Gov. Laura Kelly has ordered the Kansas agency that oversees foster care to investigate the death of a 17-year-old who was restrained face down for more than 30 minutes last fall at a Wichita juvenile intake center after his foster father called begging for help because the teen was hallucinating.

“This situation is tragic, and we must find a way to ensure something like this never happens again,” Kelly said in a written statement calling for the Kansas Department for Children and Families to review the case of Cedric Lofton and see if policies needed to be changed.

Meanwhile, the Sedgwick County Department of Corrections announced Tuesday that it was forming a task force to review what happened. Glenda Martens, the department’s director, said the work would be “painstakingly difficult.”

The developments come one week after Sedgwick County District Attorney Marc Bennett expressed concerns about the handling of Lofton’s case when he announced that he wouldn’t file any criminal charges. He said he struggled with whether an involuntary manslaughter charge was justified, but concluded that the state’s “stand-your-ground” law prevented him from pursuing it because staff members were protecting themselves.

Kelly also said she was looking forward to hearing recommendations from Bennett, the Legislature and advocates on ways to clarify or modify the law.

According to Bennett’s report, Lofton’s mental health got markedly worse after the teen attended his grandmother’s funeral. Lofton’s family expressed concern to the foster father that Cedric “was having either a mental breakdown and, or he was having an onset of schizophrenia.”

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And one of his foster brothers later told investigators that Lofton had complained that there were kids in his class at school that were robots who were trying to kill him, the report said.

At the urging of a case manager with DCCCA, a private foster care agency that contracts with DCF, the foster father drove Lofton to a mental health provider, but he walked away. When Lofton returned home in the pre-dawn hours of on Sept. 24, the case worker told the foster father to not let the teen into the house and to call police.

Bennett wrote in his report: “Whether the State of Kansas should accept a foster care system that responds to a foster father’s expression of concern that his foster son is in mental distress by telling the man, don’t let him in the house and call the police — is a legitimate question. A question, in fact, that may well demand answers.”

DCF spokesman Mike Deines didn’t comment about the investigation but did note that policy stipulates that providers are expected to have staff available, accessible and able to manage a crisis.

Police who arrived at the home spent nearly an hour trying to convince Lofton to go to a hospital for mental health treatment. But Lofton refused, telling officers he was concerned about people trying to kill him, the report said.

When officers tried to escort the 5-foot-10, 135-pound Lofton to the patrol car, Lofton struck and kicked at them, the report said. They ultimately restrained him in something called the WRAP, a device comprised of a locking shoulder harness, leg restraints and ankle straps.

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A sergeant said in an interview that he believed Lofton was too combative to take to the hospital. But at least one officer involved can be heard saying on a body camera recording that he thought the teen should have been taken there and not to the Sedgwick County Juvenile Intake and Assessment Center.

Once at the center, Lofton scuffled with staff after the WRAP restraint was removed. Surveillance video released Friday shows him punching one of the juvenile detention employees in the head.

Bennett’s report said staff shackled Lofton’s ankles and put him on his stomach on the floor. His report said Cedric was “mumbling” at times, repeated that he was Jesus and saying staff should kill themselves and that he would “hex” them. Staff noticed he wasn’t breathing after they called to arrange for Lofton to be taken to a hospital for a mental health evaluation. Paramedics rushed to the scene, but Lofton died two days later.