A 15-year-old patient at a Northern Virginia mental health facility who died after police say he was restrained had been agitated by bullying and was punching walls before staff stepped in, according to details in an internal facility report.
"It's heartbreaking because he didn't have to, he didn't deserve that . . . he didn't deserve the way he died," said Kinnisha Flemming, 35, of her son, Jeremiah.
"Jeremiah, he's an easy kid. All you had to do was talk him down. It didn't need to go that far,' " she said of her son's death in November while he was a resident at North Spring Behavioral Healthcare in Leesburg.
William P. Herndon, a mental health technician at North Spring at the time, was arrested Jan. 16 on charges of involuntary manslaughter after the state medical examiner concluded that the teenage patient he allegedly restrained died of positional asphyxiation.
The center and police have not publicly named the teen, but Flemming confirmed it was her son and provided a copy of an internal incident report that also names Jeremiah. In the report, it is not clear exactly how Jeremiah was restrained or how many employees were involved.
His mother said she agreed to speak out because she wants people to know what happened to the boy from Norfolk who liked playing basketball and dancing, wanted to play football and wrote a few songs because he hoped to be a rapper. Jeremiah was part of a North Spring program for children with serious emotional issues.
The center remains open, but admissions for children's residential services were halted the day after the incident that led to Jeremiah's death amid an ongoing investigation of the 87-bed program by state regulators. North Spring is one of 10 Universal Health Services facilities licensed in Virginia, according to Dev Nair, the assistant commissioner for the Quality Management and Development unit of the state Department of Behavioral Health and Developmental Services.
Herndon's attorney, Todd Sanders, declined to comment because the case is pending. Herndon, 47, of Martinsburg, W.Va., was released on bond from the Loudoun County Adult Detention Center.
In a prepared statement, North Spring CEO David Winters called the teen's death a "sad, unexpected event" and said the facility is cooperating with the investigation. Winters's statement said the employee, whom he did not name, had been placed on administrative leave after the incident.
"North Spring prides itself on providing high quality behavioral health and residential treatment to patients facing serious psychiatric illnesses who come to our facility during some of the most difficult periods of their lives," according to the facility's statements.
Winters declined to answer specific questions about Herndon's employment or Jeremiah's stay.
Almost all of the children accepted into North Spring's residential program are referred from state and county agencies or school systems, Winters said in an email. A children's residential facility offers 24-hour supervised care for issues with mental health or substance abuse, and academic studies, Nair said.
During 2017, state records show, North Spring said it terminated employees involved in three physical run-ins with patients, all confirmed by video. Staffers pushed a patient into a wall in one incident, stepped on a patient's head in another and used restraints unnecessarily in the third, according to facility reports to state regulators between January and early December 2017.
A fourth event — in which a patient with a severe nut allergy was given cookies with nuts and had to be taken to an emergency room — also was reported to state regulators.
State records show no other death at the facility in records that go back to 2010, Nair said.
Jeremiah had been at North Spring for less than a week, according to his mother, who said he had been at another facility for about a year and a half. Her son, she said, "had aggression" and called her the week he was admitted at North Spring to say he was being bullied and ready to leave.
Before his transfer, Flemming said, Jeremiah's grades had been improving, he was calling home more often, and his relationship with his now-14-year-old sister had improved.
On the afternoon of his death, the internal facility report states that a peer was bullying and trying to provoke Jeremiah, who threatened to "fight and kill the peer" and tried to "attack" the person.
Jeremiah was sent to a "cool down room," but once there, he began punching walls and would not stop, according to the incident account. The report refers to "staff" and at least three nurses responding but does not name individuals or clearly state how many were present or how much time elapsed during the encounter in the room. A total of four are listed as witnesses by job title: nursing staff, mental health specialist, shift lead and nurse practitioner.
"After receiving multiple redirections, Jeremiah did not stop and staff initiated a physical restraint," and nurses responded, the report says. Jeremiah and the staff were struggling while he was in a hold because he was "fighting and sliding on the floor in the doorway," according to the report.
The report states, "About 2 minutes into the hold nurse observed that Jeremiah dropped his head down and sounded like he was snoring."
He was released from the hold and was breathing and had a pulse, the report states. "The nurse went to get the smelling salts, but Jeremiah did not respond to it," the report continues.
A nurse "saw scant blood on the end of his nose" as the nurse wiped his face with a cold cloth and Jeremiah's breathing and heart rate continued to be checked, the report states.
A nurse called 911 — the report does not say at what time the call was made — and emergency crews responded, put Jeremiah on a stretcher and took him to a hospital, where he died.
The Loudoun County Sheriff's Office, in a statement announcing the arrest of Herndon, said sheriff's personnel responded at about 3:37 p.m. Nov. 19 to assist on a rescue call.
After Herndon's arrest, the sheriff's office alleged that the "victim lost his life after being restrained by the employee, a Mental Health Technician at the facility."
Nair said the department's "general principle" is that employees should work to de-escalate situations so restraint will not be necessary. "That obviously won't always be done," he said, "but I think the goal is always to try to manage behavior to avoid having to initiate a restraint in the first place."
To become a mental health technician at North Spring, an individual must complete requirements including 75 hours of training and multiple written tests, Winters wrote in an email.
The state records on previous incidents at North Spring show that in August, a staff member was terminated after a shift supervisor reviewed a video of the employee physically restraining a patient and "questioned the need for the restraint feeling the restraint should have been avoided."
In March, a staffer "tried to intimidate" a patient "by putting his foot on the patient's head while he lay on the floor of the timeout room." The act was confirmed in a video and the staffer was terminated, state records show.
Another staffer roughly pushed a patient into a wall in March, which also was confirmed by video and resulted in the employee's termination, according to state records.
Winters did not respond to specific questions about those three previous incidents. He said in a statement that "over the course of treating thousands of patients annually, isolated and regrettable incidents invariably occur."
The statement said the facility demands "accountability from all staff for any actions which may deviate from our policies and values.
Such issues are not unique to North Spring and are commonly experienced by nearly all behavioral health providers treating similar patient populations."
The last time Flemming saw her son was when she dropped him off at North Spring, she said. It's been two months since his death, and she keeps thinking: "It should have never happened.
"I want my son back."