Staff at a North Carolina wilderness therapy camp failed to check that a 12-year-old boy was breathing during his first night at the facility, a state report released Tuesday found.
The boy, who has been identified in law enforcement records only by his initials, CJH, was found unresponsive around 7:45 a.m. on Feb. 3 at Trails Carolina, a camp for troubled adolescents in the western part of the state.
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.
A “statement of deficiencies” report from the North Carolina Department of Health and Human Services concluded that staff failed to provide proper supervision of CJH, who was physically healthy when he arrived on the afternoon of Feb. 2.
Trails Carolina did not immediately respond to questions about the bivy or other findings in the state’s report. A Trails Carolina spokesperson previously said it uses the “tent-like weather-proof covers to support the psychological and emotional well being” of the children.
In a “plan of correction” included in the report, the camp said the state had previously approved the sleeping arrangements used for the children. The state did not respond to questions about its regulation of the sleeping arrangements or whether it plans to change any rules.
The medical examiner’s report is still pending, the report said, but preliminary results indicated the boy’s death was unnatural. A spokesperson for Trails Carolina has said the death appeared to be accidental.
The state health department has suspended admissions to Trails Carolina and said last month it plans to revoke the camp’s license, which would force it to close; it also fined the program $18,000. Trails Carolina submitted a plan of correction this month, detailing how it will comply with state regulations laid out in the report so it can keep its license. The department has not yet made a final determination about the camp’s license.
Founded in 2008, Trails Carolina is a for-profit wilderness camp that treats children with diagnoses such as autism, ADHD, bipolar and post-traumatic stress disorders, as well as those struggling with depression or unruly behavior.
The report offers new details on the death that led the state to order the removal of all children from the camp in mid-February.
Trails Carolina routinely placed children in a sealed bivy with an alarm on the zipper overnight when they first arrived, until a therapist deemed they were safe to sleep without one, but therapists and the executive director at the camp were unfamiliar with the bivy sleeping arrangements, the report found. Two parents told the state inspectors they did not know children were required to sleep in a bivy. The camp had previously required children to sleep in a “burrito” — in which they were zipped into their sleeping bag and then covered with a tarp — but told NBC News it changed to the bivy system last year.
The department’s licensing inspectors concluded that the sleeping arrangements did not provide “dignity or respect” to children, violating state regulations. The state also determined that Trails Carolina had failed to properly document medication disbursement and violated clients’ rights by restricting the campers’ communication with their parents and screening all incoming and outgoing mail.
The boy who died had asked to call his mother shortly after he arrived, but was not allowed to do so under the camp’s policies, according to the report.
Trails Carolina responded to the state within the report by arguing that allowing students to receive mail that camp staff had not read “could potentially provide harm” to the children. The camp said it would address medication management problems with improved documentation and communication protocols, noting that sometimes it has had problems reaching parents to discuss children’s prescriptions.
According to the report, a staff member told law enforcement that he’d heard CJH “breathing heavily” around 3 a.m., but “couldn’t physically see the inside of bivy because it wasn’t clear.” The staff member, who is unnamed in the report, said they later heard mumbling and “shallower breathing” from the direction of the bivy, and were unsure if it was from CJH or another employee.
Trails Carolina conducted an internal investigation into the death. It declined to share the details with the state health department, according to the report.
A law enforcement investigation led by the Transylvania County Sheriff’s Office is ongoing.
This article was originally published on NBCNews.com