|
System Loses Lives and Trust
By Katherine Boo
Washington Post Staff Writer
Sunday, December 5, 1999; Page A1
Page One of Three
The corpse measured 66 inches from blue toes to jutting ears. In a beige house on Tenley Circle, a dentist-entrepreneur lugged this cargo
down the stairs into the basement and laid it to rest by the washer.
The body in plaid pajamas was that of a 57-year-old retarded ward of
the District of Columbia. On the streets outside the city-funded group
home where he had lived and died, kids sometimes called him Retard-O.
Inside, he sweetened the hours by printing the name his mother gave him
before she gave him up. Frederick Emory Brandenburg. He blanketed old
telephone directories with that name, covered the TV Guides the home's
staffers tossed aside. He glutted the flyleaves of his large-print Living
Bible. The immensity of the effort made his hands shake, but the habit
seemed as requisite as breath. In this way Brandenburg, whose
thick-tongued words were mysteries to many, impressed the fact of his
existence on his world.
In January 1997, that existence was obliterated by his caretakers.
In one of 14 group homes for which the city pays dentist Arthur Stubbs
and his partner, Sheila Gaither, $6 million a year, Brandenburg was
tranquilized in a staff mix-up, grew acutely ill and, surrounded by
caretakers, slowly died without treatment. His body was washed, moved by
Stubbs into the basement, and cremated without autopsy. The White Pages
emblazoned with his name were dispatched to a trash can out back. His
caretakers altered the time and circumstances of his death in records they
submitted to the city, house documents show. Government officials who were
supposed to ensure his safety kept evidence of wrongdoing from the police.
And this summer, after The Washington Post asked questions, Brandenburg's
city case manager shredded records on his death. Today, in the name of the
privacy and dignity of the retarded, top city officials say they can't
publicly acknowledge that a man named Fred Brandenburg was ever in their
care.
This erasure of a life was not an exceptional event in what was
supposed to be America's most compassionate and costly effort to
deinstitutionalize the mentally retarded.
As the 1990s began, a historic reform moved the District's mentally
disabled wards from a large, exurban asylum called Forest Haven into a web
of small, privately run group homes and therapeutic programs in the heart
of the city - programs funded by more than 1 billion public dollars. But
in those intimate settings, a Post investigation has found, corporate
misrepresentation and city complicity have concealed the facts of dozens
of troubling deaths.
In 86 cases from 1993 through September 1999 in which The Post could
ascertain a cause of death, it found documentary evidence in 34 - more
than one-third - of delayed treatment, neglect, falsifications in reports
or other lapses.
Among the dead were:
• Profoundly retarded, elderly Calvin Nielson, fatally scalded in a
home owned by a prominent developer. An aide left him alone in an
overheating shower about which city inspectors had repeatedly complained.
• Herbert Scott, 43, whose decaying corpse was discovered by his
caretakers only when the odor snaked under his door into a hallway.
• Antonio Silva, 16, who choked and died when counselors at his day
program - the same program where 12 months earlier a boy died unattended
in a hallway - couldn't locate paperwork they said they needed in order
to suction his pneumonia-ridden lungs.
• Reginald Lovette, 28, who was strangled by his 250-pound roommate.
For a year, his repeated pleas for protection had been disregarded by the
convicted criminals who served as his group home counselors.
For these four cases, the city's Department of Human Services - the
municipal custodian of D.C.'s retarded wards - produced, in seven months,
exactly one record: a note from the organization that cared for Herbert
Scott saying that his body had been found.
Although DHS officials told The Post earlier this year that many of the
deaths had been investigated, a study of records shows that in the face of
ample evidence of neglect, DHS hasn't investigated a single death of a
retarded person since at least 1993. Only 14 received an autopsy - and six
of those autopsies were left unfinished. Government officials routinely
closed death cases on the basis of phoned-in or brief written accounts by
group home and day-program officials - accounts that, The Post found, were
frequently false.
Today, city records on many of those deaths have vanished. In April,
using the Freedom of Information Act, The Post requested the records of
all retarded persons who died in the city's care since 1993. In June 1999,
DHS released heavily edited records documenting a total of 11 deaths.
Pressed, DHS officials combed files and surveyed group home operators and
by October had documented 69 dead. DHS Director Jearline F. Williams said
last month that she could not explain why there were no records on 47
other deaths found by The Post.
