NC - 12-year-old dies at Trails Carolina wilderness therapy camp, Lake Toxaway, February 2024

[tlcya]

It is tragic and negligence. This place needs to never be opened again, and I do not think it will be considering their having doubled down on the "nothing to see here, we've done nothing wrong" BS.

What worries me is that there will likely be a replacement camp within a week. It is just so very wrong.

 

[Simply Southern]

I read the entire 88 pages, twice. I am NOT defending this facility. I am stating my opinion. I'll go in order of the report.

*Major problems with physician orders (reorders for medication). Industry wide problem. Pharmacy/facilities send initial and reorders, physician offices slow to respond, require an in person visit to renew.
Families using out of state physicians, out of state pharmacies and dependant on insurance reimbursement. Takes the facility out of control, of acquiring medicine. Some medications are not covered by certain insurance plans, or require extensive physician chart notes(most don't have) as to why other medications are ineffective. Very time consuming, some physicians will not switch medications, some will not provide chart notes to insurance companies. This is a ongoing battle in all medical, mental Health, impatient as well as outpatient facilities. The State signed off on facilities policy and procedures for trying to acquire medication, due to physician, family, and or insurance restrictions.

*MARS errors, requires intense daily review, a weak link in most facilities, greater than a few clients. MOO... Most facilities fail to provide manpower and appropriate time for a daily review. This facility clearly lacks MARS oversight.
MOO.. facilities need to bite the bullet, and hire an RN a few hours a month, to review/audit MARS.


*Yes, the facility is in disagreement with the state on AP procall, the state did sign off and approve this process/policy, via written document. State has NOT retracted in writing, until the death occured.

*Access 24/7 to contact family via phone. Yes, the law states this, however, most all mental Health facilities limit outside contact the first 3 days and at times more frequently. MOO..kids would be calling any and all family begging to come home, rather than focusing on treatment. Limiting contact usually covered in the admission agreement, signed by the responsible party. State was/is aware this was the policy of the facility and not sighted as a violation previously.


** The facility is in disagreement, with the pathologist count of medication for the deceased client. The facility notes the count of medication by staff, LE and the ME do not match the count provided from pathologist.
Not sure what's going on here, but the LE/ME count should match the pathologist count. I would assume, the medication was collected and counted as evidence by LE and ME and signed off on by staff member, LE and ME and placed in an evidence bag.
Interesting....

The above is my opinion, and is NOT to state facility is blameless. It is merely meant to show the discrepancies between the state and the facility. I assume these will be presented and a court of law, and determined by judge. If in fact the facility is in possession of letters, documents approving the above, the state's going to have a hard time explaining why they previously approved the referenced procedures/policies. Moo

 

[tlcya]

@Simply Southern curious to read your thoughts specifically on the bivy, it's busted zipper, the use of a zip tie instead, and most importantly the lack of night checks on the deceased client (per the camp's own stated policy)

You say that the state did sign off on the AP protocol, have you seen evidence of this or are you simply stating what the facility claims about that?

 

[ChatteringBirds]

Imagine if a parent forced their child to sleep this way and the child died. No one would believe it was legal and an accident and that they shouldn't be charged with a crime.

Was this an example of the age-old problem -- good people doing something horrible because someone in a position of power told them it was okay?

 

[Izzylizzy]

Suffocation is being said as a possibility.
But he wasn't alone in the cabin there were 3-4 other boys,
Was he able to call for help?

We don't know what the other boys in the cabin with him told LE.
IIRC: They were between 8-10 yrs old.

Waiting on the autopsy report and asphyxiation caused by being over medicated or being given a camp non-prescribed mediation is top on my list.

 

[Simply Southern]

@Simply Southern curious to read your thoughts specifically on the bivy, it's busted zipper, the use of a zip tie instead, and most importantly the lack of night checks on the deceased client (per the camp's own stated policy)

You say that the state did sign off on the AP protocol, have you seen evidence of this or are you simply stating what the facility claims about that?

Moo.. I feel the facility will be liable for use of faulty equipment. Never, never should anyone alter any device, product, or drug.

Under the FDA, it is a federal crime, to alter any medical device or drug, can and does result in prison time.
However, the bivy it's not classified as a medical device under the FDA, so that rule would not apply.

