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By CCHR International
August 10, 2020

Rev. Frederick Shaw champions a campaign through CCHR and his Task Force Against Institutional Racism in the PsychiatricIndustry to stop the use of restraints that has led to so many lostAfrican American lives. The tragedy of Cornelius Frederick in May 2020 raises concerns about institutional racism in the mental health and foster care/juvenile detention systems. As the 16-year old was restrained in a psychiatric facility for throwing a sandwich on the floor.  African Americans are over-represented in restraint-related deaths of children and adults with disabilities and are eugenically stereotyped as violent, which can predispose them to being drugged and restrained. [See FactSheet for more information.]

The Restraint Death of 16-year-old Cornelius Frederick

OnApril 29, 2020, 16-year-old Cornelius Frederick, an African American, was physically restrained at Sequel Youth & Family Services’ Lakeside Academy in Kalamazoo, Michigan, a residential psychiatric facility that treated foster care and other kids with behavior aliases.  Cornelius went into cardiac arrest while being restrained by Lakeside Academy staff. According to the family’s attorney, Cornelius started yelling, “I can’t breathe! ”before passing out. Thirty hours later, on May 1, he was dead. A witness to Cornelius’s restraint said, “[T]his kid threw a sandwich. He was being unruly and they couldn’t control him. So, four guys…the size of rugby players tackled him.’”

Cornelius had been a ward of the state since 2014, after his mother passed away and his father’s parental rights were revoked, according to Jon Marko, the civil rights attorney representing Frederick’s family.

TheKalamazoo County Medical Examiner’s office confirmed Frederick’s manner and cause of death was a homicide and three staff—Michael Mosley, Zachary Solis andHeather McLogan—were charged in June 2020 with involuntary manslaughter and second-degree child abuse. Mosley and Solis were also accused of restrainingFrederick in a “grossly negligent manner,” Kalamazoo County Prosecutor JeffGetting announced.

Tragically,“I can’t breathe,” which has become the uniting message in protests against racial injustice, is an all-too common cry from patients during restraint use in psychiatric hospitals and why the practice should be banned.

The Michigan Department of Health and Human Services (MDHHS) has terminated its contract with Lakeside and started the process to revoke its license. MDHHS DirectorRobert Gordon issued a statement on June 22 that “we will not rest until we have changed the system that allowed his death,” and MI Governor Gretchen Whitmer has directed actions be taken to correct the system. MDHHS said it“will change its policies to forbid the use of physical restraints in all its licensed and contracted facilities.”

Nationwide,Sequel Youth & Family Services has come under government scrutiny over its treatment of foster care and other youth and use of restraints. Starr-AlbionPrep in Albion, MI, was the subject of nearly 60 investigations since 2014 by the Department of Health and Human Services (HHS). Reports showed that staffers in 2018 restrained youths unnecessarily and used unapproved techniques, in one case breaking a child’s thumb.

In August 2019, Sequel’sRed Rock Canyon School in Utah closed after “numerous accounts of mistreatment, abuse, acts of violence and overall disrespect toward residents.”[vi]  Three months later, Sequel Pomegranate in Columbus, Ohio, came under scrutiny when video footage showed a nurse attempting to restrain a patient, wrapped her left arm around a patient’s neck,” “took the patient to the floor,” “kicked,” and “appeared to strike the patient five times with a closed fist in the face/head region.” The child had sustained a concussion a month prior.

Petition for Justice for Cornelius

Fight for Kids supports a petition started by the Michigan Center for Youth Justice, calling for the shutdown of Sequel Youth and Family Services operations in Michigan and around the country. Please sign the petition to get Justice for Cornelius and Shut Sequel Down, which Fight for Kids supports.

The Killing of Elijah McClain    

In August 2019, police officers in Aurora, Colorado, approached 23-year-old Elijah McClain, anAfrican American, as he innocently walked home from a grocery store. The AuroraPolice Department later said that a 911 caller had reported a “suspicious person”in a ski mask—a mask his sister later said he wore because he “had anemia and would sometimes get cold.” He was not armed and had not committed any crime but because he “resisted arrest,” he was tackled to the ground and put him in a carotid (strangle) hold.  He struggled and cried, “I just can’t breathe correctly.” Paramedics who had been called, injected him with a powerful drug, ketamine.  He had a heart attack on the way to the hospital and was declared brain dead. Six days after he was stopped by police, his family took him off life support, and he died.

