A 17-year-old special-education student's death at a Prince George's County school came after staffers used a questionable restraint technique and failed to administer medical aid for as long as 20 minutes, an advocacy group for the disabled contends in a new report.

Carlton Eugene Thomas died May 14 last year at Edgemeade-Raymond A. Rogers Jr. School in Upper Marlboro. Thomas suffered a fatal asthma attack triggered when a school staff member held him to the floor after the student refused an order to go outside, according to a state medical examiner's report.

In investigating the death, the Maryland Disability Law Center found that staffers ignored alternative techniques found in Thomas' file that outlined how to deal with bad behavior, instead pinning him face down in a manner that led to his death.

State and school officials disputed aspects of the report yesterday, pointing to the fact that Ronald Washington, the staff member who held Thomas down, was acquitted in June of manslaughter and child abuse charges by a Prince George's County jury.

Thomas' mother, Sheila H. Bracey, has filed a wrongful death lawsuit against the school.

No one attempted to give Thomas asthma medication as he gasped for air and pleaded for help, according to the report. And no one attempted cardiopulmonary resuscitation until a nurse arrived, though all staffers were required to be trained how to perform it, the report said.

"Staff wasted critical minutes while [Thomas] lay restrained and dying, debating among themselves whether [he] was 'faking' before calling for medical intervention," it said.

'Should be ashamed'

Lauren Young, legal director for the advocacy group, said she hopes to meet with state officials about the case.

"They've failed here, and they should be ashamed," she said.

Officials at the school referred questions about the report yesterday to chief financial officer Ronald DeCarlo.

DeCarlo said he had not read the report and could not comment on many aspects of it, but he said staffers did perform CPR before the nurse arrived.

He said the altercation with Thomas qualified as an "emergency" situation -- the only time staffers are to use the face-down hold -- because several other students had entered the fray.

Since Thomas' death, the school, which is run by a nonprofit organization, has increased training in restraining holds and "de-escalation" techniques to defuse confrontations, DeCarlo said.

The report criticized a review of the death by the state Office of Health Care Quality, which it said failed to address problems with the use of restraint and the slow response to Thomas' distress. That investigation, closed before the medical examiner ruled the death a homicide, has not been made public, though an executive summary has been.

Carol Benner, head of the Office of Health Care Quality, defended yesterday the completeness of her investigation.

"This is certainly a tragic incident," she said. "It's never nice when anything like this happens. In our point of view, we didn't see where this could have been foreseen, and we did not find any regulatory violations."

The face-down hold

The state Developmental Disabilities Administration banned the use of the face-down hold after the death of a 30-year-old man at Rosewood, a state-run facility in Owings Mills for brain-injured patients, in 2000. He had been restrained in a similar way. But the Mental Hygiene Administration -- a sister state agency that regulates schools like Edgemeade -- still allows it, the advocacy group reported.

Brian Hepburn, acting state mental hygiene director, said his agency is open to evaluating whether the face-down restraint should be allowed. But because Edgemeade is a private facility, it would take a change in state regulations to prohibit the restraint, he said.

"We'll work with [the law center] on this," Hepburn said. "What we'll need to do is take a look at it."