When an untrained employee at St. Aemelian Hospital tried to intervene against the only 13 year old boy the boy died.
The employee had a reputation of using "power" to discipline the children and he had been suspended before. Regardless of that he was allowed to restrain Joshua Ferrarini alone and declined help from a co-worker.
As it was custom in the 1980s there was no prosecution against the employee and the Hospital only received minor discpline actions.
So it took som decades more before things started to improve. Improper use of restraints continued to be a major factor when it came to claim the lives of children in residential care.
Cases like the one with Joshua Ferrari could have ended without his death. Unfortunately the political willpower wasn't existing and it claimed his life in the end.
May he rest in peace.