A teen who died after employees of a Michigan group home sat on him for throwing sandwich bread was improperly restrained, and staff failed to quickly provide medical help, state officials say.
An investigation report about the death of Cornelius Fredericks — a 16-year-old boy who lived at Lakeside Academy in Kalamazoo, Michigan — says staff members restrained the teen for 12 minutes as he struggled to breathe while other employees stood by without correcting them. Fredericks, who suffered cardiac arrest, died two days later on May 1, officials say.
“Throwing bread is not a demonstration of imminent threat of harm to self or others and did not warrant physical management,” according to the Michigan Department of Health and Human Services report obtained by McClatchy News.
“Cornelius’ scream of ‘I can’t breathe’ was not enough to get the staff members to stop the excessive restraint,” the lawsuit says. “The excessive use of restraints and the lack of concern for Cornelius’ life draw an eerily similar comparison to that of George Floyd’s death.”
Floyd, a Black man, died after a Minneapolis police officer pinned his neck to the ground while three others stood by and watched. The city fired the officers, and all four are charged in the death, which sparked nationwide protests against police brutality.
Response to Fredericks’ death
In a statement to McClatchy, Sequel declined to comment on the pending litigation. The company said it was “deeply saddened by the tragic loss of Cornelius” and fired all staff involved in the incident as well as the executive director of the facility.
“We have been in regular contact with law enforcement and state officials to help ensure justice is served and have accelerated the work that was already underway across our organization to move to a restraint-free model of care,” Sequel said. “We take our obligation to meet the significant behavioral health needs of all our students incredibly seriously and remain focused on our mission of providing the absolute best care and treatment possible for our clients.”
The Kalamazoo County Prosecutor’s Office is investigating the death following completion of the state’s probe.
Video of the restraint
According to the state report, Fredericks was throwing pieces of bread from his sandwich at another child before a staff member pushed the boy from his seat to the floor. Video shows multiple staff members put their weight on the boy’s chest, abdomen and legs, “making this an unsafe and excessive restraint,” while supervisors watched, the report says.
In all, seven men restrained the boy. One of the men laid across Fredericks’ body and remained there throughout the entire restraint.
Video shows the boy was released after 12 minutes when his body went limp, unresponsive and motionless, officials say. A staff member sat the boy upright in a seated position, but his head dropped down and his arms fell when he was let go, officials said. He then slumped over and rolled onto his back, apparently unconscious.
The nursing director did not call 911 or instruct anyone to start CPR for another 12 minutes despite concerns about his breathing, coloring and pulse, the report says.
Paramedics arrived and took Fredericks to a hospital, where he was declared brain dead about 30 hours later, the report says. He tested positive for COVID-19 at the hospital.
The Department of Health and Human Services did not release the video due to the ongoing investigation by prosecutors.
Changes after the death
The department has suspended Lakeside’s license, and all 125 children at the facility were removed. The agency has begun the process for revoking the license.
State officials say they no longer will allow physical restraints to be used in institutions that care for children. Additionally, Health and Human Services is taking steps to no longer use Sequel for services licensed by the agency, officials said.
“It was a tragedy and an outrage,” Michigan Department of Health and Human Services Director Robert Gordon said in a statement to McClatchy. “We cannot bring this young man back to life, but we will not rest until we have changed the system that allowed his death.”