Skip to Full Menu

Providing information, education, and training to build knowledge, develop skills, and change attitudes that will lead to increased independence, productivity, self determination, integration and inclusion (IPSII) for people with developmental disabilities and their families.

Medical Examiner: Holmes' Death Caused By 'Extreme Agitation'
By Dave Reynolds, Inclusion Daily Express
October 20, 2004

BELLEFONTAINE NEIGHBORS, MISSOURI--On August 3, George Holmes telephoned his stepmother from the Bellefontaine Habilitation Center and told her that the staff at the state-run institution were beating him.

A few hours later he was dead.

A medical examiner said Tuesday that Holmes, 33, did not die from abuse or assault, nor from a heart attack, as state officials had initially reported.

Instead, St. Louis County Medical Examiner Mary Case said Tuesday, Holmes died of natural causes brought on by extreme agitation.

"I know there was a report that he had been abused," Case explained. "But this man was severely agitated and had been for a few days."

"In this case, the aggravation was part of (Holmes') mental disorder - and was not from drugs," Case said. "It was not triggered by an act of his own volition or because he was acting up or being bad."

"What happened was his psychiatric disorder caused him to be so highly agitated that his heart began to beat very erratically. Eventually, the heart is no longer able to support life, and it causes a rather abrupt death."

Case explained that, while her autopsy could not determine how Holmes had sustained bruises and scrapes on his face and left side, the injuries did not cause his death.

Case's office reviewed police statements by staff members and by two residents that witnessed workers struggling with Holmes on the night of his death. She said that all of the statements matched, leading her to believe that Holmes died of natural causes.

"No one did anything to him to cause him to die," Case said.

Martha Washington, Holmes' aunt, disputed Case's claim that he had been agitated for several days prior to his death. Washington told the St. Louis Post-Dispatch that her nephew was not upset or agitated when he stayed with her just two days before he died.

"George was not the type of person who got agitated," Washington said. "I knew his personality and that would not have happened. I will not accept it. I will not believe it."

Anne Deaton, director of the Missouri Division of Mental Retardation and Developmental Disabilities, which is responsible for BHC, announced last week that four employees have been fired and four others disciplined in the midst of investigations into abuse and neglect at the institution. She added that 47 other employees have been suspended with pay while more allegations are being investigated.

While the Post-Dispatch and the Associated Press have both reported that Holmes had mild mental retardation, neither news service mentioned specifically which psychiatric disorder is believed to have brought about his severe, and lethal, level of agitation.

"Natural causes are cited in death at care center" (St. Louis Post-Dispatch)
"State Suspends Dozens Of Institution Staff, And Fires Four, Over Abuse Claims" (Inclusion Daily Express -- Oct. 12, 2004)


©2018 The Minnesota Governor's Council on Developmental Disabilities
 370 Centennial Office Building  658 Cedar Street   St. Paul, Minnesota 55155 
Phone: 651.296.4018   Toll-free number: 877.348.0505   MN Relay Service: 800.627.3529 OR 711   Fax: 651.297.7200 
Email:   View Privacy Policy   An Equal Opportunity Employer 

The GCDD is funded under the provisions of P.L. 106-402. The federal law also provides funding to the Minnesota Disability Law Center,the state Protection and Advocacy System, and to the Institute on Community Integration, the state University Center for Excellence. The Minnesota network of programs works to increase the IPSII of people with developmental disabilities and families into community life.