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Death Caused By Restraint "Jumpsuit"
By Dave Reynolds, Inclusion Daily Express
March 12, 2003

CHIPPEWA FALLS, WISCONSIN--Police records released Tuesday show that Beverly J. Frawley, a resident of Northern Wisconsin Center for the Developmentally Disabled, likely died from "positional asphyxia" caused by a locked restraint "jumpsuit" that was made for a much smaller person, local news sources reported.

According to the records, the body of Frawley, 42, was found on the morning of February 25, kneeling face-down atop her mattress with a blanket pulled over her head. She was in a one-piece jumpsuit that opened in the back with steel grommets that were locked in place with a "big safety pin" device. Frawley had ligature marks around her neck caused by the tight clothing.

The institution, which houses 169 residents, was cited for violating federal and state regulations. It has until March 22 to correct the problems or lose its federal Medicaid funding.

The case has been turned over to the district attorney's office to investigate if staff or administrators were criminally negligent.

Records indicate that Frawley had been placed previously in a restraint that she could take off when she became agitated and started to remove her clothes.

On February 21, frustrated staff members obtained a doctor's order for the locked jumpsuit. Instead of waiting for one that fit, they borrowed one from another resident who was 6 inches shorter than Frawley.

During the four days leading up to her death, Frawley was placed in the locked jumpsuit for periods of time ranging from 45 minutes to seven hours. While in the restraint she would sometimes yell and scream, talk incoherently and show "aggression toward others."

"There was no documentation to show how a locked one-piece suit would eliminate these behaviors," state inspectors wrote.

The night before her death, Frawley had been placed in the restraint after she began stripping. One staff member told state inspectors that Frawley "was running around pulling on her suit and continually trying to get out the door. She was calling out, grimacing and appeared generally uncomfortable."

People First of Wisconsin, an advocacy group of people with developmental disabilities, has been pushing for the closure of Wisconsin's three state-run institutions. They have welcomed plans by Governor Jim Doyle to downsize Northern Wisconsin Center and move 150 of its residents back to their home counties by June of 2004.

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