A coroner could not determine the cause of death but said “an idiosyncratic drug reaction (an unexpected reaction to a drug even at a therapeutic level) cannot be ruled out” in reference to the ketamine dosage.

The coroner’s autopsy report dated 3 September 2019, said Elijah had developed acute kidney injury at the hospital which was addressed but he then had a second cardiac arrest.  Following brain death, his body became an organ donor. His medical history included asthma. “Nonetheless, the patient’s sudden collapse after an intense struggle is commonly seen inExcited Delirium. It is thought that when adrenaline levels drop, potassium levels surge resulting in an arrhythmia. This mechanism may well explain the cardiac arrest which led to anoxicencephalopathy (brain injury that begins with the cessation of cerebral blood flow to brain tissue),” the autopsy report said. Astoundingly, the report also says “Most likely, the decedent’s physical exertion contributed to his death.”  

As this could occur in any restraint use, why are they even used as it would be a natural reaction to fight against restraint, especially when can’t breathe—in other words, fighting for your life.

However, the point is, as neuroscientist Carl Hart, chair of Columbia University's psychology department, said: “Why anyone would be giving ketamine in that circumstance is beyond me. The major problem here is we should never be ordering any medication, and no one should be taking or given it against their will."

Yet, it is a very common practice for psychiatrists to force psychotropic drugs—tantamount to chemical restraint—on individuals every day. The fact that children and young teens—who can’t consent—are drugged and in cocktails seen as “chemical restraint”—is even more egregious.

  • Ketamine is FDA-approved as a sole anesthetic agent for diagnostic and surgical procedures.It is not FDA-approved for other indications but, off-label (without agency approval), it has been used to sedate “difficult to sedate violent patients” in emergency rooms.
  • It is so powerful, that when abused on the streets, it is known as a “date rape” drug because it can cause disassociation, meaning victims enter a state in which they feel as if their mind and body aren’t connected.
  • In 2017, theAmerican College of Emergency Physicians endorsed the use of ketamine withoutFDA approval for sedation of agitated patients in the emergency department (ED),despite limited evidence. (Emphasis added)  In 2018, the Minneapolis Office of Police Conduct Review, a division of the city’s Department of Civil Rights, investigated how police officers had asked emergency medical responders to use ketamine to sedate suspects and others who were restrained. In some cases, the drug had caused heart or breathing failure and required those injected to be revived or intubated.  It was given on the site of the restraint, despite “the immediate effects on breathing and heart function that the drug induces.”
  • Health hazards and side effects of ketamine, even in low doses, can cause agitation and in higher doses, “violent behavior,”“severe anxiety, fear, panic, anxiety, exaggerated strength, and aggression, muscle rigidity, respiratory depression,”and more.

An Aurora Fire Department press release said ketamine is "routinely utilized to reduce agitation" during arrests—despite aggression-causing adverse effects.  One comment heard in the police body camera footage of Elijah’s restraint suggested the dose of ketamine given him may have been 500 milligrams. That approaches the dose of 700 milligrams that would produce up to 25 minutes of full surgical anesthesia for someone of McClain's reported weight of 140 pounds.


“Foster care teen’s death draws scrutiny to group home outbreaks: Who is looking out for these children?” Journal Star, 15 May 2020, https://www.pjstar.com/zz/news/20200515/foster-care-teens-death-draws-scrutiny-to-group-home-outbreaks-who-is-looking-out-for-these-children

Corey Williams, “Lawsuit: Michigan Teen Screamed ‘I Can’t Breathe’ During Restraint,” WPVE, 22 June 2020, https://www.wvpe.org/post/lawsuit-michigan-teen-screamed-i-cant-breathe-during-restraint

“Father worried about son’s well-being after he witnessed student's death: Son tells father 'four guys the size of rugby players tackled [teen]’ at Lakeside Academy last week,” Fox 17 news online, 8 May 2020, https://www.fox17online.com/news/local-news/kzoo-bc/kalamazoo/father-worried-about-sons-well-being-after-he-witnessed-students-death

“Cornelius Fredericks: 3 charged after medical examiner rules Black teen's death was homicide,” Associated Press, 25 Jun. 2020,  https://www.usatoday.com/story/news/nation/2020/06/25/cornelius-fredericks-death-3-charged/3256015001/?fbclid=IwAR0BBtH9pDQHpXzD3c7LAku-AzTl4Q_9Ku_UR6ueITpGUStd4qRHadv7w6w