Two days ago, DHS officials turned over death certificates that they
said represented 114 deaths, at least 45 more than they had previously
disclosed. Most of the details on the certificates had been whited out -
giving no indication of who had died, where, how or under whose care.
Among public health researchers, fatalities of wards of the state are
sometimes tagged "sentinel events": Like lifeless canaries in
the pit of the mine shaft, they warn of perils that may await the living.
But the D.C. government has for years resisted inquiry - by the press, by
a federally funded advocacy group and even by the U.S. Department of
Justice - into deaths within its taxpayer-funded network of care.
"We have a sacred trust to ensure the well-being of our most
vulnerable clients," Mayor Anthony A. Williams said in July, after
blind, retarded Patrick Dutch died of heat exhaustion when his caretakers
forgot him for seven hours in a locked and stifling van. But the city's own records reveal a system that, buffered
from public scrutiny, failed that trust.
The Post investigation used District medical examiners' records, DHS
and Department of Public Health documents, funeral home and cemetery
databases, Social Security death records and more than 200 interviews with
retarded people and their caretakers, families and doctors to develop an
accounting of who died and how.
In interviews, top officials of DHS, D.C. police, the health department
and the medical examiner's office did not attempt to defend their
agencies' handling of deaths among the retarded. "The system is
broken," said Jearline Williams in response to The Post's findings.
"The families of the dead have my sympathy, they have the District
government's sympathy."
Williams and other agency heads said that, with the help of the
District's inspector general and the U.S. Department of Health and Human
Services, they were working frantically to initiate structural changes and
investigate abusive contractors and negligent city employees. "We
can't sit back and cover up things," said Williams. "It took a
long time to get to this state, and it is going to take time to fix. But I
promise that there will be radical changes, starting now, to ensure that
those still in the group homes are safe. This will never happen
again."
Some of the city's unrecorded dead lie in a Northeast cemetery:
numbered discs, silted over, in rows by a chain-link fence. Others rest
elsewhere, in unmarked group graves or plastic cartons. A tour of these
shadowlands might begin with Fred Brandenburg. Although his body was
cremated before burial, interviews and extant city records allow an
account of his death to be exhumed.
An Erasing
At Forest Haven, where Brandenburg grew up, a child-size wheelchair is
draped in reindeer moss. A stand of scrub oaks is shrouded in yellow
steam, the off-venting of a nearby juvenile jail. If Brandenburg had died
at this remote Laurel asylum in the final years before its court-ordered
1991 closing, the Justice Department would have sent in medical experts to
find out why. A federal suit filed by residents' families had exposed so
much medical neglect that Justice's civil rights division had joined the
action, investigating every fatality.
But a 1997 death inside a D.C. Family Services house in Tenleytown -
where the court rescue had eventually deposited Brandenburg - would be a
far more secretive affair.
Stubbs, co-owner of D.C. Family Services, told The Post early last
month that he was too busy to answer questions about Brandenburg's death,
or other deaths in his homes, and did not return subsequent phone calls.
His partner, Gaither, who is the company's executive director, also did
not return repeated calls. Last week, Stubbs and Gaither, through their
lawyer, declined to comment.
Employees observe that Stubbs doesn't often visit the 14 homes for the
retarded that had helped him buy his own million-dollar home off Foxhall
Road. But on Jan. 10, 1997, his presence was required.
For two years his company's nursing staff had failed to carry out a
cardiologist's orders for medicating Brandenburg's long-standing heart
condition, health department records show, while improperly medicating one
of his housemates with Valium. On Jan. 8, Brandenburg, who was rarely
sedated, was tranquilized, too. And something went wrong.
That morning, a staff nurse gave him an injection of Ativan without the
required doctor's orders, city records indicate. The nurse did so, group
home records show, in the belief that another staffer would be taking him
to a minor medical test that might frighten him. Brandenburg would not
make it to any test. For the next two days, records show, Brandenburg
couldn't stand without assistance and could barely open his eyes. He
sweated and shook; staffers trying to make him eat saw bread fall from his
lips, unchewed . But group home officials did not call a doctor or dial 911.
Nor did a health department inspector who happened to come to the house
Jan. 8 for an annual survey of the home's quality of care. She found
Brandenburg in a stupor on a back-room couch. The home's records indicate
that staff members sought to hide the extent of his incapacity. They
weren't successful. Over the next two days, records show, the inspector
diligently documented Brandenburg's poor condition - and her discovery
that the staff had lied to her about the circumstances surrounding the
tranquilization. But she left the house without taking action to secure
treatment for him.