I do think the staff, did not follow the facility policy/protocol for a visual inspection. I do believe that this delayed discovery, but may not have caused the death.
Reading from the portions that are not redacted for "DC1", I do you see he was found feet first, with his head at the bottom of the sleeping bag. It is noted, early DC1 was removed from the bivy earlier and fell asleep on the counselor's mattress. He was awakened and returned to the bivy, no time was noted. It appears the checks were done, without visual contact with DC1, at the time stated in their policy. It was noted, a counselor was sleeping at DC1 head.

....
I checked all available (2019) surveys. Absolutely no mention of bivy in deficiencies.
The current (2024 at time of death) survey, states the facility has written documentation approving. Moo.. I highly doubt, especially given the circumstances of a death, the owner would make the statement without written back up. I know I certainly wouldn't, falsifying information in a governmental investigation is a serious offense.
...moo... When facilities make changes or provide new products, usually State inspectors are consulted, not only verbally but in writing. This would be prior to use and not contained in a survey, unless non-compliant. Facilities are generally not going to invest in a product or appliance without prior approval, due to investment cost. These decisions are usually made on an upper management level , and in direct communication with the state.
I don't know if they in fact have a written approval.

Moo

 

[Simply Southern]

Suffocation is being said as a possibility.
But he wasn't alone in the cabin there were 3-4 other boys,
Was he able to call for help?

We don't know what the other boys in the cabin with him told LE.
IIRC: They were between 8-10 yrs old.

Waiting on the autopsy report and asphyxiation caused by being over medicated or being given a camp non-prescribed mediation is top on my list.

DC1 had a counselor sleeping at his head. At some point, he was removed from the bivy and fell asleep on the counselors mattress and returned. I would assume, all he had to do was call out or yell for assistance.

If you read the report, the campers in his cabin we're interviewing by LE, with their parent present. There was never a mention that DC1 called for help.

Now I do agree, there may be a non physician prescribed substance noted during the autopsy. I do not believe that Trials does Not perform a body cavity search. It was noted in the initial report, DC1 was found with no underwear on, located at the head of the bivy.

 

[Izzylizzy]

Imagine if a parent forced their child to sleep this way and the child died. No one would believe it was legal and an accident and that they shouldn't be charged with a crime.

Was this an example of the age-old problem -- good people doing something horrible because someone in a position of power told them it was okay?

BBM:
I think it comes down to people of all ages, educated in the field or not, be given authority and power when they shouldn't have it.
Problem is you usually don't know how they handle it until its given to them.

I always go back to thinking about when I was in my early 20s and was a waitress in a somewhat upscale resturant, good food, great tips with a well run kitchen.

All of the waitstaff/chefs/cooks got a long quite well including the gal who would always flirt with the manager.
He was much older then all of us and became infatuated with her.
She was about 25.
One day he informs us all that so and so was now going to be head waitress.
She wasn't even considered an exceptional server.
Before this he had done all the scheduling, taken care of any issues, etc.
She did a 180 and became an authoritarian witch overnight, everything had to be done her way and she would constantly run to the manager with complaints about all of us.
So now that happy waitstaff was miserable and taking behind her back and we had a manager who we no longer liked or respected.
It's a dumb, non-dangerous example of what power can do to a person but it has always remained with me.

 

[tlcya]

Moo.. I feel the facility will be liable for use of faulty equipment. Never, never should anyone alter any device, product, or drug.

Under the FDA, it is a federal crime, to alter any medical device or drug, can and does result in prison time.
However, the bivy it's not classified as a medical device under the FDA, so that rule would not apply.

I do think the staff, did not follow the facility policy/protocol for a visual inspection. I do believe that this delayed discovery, but may not have caused the death.
Reading from the portions that are not redacted for "DC1", I do you see he was found feet first, with his head at the bottom of the sleeping bag. It is noted, early DC1 was removed from the bivy earlier and fell asleep on the counselor's mattress. He was awakened and returned to the bivy, no time was noted. It appears the checks were done, without visual contact with DC1, at the time stated in their policy. It was noted, a counselor was sleeping at DC1 head.