“MDHHS Director Robert Gordon Issues Statement About Actions Department is Taking in Response to Death of Youth at Kalamazoo Facility; Department Releases Investigation Report,” 22 June 2020, https://www.michigan.gov/mdhhs/0,5885,7-339--532626--,00.html

Re: License #CI130201440, Investigation #2018C0103021, Starr Commonwealth, Michigan Dept. of Health and Human Services Division of Child Welfare Licensing, 12 June, 2018

Allegra Abramo, “WA Foster Kids Sent to Out-of-State Group Homes with Checkered Records,” Investigate West, 5 Feb. 2019, https://www.invw.org/2019/02/05/wa-foster-kids-sent-to-out-of-state-group-homes-with-checkered-records/

Jessica Miller, “He was abused by staff at Red Rock Canyon School. Now, this Oregon teen wants to change the foster system that sent him to Utah,” The Salt Lake Tribune, 6 Feb. 2020, https://www.sltrib.com/news/2020/02/07/he-was-abused-by-staff/

Jessica Miller, “Violence, sex abuse and mistreatment: Utah officials threaten to pull the license of this St. George school for troubled youth,” The Salt Lake Tribune, 17 May 2019, https://www.sltrib.com/news/2019/05/17/violence-sex-abuse/

Kara Hartnett, “Acadia facility closes amid abuse allegations,” Nashville Post, 5 Apr. 2019, https://www.nashvillepost.com/business/area-stocks/article/21063192/acadia-facility-closes-amid-abuse-allegations

“Update: Michigan Center for Youth Justice Seeks Justice For Cornelius Fredricks,” National Juvenile Justice Network, 29 June 2020, https://www.njjn.org/article/michigan-center-for-youth-justice-seeks-justice-for-cornelius-fredricks

“Elijah McClain was injected with ketamine while handcuffed. Some medical experts worry about its use during police calls,” ABC News, 1 July 2020, https://www.nbcnews.com/news/us-news/elijah-mcclain-was-injected-ketamine-while-handcuffed-some-medical-experts-n1232697

“What We Know About the Killing of Elijah McClain,” The Cut, 11 Aug. 2020, https://www.thecut.com/2020/06/the-killing-of-elijah-mcclain-everything-we-know.html

“One glaring question about the police killing of Elijah McClain,” The Week, 26 June 2020, https://theweek.com/articles/921867/glaring-question-about-police-killing-elijah-mcclain

“What you should know about date rape drugs,” Medical News Today, https://www.medicalnewstoday.com/articles/320409.php; https://www.bloomberg.com/news/features/2019-02-05/ketamine-could-soon-be-used-to-treat-suicidal-ideation

“What to know about ketamine, a common date rape drug,” Gov.1, 30 May 2018, https://www.efficientgov.com/public-safety/articles/what-to-know-about-ketamine-a-common-date-rape-drug-8DxnS7OteEhx7UmX/

“At urging of Minneapolis police, Hennepin EMS workers subdued dozens with a powerful sedative: EMS workers used date rape drug ketamine, stopping some suspects’ hearts or breathing,” The Star Tribune, 15 June 2018, https://www.startribune.com/at-urging-of-police-hennepin-emts-subdued-dozens-with-powerful-sedative/485607381/;

“Ketamine Used to Subdue Dozens at Request of Minneapolis Police, Report Says,” The New York Times, 16 June 2020, https://www.nytimes.com/2018/06/16/us/ketamine-minneapolis-police.html

“Ketamine Abuse,” Drugs.com, https://www.drugs.com/illicit/ketamine.html

Laura Iappleman, “Deviancy, Dependency, and Disability: The Forgotten History of Eugenics and Mass Incarceration,” Duke Law Journal, Vol. 68, No. 3, Dec. 2018, https://scholarship.law.duke.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=3958&context=dlj

“‘I’m just different’: The family of Elijah McClain, a 23-year-old Black man killed by Colorado cops almost a year ago, is still waiting for justice,” Yahoo! News, 27 June 2020, https://news.yahoo.com/im-just-different-the-family-of-elijah-mc-clain-a-23-yearold-black-man-killed-by-colorado-cops-090048258.html


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