Investigators find multiple safety
violations at wilderness camp
Teen who died was improperly restrained,
report says.
By Jonathan Osborne and Mike Ward
Thursday, January 23, 2003
The October death of a 17-year-old at a Hill
Country wilderness camp came after he was taunted and improperly
restrained for refusing to stop talking and come out of his tent, a
state report revealed Thursday.
The findings by the Texas Department of
Protective and Regulatory Services cited the On Track wilderness
program for 28 separate violations of state regulations, including
improperly restraining Chase Moody as a "cruel and unnecessary
punishment," using a prohibited method of restraint, mishandling
medical records and failing to follow its own procedures and
policies.
"At the center of all this is the fact that a
child died, and a child died as a result of the violations found in
this report," said Geoffrey Wool, spokesman for the department. "I
think it's important to remember that in this business, we're all
about ensuring the safety of children, and obviously these
violations indicate that that system was not working properly, and
the violations indicate that obviously something needed to happen to
fix the system."
The Brown Schools, a Nashville, Tenn.-based
company that owned and operated On Track, will have two
opportunities to dispute the investigators' findings: first with the
regulatory department's administration and then with the State
Office of Administrative Hearings.
The company, which closed On Track in December
after losing its lease to the 6,000-acre Mason County ranch where
the camp was located, had relinquished its operating license prior
to learning of the state's findings. Officials with the Texas Parks
and Wildlife Department, which owns the land, have said the lease
cancellation was unrelated to Moody's death.
Brown Schools President and CEO Marguerite
Sallee challenged the state's findings and said the company plans to
appeal, even though they have no plans to reopen On Track.
"It's just not good for a company to have black
marks," Sallee said.
Moody was the fifth youth to die after being
restrained in a Brown Schools facility since 1988.
Thursday's report was released almost three
weeks after three staff members involved in the restraint of Moody
were accused of abuse and neglect in a separate state investigation.
All three are appealing those findings.
The 12-page report, based on interviews with
staff and an on-site investigation by the agency, is also separate
from an ongoing criminal investigation.
"We are very disappointed with the findings,"
Sallee said. "We firmly believe our staff acted appropriately, and
we will take advantage of the appeals process to provide evidence
that presents a more complete view of this tragic accident."
On Track was marketed as a 28-day adventure
program that offered therapy for troubled teenagers. The Brown
Schools operates a national network of 19 facilities in eight states
and Puerto Rico — including centers in Austin, San Marcos and San
Antonio.
Moody, who lived in Richardson with his mother,
had been sent to the camp primarily to work out anger issues, his
parents said. However, the report reveals that an admission
assessment — required by the state prior to the acceptance of a
youth into a regulated program — was not completed until three days
after Moody's death.
It also says that the staff members were not
given information about Moody's "immediate needs or anger problems."
According to the report, Moody was restrained
as punishment after he "refused to stop talking and exit his tent as
instructed." At one point, the report says, Moody was subjected to
remarks that belittled him, when one staff member made the remark,
"Boy, who are you calling boy?"
Sallee said Moody's death was precipitated by a
violent outburst, which the report does not detail. As a result of
the outburst, Brown School officials said, staff members placed
Moody in what's called the "team control position," where they
interlock legs, pull back the person's wrists and cup their hands on
the person's shoulders. In the course of the struggle, they fell
forward and continued to restrain Moody on the ground and used a
cell phone to call for help.
Sallee said Thursday that physical restraint is
used only as a last resort. The report, however, says that "no
information was found to indicate what other preventive, de-escalative,
less restrictive techniques were tried and proven ineffective at
defusing the situation before doing a restraint."
The report also accuses the staff members of
restraining Moody in such a way that they couldn't see his face,
that he could not communicate with them and that impaired the
teenager's breathing — all in violation of state regulations.
When Moody began to throw up, the report says,
the staff members failed to "provide treatment."
According to an autopsy performed in Travis
County, Moody died after suffocating on his own vomit. Brown Schools
officials have disputed the cause of death.
Sallee declined to discuss specific citations
Thursday.
"The heart of the question is whether staff
used a restraint that was not appropriate, and we believe they did
not," she said. "We believe they did the best they could during a
crisis situation.
"It is a gray area. Anytime you have an
emergency situation, it is not always black and white."
Sallee also said the company has "redoubled"
its training efforts and is reviewing its policies and procedures to
ensure that such tragedies are avoided in the future.
Moody's father, Charles Moody, said he had not
yet received a copy of the report.
"The only thing I would say is that . . . I'm
not surprised at anything that might be in there," he said. "I'd
really like to read it.
"Some days are OK, and some days aren't so
good," he said of the time that's elapsed since his son's death.
"But we get through them."
josborne@statesman.com; 445-3621
mward@statesman.com; 632-9561
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