....
I checked all available (2019) surveys. Absolutely no mention of bivy in deficiencies.
The current (2024 at time of death) survey, states the facility has written documentation approving. Moo.. I highly doubt, especially given the circumstances of a death, the owner would make the statement without written back up. I know I certainly wouldn't, falsifying information in a governmental investigation is a serious offense.
...moo... When facilities make changes or provide new products, usually State inspectors are consulted, not only verbally but in writing. This would be prior to use and not contained in a survey, unless non-compliant. Facilities are generally not going to invest in a product or appliance without prior approval, due to investment cost. These decisions are usually made on an upper management level , and in direct communication with the state.
I don't know if they in fact have a written approval.

Moo

Thank you. While you and I do not seem to share a POV on this case, I do appreciate your taking the time to respond with your thoughts.

I note the report also made mention of an informal conference that was planned between facility and state for 4/23/24. I look forward to learning more and hope the press continue to keep us updated.

ETA by not sharing POV I mean that you are much more willing to give the camp the benefit of the doubt while I am horrified such places exist at all.

 

[Simply Southern]

Moo... What I think is a high possibility.

DC1 was found with no underwear on his body. He was found with his head at the foot of the sleeping bivy and his feet were sticking out. It is noted he had on a red hoodie.
<modsnip - not victim friendly>

I do not believe any member of Trails intentionally harm DC1. I do believe the protocol of check every three hours was insufficient in this situation. I don't think the bivy is a good idea, in hindsight, but was approved by the state.

It was noted in the state report, staff had a hard time understanding how he was able to turn around and place his head at the foot of the bivy, it was a tight space.

Moo

 

[tlcya]

<modsnip - quoted post was snipped>

I think it is much more likely that the kid had a panic attack while in the close quarters of the bivy and was attempting to get out of it but couldn't because it was ziptied shut while he was boxed in between two walls a bunk and a person much more likely. So he turned himself about in there attempting to find a week spot or other opening and suffocated in the process. Others mileage will of course vary.

 

[MsMarple]

<modsnip - quoted post was snipped>

Just my own opinion. I’m not impressed with the staff’s behavior that night from the information released so far.
MOO

 

[Simply Southern]

<modsnip - quoted post was snipped>

I think it is much more likely that the kid had a panic attack while in the close quarters of the bivy and was attempting to get out of it but couldn't because it was ziptied shut while he was boxed in between two walls a bunk and a person much more likely. So he turned himself about in there attempting to find a week spot or other opening and suffocated in the process. Others mileage will of course vary.

I agree, this is clearly another possibility.

 

[BeginnerSleuther]

I read the entire 88 pages, twice. I am NOT defending this facility. I am stating my opinion. I'll go in order of the report.

*Major problems with physician orders (reorders for medication). Industry wide problem. Pharmacy/facilities send initial and reorders, physician offices slow to respond, require an in person visit to renew.
Families using out of state physicians, out of state pharmacies and dependant on insurance reimbursement. Takes the facility out of control, of acquiring medicine. Some medications are not covered by certain insurance plans, or require extensive physician chart notes(most don't have) as to why other medications are ineffective. Very time consuming, some physicians will not switch medications, some will not provide chart notes to insurance companies. This is a ongoing battle in all medical, mental Health, impatient as well as outpatient facilities. The State signed off on facilities policy and procedures for trying to acquire medication, due to physician, family, and or insurance restrictions.

The above is absolutely untrue or at least a wild exaggeration of fact IME. No, this isn't an ongoing battle in all medical and mental health treatment. It absolutely, positively is not. Medication orders are medication orders. If the patient has been seen, then the prescriber can prescribe for at least a year without seeing the patient again unless under very extraordinary circumstances or for controlled substances.

*Access 24/7 to contact family via phone. Yes, the law states this, however, most all mental Health facilities limit outside contact the first 3 days and at times more frequently. MOO..

If this "camp" wants to compare itself to a legit mental health facility rather than a child abuse murdering mill (JMO), then they need to follow other restrictions mental health facilities have too, such as limitations on physical restraints and very clear protocol on safe restraints. They don't get to pick and choose when to compare themselves to a mental health facility.

