Pueblo Patient Suffocated In Restraint, M.E. Rules

6 Jun


Death Of Troy Geske Results In Independent Review Of Hospital Procedures

A patient who died last month while tied face down in restraints suffocated at the Colorado Mental Health Institute at Pueblo.
7NEWS Investigator John Ferrugia obtained the death certificate for 41-year-old Troy Geske which showed Geske died from positional asphyxia — he couldn’t breathe because of the way he was restrained. Pueblo County Coroner James Kramer ruled his death accidental.

Now, the Pueblo County District Attorney must weigh evidence collected in a search warrant and investigation and decide if criminal charges will be filed in connection with Geske’s death.


An investigation by 7NEWS found that Geske had been isolated and restrained because the hospital staff said he was belligerent and out of control.

Geske died in the forensic unit of the state hospital.

Sources who have seen a videotape of the incident told 7NEWS that Geske was not flailing or hitting anyone when he was escorted into the isolation room by staff members. Geske was strapped face down and spread eagle on the bed with a pillow.

He was left restrained in the room, alone, and a staff member was stationed outside the locked door of the room.

Shortly afterward, the staff member, looking through a window on the door, noticed Geske had stopped moving. The staff member then went into the room and found Geske was not breathing.

CPR was begun on Geske, but he could not be revived.

An investigation found that Geske, who was 5 feet 8 inches tall and weighed 260 pounds, had trouble breathing while spread face down on the bed and pillow. He had tried to turn his head to the side to get air, but died of positional asphyxia — a form of asphyxia that occurs when someone’s body position prevents them from breathing adequately.

An FBI law enforcement bulletin published in 1996 warned law enforcement officers that research suggested that restraining a person in a face down position was likely to cause greater restriction of breathing than restraining a person face up.

Colorado Dept. of Human Service spokeswoman Liz McDonough told 7NEWS the prone position restraint is controversial and has been banned in some states.

Geske’s mother, Linda, believes the hospital staff made serious mistakes and was negligent in her son’s death in using the face down restraint.

“He couldn’t breathe because of the way he was restrained,” she said.

“That’s torture. That’s what it was. He was tortured to death,” said Geske’s father, Rex.

Geske’s death marks the fourth at the state hospital since 2007.

“I want people to quit dying down there. That’s what I want,” said Rex Greske.

After his son”s death, hospital Superintendent Dr. John DeQuardo suspended the use of the prone restraint position at the Pueblo State Hospital.

Three other incidents at the state hospital have resulted in a third-party review of the facility.

Edward F. Benge, 49, was brain dead but was on life support earlier this week after hanging himself from a door frame on Monday. He had jammed the door lock to his room to keep hospital staff from reaching him quickly.

Benge had written to 7NEWS last February to complain about conditions at the hospital.

Benge wrote, “Staff are keeping patients locked on these wings with absolutely no staff supervision. When patients are locked on the wings it is impossible for staff to hear through the locked door… and its (sic) impossible for them to be able to see anything that might be happening in the patient’s rooms.”

He concluded his letter with a stinging indictment of those responsible for his care.

“They absolutely do not know how to run this new facility. And its (sic) not because we don’t have enough staff. Its (sic) because the staff that we already have are incompetent.”

Another patient, Sergio Taylor, 23, died after suffocating himself with a plastic bag in 2009.

Ferrugia spoke to Benge by phone last year, after Taylor suicide.

Benge told Ferrugia he was distraught and said he suspected the staff at the hospital were to blame for not following procedure and conducting the required checks of Taylor.

A coroner found in 2007 that Joshua Garcia, 21, died from numerous health problems due to being overmedicated. His family sued the state hospital and settled last May for more than $223,000.

This week, the state human services department announced an independent review would be conducted of the hospital’s “patient care, supervision and monitoring policies and practices.”

“Recent deaths at the hospital have raised a level of concern in terms of the operations, in terms of patient care, supervision and monitoring that we felt a thorough review is necessary at this point,” said McDonough.

She and others in the department have acknowledged that the CALL7 Investigations into the deaths of Sergio Taylor, Josh Garcia and Troy Geske have been, in part, responsible for the review.


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: