was called and arrived 15 minutes later. Lewis was not breathing, had no pulse, and CPR was not effective. When the fire department arrived at 2:43 P.M. Lewis was in respiratory and cardiac arrest. He was later pronounced dead at the hospital at 3:40 P.M.
While Lewis was on the restrainer board, he was observed fighting the restraints and yelling incoherently during each routine visual observation. However, the CMS employees at no time took his vital signs, respiration, temperature, and at no time checked his airway, all in violation of CMS policies and procedures. The EPCSO deputies did not move his head and release and move his extremities for circulation every 30 minutes, as required by EPCSO policies and procedures. Despite the fact that everyone knew Lewis was psychotic three days before his death, no treatment was rendered for his psychotic condition and no arrangements were made for his transfer to a hospital until he was placed on the restrainer board for the second time on May 7. While on the restrainer board, he was not given water or liquids, was not seen by the house physician who was on premises, and the consulting psychiatrist was not called.
Plaintiffs' expert witnesses testified that the cause of Lewis' death was positional asphyxia. The autopsy report stated that Lewis had moderate arterial sclerosis but no evidence of an acute myocardial infarction. The coroner attributed the death to "the combination of hyperactivity, the restraint board usage, and sedation by Haloperidol, Imipramine, and Benadryl may have contributed to his sudden unexpected death in custody."
CMS and EPCSO retained an expert witness who claimed that the cause of death was heart failure brought about by the exertion in fighting the restraints on the board.
Prior to the death of Lewis, there was a substantial body of literature describing positional asphyxia resulting in death when law enforcement personnel place people in a position which interferes with the interaction of the diaphragm with the musculature of the rib cage and the abdomen. This would occur if pressure was placed on the back which inhibited full use of the diaphragm in breathing. This is precisely what the velcro straps did when placed across Lewis' back as he struggled against those straps. Strapping him to the board interfered with circulation as well as his ability to breathe. It creates shallow breathing. Shallow breathing creates a carbon dioxide buildup, metabolic acidosis and eventual death.
There was evidence developed during depositions that CMS and EPCSO personnel knew that "positional restraint asphyxia" can result in death.
The lawsuit resulted in a settlement one month before a three week trial was to commence on May 21, 2001. The total amount of the settlement is subject to a Protective Order entered by the Court. The settlement with EPCSO was in the sum of $116,000. However, the settlement with CMS is for an undisclosed amount pursuant to the Court's Protective Order.
The damages claimed by the Plaintiff were damages for mental anguish and grief caused by the death of her son, Michael Lewis. No economic damages (loss of earning capacity or loss of her son's support) were claimed because the mother sustained no economic losses as a result of the death.
The lawsuit was filed in the El Paso County District Court, Aylett Lewis as next of kin and personal representative of the estate of Michael Lewis v. Correction Medical Services, et al and El Paso County Sheriff's Office, et al , Civil Action Number 99-CV-1849. Lewis' mother was represented in the lawsuit by Bill Trine and Jeff Hill of the law firm of Trine and Metcalf, P.C., in Boulder, Colorado.
The restrainer board is no longer in use at the El Paso County Criminal Justice Center.
A§ 1983 civil rights lawsuit and medical/healthcare negligence lawsuit was brought by the mother of 54 year old Michael Lewis, who died on May 7, 1998, after being placed on a "restrainer board" while incarcerated as a pre-trial detainee at the El Paso County Criminal Justice Center in Colorado Springs, Colorado.
The lawsuit was brought against Correctional Medical Services, Inc. (CMS) who had a contractual obligation to provide medical services for prisoners and detainees at the facility. The mother claimed that CMS and its employees condoned and participated in the use of excessive force in violation of the substantive due process clause of the 14th Amendment to the U.S. Constitution, and in violating the cruel and unusual punishment clause of the 8th Amendment through deliberate indifference to Michael Lewis' medical needs.
The mother's § 1983 claims against the El Paso County Sheriff's Office (EPCSO) were based on the same constitutional violations brought against CMS: (1) the use of excessive force by EPCSO employees; (2) deliberate indifference to medical needs; (3) the adoption of policies and procedures that violated §1983; (4) failing to enact policies and procedures to prevent Michael Lewis' death; and (5) failure to properly train employees resulting in deliberate indifference to Michael Lewis' medical needs.
Michael Lewis was arrested and jailed April 14, 1998, for sexual abuse of a minor. He had no previous criminal record; however, he did have a mental health record. Lewis was previously diagnosed with Attention Deficit Disorder (ADD) and "hyperaction" and a possible bi-polar disorder. He was disabled with ADD and depression and was on medication at the time of his arrest. Because of his condition, he had not been able to sustain steady employment and had received welfare type assistance.
On Monday, May 4, 1998, three days before his death, CMS employees and EPCSO employees noted that Lewis had become psychotic. Chart entries indicate that he was delusional and confused, was talking to himself and decompensating, was disheveled and disoriented. _ knowing only that he was in jail, and his name.
