Public Advisory

Prone Restraint: An Ineffective and Deadly Method of Restraint

Click here to view a report on the dangers of prone restraint (Acrobat file, 215k).

The Advocacy Center for Persons with Disabilities, Inc. is Florida’s federally funded Protection and Advocacy (P&A) system for individuals with disabilities. Our mission is to advance the dignity, equality, self-determination, and expressed choices of individuals with disabilities. In this role, the Advocacy Center investigates incidents of possible abuse and neglect. The following incident has prompted us to issue this public advisory, in an attempt to raise public awareness of the dangers associated with the use of prone restraint.

In 2003, a forty-two year old man with developmental disabilities died as a result of being physically restrained by his Florida Home and Community Based Services Medicaid Waiver provider staff. Officially, the medical examiner determined the cause of death to be cardiac ventricular arrhythmia, due to acute psychotic episode with hypertensive and focal arteriosclerotic heart disease, and identified blunt trauma and physical restraint as contributing causes.

The decedent, “C,” was part of a group traveling in a facility van when a tire went flat. The staff found a place for the group to wait while staff called for a replacement vehicle. At some point while the group was loading into the second vehicle, a minor altercation between C and another individual with developmental disabilities ensued. Staff members restrained C facedown for several minutes. From the various reports and investigations, it is unclear exactly what happened next, but it is clear that C was restrained facedown on the ground a second time for several minutes. When the police arrived, C was turning blue. Emergency personnel attempted lifesaving efforts at the site, and C was transferred to the local hospital, but pronounced dead shortly thereafter.

C’s death is a tragic reminder of the dangers of employing the prone method of restraint. His death could have been avoided altogether, had staff used different restraint methods or avoided the use of restraint by more closely following the de-escalation instructions provided in his individual behavior plan. The attached report (Acrobat file, 215k), produced by the California P&A, Protection & Advocacy, Inc., is a thorough examination of the dangers of prone restraint. It provides background information on prone restraint, scenarios, recommendations and alternatives to prone restraint. The Advocacy Center, as Florida’s P&A entity, recommends that you read this information, share this information with your staff and include the information in staff trainings. It is crucial that everyone understands the dangers to using prone restraint, and adopt and implement alternatives to its use.