"It does not appear to have been an unsafe method of restraining her"
It was the understatement of the year in 1999.
The 16 year old Kristal Mayon-Ceniceros returned from lunch at the New Alternatives residential care facility. She found someone at her work desk and became upset. The staff tried to calm her down and decided to restrain her. It led to her death.
We don't know why she was sent there for treatment but for some persons suffering from mental illnesses like autism everything must be in place. Small changes can upset them. They have to be given tool to deal with changes and while they are learning these tools only minor chances must take place.
Something went wrong with her treatment plan. And as descriped above the restraint method turned out to be a killer.
She was basically failed two times. May she rest in peace.