 

[j_in_c]

As someone who owns an actual bivvy sack and has used it for its intended purpose of keeping oneself dry when sleeping outdoors, there is no real manufacturer use case for using one as a restraint! The idea of being purposefully trapped in one sounds terrifying and I'm once again saddened that adventure equipment was being used in such a manner. I would not be surprised if kids who were forced into this so called burrito will never feel comfortable using a sleeping bag

 

[MsMarple]

As someone who owns an actual bivvy sack and has used it for its intended purpose of keeping oneself dry when sleeping outdoors, there is no real manufacturer use case for using one as a restraint! The idea of being purposefully trapped in one sounds terrifying and I'm once again saddened that adventure equipment was being used in such a manner. I would not be surprised if kids who were forced into this so called burrito will never feel comfortable using a sleeping bag

Just reading about burritos and bivvys aggravates my asthma. I can’t begin to imagine the desperation the boy felt being restrained and smothered in layers of material. Gosh it’s enough for me to reach for my inhaler! How could they?

 

[Izzylizzy]

Moo.. I feel the facility will be liable for use of faulty equipment. Never, never should anyone alter any device, product, or drug.

Under the FDA, it is a federal crime, to alter any medical device or drug, can and does result in prison time.
However, the bivy it's not classified as a medical device under the FDA, so that rule would not apply.

I do think the staff, did not follow the facility policy/protocol for a visual inspection. I do believe that this delayed discovery, but may not have caused the death.
Reading from the portions that are not redacted for "DC1", I do you see he was found feet first, with his head at the bottom of the sleeping bag. It is noted, early DC1 was removed from the bivy earlier and fell asleep on the counselor's mattress. He was awakened and returned to the bivy, no time was noted. It appears the checks were done, without visual contact with DC1, at the time stated in their policy. It was noted, a counselor was sleeping at DC1 head.

....
I checked all available (2019) surveys. Absolutely no mention of bivy in deficiencies.
The current (2024 at time of death) survey, states the facility has written documentation approving. Moo.. I highly doubt, especially given the circumstances of a death, the owner would make the statement without written back up. I know I certainly wouldn't, falsifying information in a governmental investigation is a serious offense.
...moo... When facilities make changes or provide new products, usually State inspectors are consulted, not only verbally but in writing. This would be prior to use and not contained in a survey, unless non-compliant. Facilities are generally not going to invest in a product or appliance without prior approval, due to investment cost. These decisions are usually made on an upper management level , and in direct communication with the state.
I don't know if they in fact have a written approval.

Moo

I would like to know more about the overnight staff.
Qualifications for handling medical emergencies, access to medications and qualifications to dispense it?
IMO:
They obviously lacked training on the use and safety of the bivies.
Probably low-level staff that would do the overnight shifts that the higher ups wouldn't even consider.
The founder ( forgot her name) has distanced herself from Bivy sac knowledge and use at the camp.
IMO:
I can see felony charges coming in from the top down and criminal negligent homicide wouldn't surprise me.

 

[Izzylizzy]

How awful! From the link;

He had been required to sleep in a tubelike tent, known as a bivy, enclosed by a solid plastic sheet. Upon discovering that CJH’s bivy’s zipper was broken, the report says, “staff needed a zip tie out of the tool bag,” though it doesn’t specify how the zip tie was used.

A staff member told law enforcement that they believed the sleeping arrangements “had a lot to do with” the boy’s death, according to the report, and that “suffocation is always possible if the equipment is being used wrong.” Another staff member, also unnamed, told law enforcement he believed CJH suffocated and that the camp was responsible for the death, the report stated.

There's the FBI investigation and they don't comment.
Hopefully they're still involved.

imo:

It's ironic that the same state health dept that was responsible for inspecting Trails for violations that endanger children's lives now comes up with a list that is reprehensible.
Had the young boy not died it would most likely still be business as usual at Trails.

 

[STAGNUM]

Lots of terrible Google reviews. This place costs many 10's of thousands of dollars $600-$100 a day, 75-96 days. They censor mail in and out, keep kids and parents incommunicado. Trails Carolina - Google Search

 

[Izzylizzy]

The Director of Operations did not find out about CJH's death until 3pm
page 42