Suzanne M. Sgroi, M.D. Executive Director New England Clinical Associates

• The death of Andrew M. on March 22, 1998 was the result of traumatic asphyxia, which has been ruled accidental. • Under no circumstances, should the physical restraint of a child include compression of the child’s thorax by the weight of an adult. • Staff response at the Facility in which Andrew died reflected an inadequate behavior management program. • The Facility utilized an outdated physical restraint training program that did not conform to currently-accepted standards established by contemporary training programs. • Although not necessarily a contributing factor to Andrew’s death, the Facility’s staff response to this medical emergency was inadequate. • Although not a contributing factor to Andrew’s death, the treatment plan at the Facility lacked sufficient direction regarding the use of physical restraints on medically compromised children. • The Department of Children and Families should have conducted an assessment of behavior management programs and physical restraint policies affecting children unde