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State says it will ban restraints that led to death of 16-year-old

Courtesy of Jonathan Marko

The Michigan Department of Health and Human Services is issuing an emergency rule to ban child care facilities from using the type of restraint that led to the death of a 16-year-old in Kalamazoo. The agency says it will also require all licensed facilities to notify children’s families within 12 hours whenever any type of restraint is used, and notify the agency within 24 hours.

“We are moving toward the goal of ending the use of restraints in institutional settings,” said MDHHS director Robert Gordon. “Restraints are too often used as an easy way to control youth in place of the harder, but necessary work of evidence based practices that help young people address mental health challenges and heal and overcome trauma.”

Cornelius Fredericks died May 1st, two days after he was placed in a restraint at Lakeside Academy in Kalamazoo. The county medical examiner ruled the death a homicide. Surveillance video of the incident shows Fredericks being pushed to the ground by a staff member after he threw a piece of a sandwich in the cafeteria at Lakeside on April 29. Eight staff members eventually joined in to help hold down Fredericks. He was pinned down for 12 minutes before being released.

"We did miss some of those early warning signs," said JooYeun Chang, executive director of the MDHHS Children's Services Agency.

“Multiple staff participated in this restraint and several were observed on the video with their weight on Resident A’s chest, abdomen, and legs, making this an unsafe and excessive restraint,” MDHHS concluded in a review of the incident.

Three staff members are facing criminal charges over the incident, and Kalamazoo County prosecuting attorney Jeff Getting hasn’t ruled out charging others.

Fredericks’ death came after years of complaints and violations at the Lakeside facility. State child welfare officials investigated more than a dozen complaints there since 2018, finding numerous violations. Despite that, the facility continued to operate.

“We did miss some of those early warning signs,” said JooYeun Chang, executive director of the MDHHS Children’s Services Agency. Chang said MDHHS staff had addressed each of the violations at Lakeside individually, and Lakeside was forced to implement corrective plans, which sometimes included firing staff members involved in the violations. But Chang said that was not enough.

“I think one of the things we want to do is make sure we are looking not only at that individual incident, but that incident in the context of the other things that the facility has in place,” Chang said during a press briefing Thursday.

The Lakeside facility in Kalamazoo was founded as Lakeside for Children in 1907, but since 2007 the non-profit that owns the facility contracted with a private, for-profit company to run it. That company, Sequel Youth and Family Services, LLC, has for years faced allegations of mismanagement and abuse at the facilities it operates in multiple states.

In 2019, NBC News reported on allegations of abuse at a Sequel-run facility in Iowa. Oregon Public Broadcasting and APM Reports also reported on other allegations, including the violations at Lakeside.

In Michigan, Sequel operated two facilities: Lakeside Academy in Kalamazoo and Starr Albion Prep in Albion.

Following Fredericks’ death, MDHHS took action in June to suspend Lakeside’s license, and Governor Gretchen Whitmer ordered the department to ensure Sequel Youth and Family Services “no longer provides services for facilities licensed by the department.”

MDHHS says all 125 children at Lakeside have already been moved. In June the department said it was in the process of relocating 66 children at Starr Albion Prep.

In addition to the emergency rule and the license suspension, MDHHS has released a report by the Annie E. Casey Foundation with six recommendations and more than 800 pages of material to improve residential programs for children. The six recommendations are:

1. Update policies to prohibit use of all restraints.

2. Communicate with families and children to inform them on use of restraints and seek advice.

3. Strengthen licensing requirements and increase inspections at facilities.

4. Improve data collection on use of restraints and seclusion, and break down data by race, gender and age.

5. Strengthen finance oversight, and separate it from licensing.

6.  Improve MDHHS caseworker policies to better monitor facilities.

Leaders at MDHHS say they are also focused on the racial disparities for kids caught in the child welfare system. Cornelius Fredericks was Black. He ended up a ward of the state after his mother died and his father was incarcerated.

“Teenagers of color are much likelier than other young people to be placed in institutions and group settings when they enter foster car,” said MDHHS director Robert Gordon on Thursday. “Much as George Floyd’s death triggered our society to grapple with institutional racism in policing, this young man’s death forces us to grapple with institutional racism in our child welfare system.”

The full report with recommendations for improving Michigan’s residential programs for children is available here.

The emergency rule banning certain types of restraints is available here.

This story was corrected to reflect that Sequel Youth and Family Services managed Starr Albion Prep, not Starr Commonwealth. Star Commonwealth is the parent organization for Starr Albion Prep.

Dustin Dwyer reports enterprise and long-form stories from Michigan Public’s West Michigan bureau. He was a fellow in the class of 2018 at the Nieman Foundation for Journalism at Harvard. He’s been with Michigan Public since 2004, when he started as an intern in the newsroom.
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