A 17-year-old ward of the D.C. government died in April while being restrained at a Texas residential treatment facility because the staff lacked adequate training to administer a physical hold safely, according to a report issued by a Texas grand jury.

Although the grand jury did not return indictments after hearing evidence in the case, it took the unusual action of issuing a three-page report aimed at ensuring that "this tragedy not be repeated here or elsewhere," according to the report.

Diane Harris had been in the $195-a-day Seguin Community Living Center in Seguin, Tex., for 12 days when staff members used a so-called five-man basket hold to prevent her from hurting herself and others, according to a center administrator. Harris had become "assaultive and combative" and the staff was trying to calm her down and return her to her room, Craig Ward, the center's administrator, said shortly after her death.

The center treats people suffering from emotional illnesses, mental retardation and physical handicaps.

Harris was one of 300 District youths placed in residential facilities throughout the country at an annual cost of $25 million. She is the first city ward to die in a facility outside the District since it began using such programs a decade ago.

The grand jury report, issued on Thursday, concluded that Harris "should not have died" and characterized her death as "bizarre."

"In this case, the hold was held for the maximum time permissible by policy, even though for at least half this time, the patient was unconscious and probably dead or dying, according to the pathologists," the report stated. "The hold was maintained even though Diane Harris had cried out in distress and had physical signs which should have indicated to staff that she was not breathing properly."

Ward, who conducted his own investigation, disagreed with the grand jury findings, saying, "In our opinion, the training is not an issue."

Nevertheless, the grand jury concluded that none of the five persons administering the hold had been adequately trained in CPR, in recognizing signs of distress or in the proper way to apply the hold. Although the restraining technique was routinely used with the knowledge and consent of the center's management, it was not approved under the center's policies, according to the report.

In Harris's case, the center's only medical professional on the premises was not involved "in any meaningful way" in supervising the hold, the report stated.

Ward has said the restraining technique used on Harris involved five people: two holding the person's arms, one holding the midsection, another holding the feet and a fifth "monitoring at the person's head."

The grand jury found that the fifth person holds the patient's head between his knees and is in a position to "apply excessive force" by adding weight and strength to the pulling of the patient's right arm.

Consequently, Harris's death, the grand jury found, appeared to have been caused by her excited state and "excessive force inadvertently applied to her right arm," causing her right arm and shoulder to be pulled so as to constrict her carotid artery and her airway.

Texas District Attorney W.C. Kirkendall, whose 25th Judicial District includes Guadalupe County and Seguin, said he agreed with the grand jury decision not to return indictments. He said that only two charges, involuntary manslaughter or criminally negligent homicide, could have been brought and that the circumstances would not have provided a strong case to support either charge.

During his six years in office, Kirkendall said, he cannot recall a single time when a grand jury took the unusual step of issuing a report in a case where there were no indictments.

The nature of Harris's death is all that has been made public about her. Officials for the D.C. mental health commission, which recently assumed the responsibility for placing and monitoring children in facilities outside the city, would not comment on how long Harris had been in the system or why she was a District ward.

Mental Health Commissioner Robert A. Washington ordered his own investigation after Harris's death. Although his findings were never made public, three other District wards were removed from the Seguin Community Living Center and returned to Washington as a result of the investigation.

The Seguin center administrator, Ward, said that 11 members of his staff who had cared for the D.C. patients were dismissed because there was no longer enough work for them to do. No one had been disciplined in connection with Harris's death, he said.

Although Washington had not seen the grand jury report, he said he was not surprised by the findings. "I am glad we brought the other children back to the city and glad that the city is supportive of our efforts to locate more children closer to home."

The District had used the Seguin facility for three years before Harris's death and had had no complaints about the center's services, according to city officials.