KALAMAZOO, Mich. (WOOD) — An investigation into the death of Cornelius Fredericks found not only that several staff members held the teen down during an improper restraint, but any justified physical altercation also would not have been consistent with his treatment plan.

News 8 obtained the special investigation report (SIR) from the Michigan Department of Health and Human Services. A licensing consultant with the child welfare licensing division sent the 62-page document to Lakeside Academy on June 17, a day before the state confirmed it would suspend the Kalamazoo facility’s license.

The 16-year-old died at the hospital on May 1, two days after going into cardiac arrest due to being restrained.

According to the state’s findings, a staff member pushed Fredericks out of his seat in the cafeteria April 29 after he threw food and did not comply with orders to stop. He is listed as “resident A” in the report narrative.

“The actions of Staff 1, to push Resident A out of his seat and initiate a restraint were significantly disproportionate to the behavior of Resident A throwing bread, and were initiated without notification to or consultation with a supervisor or coordinator, program director, or nurse as required by the agency’s policy,” the findings state.

One staff member interviewed said Fredericks was combative prior to lunch and was “making threats to staff and students, and had pulled the keys off of Staff 1’s neck and thrown them across the room” once in the cafeteria.

“Staff 2 said that this incident with Resident A began on the dorm when Resident A was trying to fight a peer. Staff deescalated Resident A and the group went to lunch while Resident A stayed back with Staff 4, who later brought Resident A to the cafeteria,” the report said.

Despite that behavior, the state found staff violated policy, including that, “The restraint was not performed in a manner consistent with Resident A’s treatment plan, which outlines anger management needs, and Resident A being triggered when antagonized or people putting their hands on him, and history of abuse. The staff techniques outlined in the plan call for staff to help Resident A utilize anger management and coping skills, encourage Resident A’s appropriate interactions, and reinforce positive self-talk, however these were not used.”

The report confirms statements made by attorneys Monday after filing a lawsuit on behalf of Fredericks’ estate. But it also paints a clearer picture of what happened as Fredericks was on the ground.

“Multiple staff participated in this restraint and several were observed on the video with their weight on Resident A’s chest, abdomen, and legs, making this an unsafe and excessive restraint,” the report said.

The restraint itself lasted about 12 minutes, according to the state’s review of video inside the cafeteria. That’s two minutes longer than an acceptable practice for justified restraints, according to the investigation, which do not include putting body weight on the person being held down.

“At most times there were six to seven male staff on Resident A,” the investigation found, after first pointing out an acceptable hold would only include two or three people.

Investigative notes also point out the weight of three staff members involved in holding Fredericks down, weighing a collective 825 pounds.

After the 12 minutes on top of the teen, employees congregated around him noted Fredericks went limp after attempts to bring him to his feet. One nurse noted he began foaming from his mouth and nose.

“The video showed Resident A fall slowly over to his right side and roll onto his back apparently unconscious. There are seven to eight staff standing near and looking at Resident A, including Nurse 1 and Supervisor 1. Supervisor 1 bends over and taps/touches Resident A. The other staff begin touching/tapping Resident A. Director 4 arrives in the area. The staff and Nurse 1 are still standing near Resident A. Approximately five and a half minutes after release, Nurse 1 takes Resident A by the right hand momentarily and releases it,” the narrative described from the video.

The report states some of those involved thought Fredericks was “playing” when he stopped moving. One even poured water on his face.

It’s not entirely clear in the report if those attitudes contributed to a 12-minute delay in calling 911 or beginning CPR, but the state noted 10 people — seven staff members, two supervisors and one nurse — involved in the incident failed their job responsibilities for not getting him medical attention sooner.

Those same 10 people were fired by the facility.

The state’s report noted seven of those people either declined to participate or could not be reached for the investigation — five staff members, the nurse and one of the supervisors.