Copy/paste of my post in the other thread on this incident.
What would possess someone to use a strop (horse collar) with out a crotch strap. (assuming that is what was used here) Any system that relies on active patient participation is doomed to failure as we have seen. We use screamer suits that you can't come out of and have a horse collar for special circumstances, and it has a crotch strap as well. It's not like they're more expensive or harder to use.