On May 5, Lewis' brother-in-law was so concerned he called the facility, but was reassured that the employees were aware of Lewis' condition, that he was being housed in the mental ward, and was under observation.
About 12:15 A.M. on May 7, Lewis was talking out loud to himself, which disturbed other prisoners, so he was removed from the mental ward, placed in a special detention cell and placed in soft restraints to prevent him from disturbing the sleep of the other mentally ill prisoners. The soft restraints simply accelerated his psychotic condition, so at 3 A.M. he was placed on the restrainer board where he was strapped down face first, with his head turned sideways and his torso and extremities strapped to the board so that he could not move. Restraints were placed across the head, upper back, upper arms, wrists, hips, thighs and ankles (11 restraints).
At 5:30 A.M. the deputies took him off of the board to allow him to eat breakfast and to return him to the mental ward where he went to bed.
At 9:20 A.M. on May 7, 1998, he was clearly psychotic. He was noticeably unsteady on his feet, and had once again begun talking loudly to the walls and pipes. He was again removed from the mental ward and taken to the isolation room where he was placed in soft restraints.
Again, the use of soft restraints aggravated his psychotic condition, causing him to yell incoherently and fight the restraints. Because of his psychotic outbursts, he was again placed on the restrainer board at 11 A.M. While on the board Lewis was incoherent, strenuously fighting the restraints and yelling. Three hours and 20 minutes later, when a transport team arrived to transfer him to the State Mental Hospital in another city, he was shaking as if experiencing a series of seizures. When he was released from the board, he was unresponsive. Code Blue was called and CMS nursing personnel arrived and started CPR. The fire department and ambulance service was called and arrived 15 minutes later. Lewis was not breathing, had no pulse, and CPR was not effective. When the fire department arrived at 2:43 P.M. Lewis was in respiratory and cardiac arrest. He was later pronounced dead at the hospital at 3:40 P.M.
While Lewis was on the restrainer board, he was observed fighting the restraints and yelling incoherently during each routine visual observation. However, the CMS employees at no time took his vital signs, respiration, temperature, and at no time checked his airway, all in violation of CMS policies and procedures. The EPCSO deputies did not move his head and release and move his extremities for circulation every 30 minutes, as required by EPCSO policies and procedures. Despite the fact that everyone knew Lewis was psychotic three days before his death, no treatment was rendered for his psychotic condition and no arrangements were made for his transfer to a hospital until he was placed on the restrainer board for the second time on May 7. While on the restrainer board, he was not given water or liquids, was not seen by the house physician who was on premises, and the consulting psychiatrist was not called.
Plaintiffs' expert witnesses testified that the cause of Lewis' death was positional asphyxia. The autopsy report stated that Lewis had moderate arterial sclerosis but no evidence of an acute myocardial infarction. The coroner attributed the death to "the combination of hyperactivity, the restraint board usage, and sedation by Haloperidol, Imipramine, and Benadryl may have contributed to his sudden unexpected death in custody."
CMS and EPCSO retained an expert witness who claimed that the cause of death was heart failure brought about by the exertion in fighting the restraints on the board.
Prior to the death of Lewis, there was a substantial body of literature describing positional asphyxia resulting in death when law enforcement personnel place people in a position which interferes with the interaction of the diaphragm with the musculature of the rib cage and the abdomen. This would occur if pressure was placed on the back which inhibited full use of the diaphragm in breathing. This is precisely what the velcro straps did when placed across Lewis' back as he struggled against those straps. Strapping him to the board interfered with circulation as well as his ability to breathe. It creates shallow breathing. Shallow breathing creates a carbon dioxide buildup, metabolic acidosis and eventual death.
There was evidence developed during depositions that CMS and EPCSO personnel knew that "positional restraint asphyxia" can result in death.
The lawsuit resulted in a settlement one month before a three week trial was to commence on May 21, 2001. The total amount of the settlement is subject to a Protective Order entered by the Court. The settlement with EPCSO was in the sum of $116,000. However, the settlement with CMS is for an undisclosed amount pursuant to the Court's Protective Order.
The damages claimed by the Plaintiff were damages for mental anguish and grief caused by the death of her son, Michael Lewis. No economic damages (loss of earning capacity or loss of her son's support) were claimed because the mother sustained no economic losses as a result of the death.
The lawsuit was filed in the El Paso County District Court, Aylett Lewis as next of kin and personal representative of the estate of Michael Lewis v. Correction Medical Services, et al and El Paso County Sheriff's Office, et al , Civil Action Number 99-CV-1849. Lewis' mother was represented in the lawsuit by Bill Trine and Jeff Hill of the law firm of Trine and Metcalf, P.C., in Boulder, Colorado.
The restrainer board is no longer in use at the El Paso County Criminal Justice Center.
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Related legal case
Aylett Lewis v. Correction Medical Services
| Year | 2001 |
|---|---|
| Cite | Civil Action No. 99-CV-1849 |
| Level | State Trial Court |
| Conclusion | Settlement |
| Damages | 116000 |
| Injunction Status | N/A |