State orders mental health facility to halt new admissions after patient death

Records show staff used controversial prone restraint on patient who later died at Ibis Healthcare in Tampa

Apr. 14, 2026 at 9:54pm

Got story updates? Submit your updates here. ›

Florida's Agency for Health Care Administration (AHCA) is investigating a Tampa mental health care facility, Ibis Healthcare, after a patient died in their care. Records show staff used a controversial prone restraint technique on the patient, who stopped breathing after six staff members held him face-down. The state has issued an emergency moratorium blocking Ibis from admitting any new patients while the investigation is ongoing.

Why it matters

The use of prone restraints, where a person is held face-down, has been criticized as potentially deadly, especially for individuals with mental health issues. This incident raises concerns about staff training, policies, and oversight at mental health facilities in Florida.

The details

According to documents obtained by 10 Investigates, a man diagnosed with schizophrenia was admitted to the 30-bed Ibis Healthcare facility on March 8. On March 19, the man became agitated while waiting to see his parents and threw a plastic hamper. Six behavioral health technicians then moved him into a seclusion room and held him face-down as he said 'I can't breathe.' Records show a tech heard raspy breathing but did not report it to a nurse. The nurse later injected the man with medication, and he went limp. Staff checked on him but did not start CPR for 17 minutes. He was pronounced dead less than an hour after the restraint began.

  • The man was admitted to Ibis Healthcare on March 8, 2026.
  • The incident occurred on March 19, 2026.
  • AHCA investigators arrived at the facility three weeks after the incident.

The players

Ibis Healthcare

A 30-bed mental health care facility in Tampa, Florida that is under investigation by the state's Agency for Health Care Administration (AHCA).

AHCA

Florida's Agency for Health Care Administration, the state agency investigating the incident at Ibis Healthcare.

Seth Stoughton

A professor at the University of South Carolina School of Law who teaches criminology and criminal justice, and is an expert on prone restraint techniques.

Got photos? Submit your photos here. ›

What they’re saying

“I have a couple of immediate questions. The first question is, how long was this individual being held in this prone position while restrained? The second question relates to the two people who are described as being on the individual's back, and particularly the individual on the upper back. I need to know where exactly that individual was on the upper back and how much weight they were putting down on the person.”

— Seth Stoughton, Professor, University of South Carolina School of Law

“If they're putting weight down on the diaphragm, it makes respiration, the act of breathing in and out, much more difficult.”

— Seth Stoughton, Professor, University of South Carolina School of Law

“The idea of putting someone in this prone position and holding them there, and then medicating them and then leaving them there, I just can't begin to justify that series of events.”

— Seth Stoughton, Professor, University of South Carolina School of Law

“I cannot begin to justify why anyone would leave someone apparently unconscious, face down and unmonitored for any prolonged period of time. That's inexplicable.”

— Seth Stoughton, Professor, University of South Carolina School of Law

What’s next

State investigators are continuing their review of the incident, and Ibis Healthcare says it is taking 'appropriate personnel actions' as part of its internal review. The facility is working to resume admissions as soon as possible.

The takeaway

This tragic incident highlights the need for greater oversight and accountability at mental health facilities, as well as the dangers of using controversial restraint techniques that can potentially compromise a patient's ability to breathe. It raises serious questions about staff training, policies, and the overall quality of care provided to vulnerable individuals.