Early the next morning, his stupor ended.
House logs and other records say that counselors checked Brandenburg
every 15 or 30 minutes in the early hours of Jan. 10. Then at 5:30 a.m.,
his breathing suddenly grew labored, they said, so they dialed 911.
But ambulance records and staff interviews indicate that paramedics who
arrived four minutes after the 911 call found a body already cold.
Brandenburg had been dead for hours.
Police officers arrived soon after the paramedics, as they do for
sudden deaths in private homes. Officers didn't note the discrepancy
between house logs and a stiff corpse, records show. Nor did they learn of
the tranquilization and the discrepancies surrounding it from health
inspection officials who joined them at the house, records and interviews
indicate. The subsequent police report would instead cite Elliot Gersh, a
pediatrician under contract with the group home company. City records show
that Gersh arrived at the house three hours after the 911 call and told
officers what he would later record on Brandenburg's death certificate:
that the 57-year-old had probably died of heart disease.
Gersh - who had examined Brandenburg the day before the drugging and
described him in medical records as "alert, smiling" and
recovered from a cold - said in an interview that health inspectors and
group home officials hadn't informed him of the two days of sickness
following tranquilization. He filled out the death certificate, he said,
at the request of group home officials.
By law, bodies of those who die unexpectedly in private homes must be
sent to the morgue for examination. To prevent evidence tampering, police
are supposed to guard the body in the home until a medical examiner
arrives. Gersh ordered the autopsy as required. But by noon - many hours
before the pathologist appeared - police officers had departed the scene,
group home records and interviews show.
In the interval, Stubbs appeared. With the help of a house counselor,
group home records show, he moved Brandenburg's body from the scene of
death, his second-floor bedroom, to the basement. At some point after the
death, internal Family Services reports indicate, Brandenburg's body was
washed, for unknown reasons.
"Totally inappropriate," said Chief Medical Examiner Jonathan
L. Arden, who assumed his position last year. He reviewed the case at the
request of The Post. The file was slim: Health inspectors had not passed
on what they knew about the tranquilization and its aftermath. "This
office should have been told," Arden said.
"I am outraged, hearing this," said Ivan C.A. Walks, the new
director of the Department of Public Health, of his inspection unit's
failure to intervene when the oversedation was discovered or to report
what it knew to police after Brandenburg's death. "I can't defend
these actions."
"We're going to have to reopen this investigation," said
Executive Assistant Police Chief Terrance W. Gainer, who also examined
police records at The Post's request.
Reopening the case will be difficult. Brandenburg's body was released
from the morgue and cremated without an autopsy. In an interview earlier
this year, DHS official Frances Bowie, who until recently headed the
department's developmental disabilities unit, explained why: Brandenburg's
two sisters had refused to permit an autopsy. DHS officials said the
sisters, who they said were Jehovah's Witnesses and would not identify,
had religious objections to the practice.
The Post located the sisters. One of them, Gloria Donovan, is a
longtime member of All Saints Catholic Church in Manassas. The other,
Juanita DeButts, worships and teaches Sunday school at the First Baptist
Church of La Plata. "We're not Jehovah's Witnesses, and we were never
asked about an autopsy," said Donovan, whose brother had just spent
the Christmas holidays at her home. "It didn't happen."
Bowie today says she cannot recall the source of her information about
the refused autopsy, and DHS Director Williams acknowledges that agency
officials have no records to support their previous assertions. Williams
also confirmed that this summer, after Post inquiries about the death,
case manager Dwayne Franklin shredded his records on Brandenburg's death.
On Nov. 4, Franklin was fired for the shredding.
In an interview, Franklin, who had been rated "excellent" in
a job evaluation this year, admitted destroying some documents and
otherwise not acting on what he considered obvious and suspicious
inconsistencies surrounding Brandenburg's death. But Franklin said that DHS officials, fearing bad
publicity, were making him a scapegoat for doing what superiors
consistently encouraged case managers to do: "hush up problem deaths
and other screw-ups."
"Sad to say, our division didn't care who died or when or how, so
they didn't give us the tools to investigate," Franklin said.
"The truth is that the agency was sloppy from the top on down, and
clients paid for it in illnesses, rapes and deaths."
The city delivered another client to Brandenburg's empty bed, records
show. Stubbs and Gaither kept collecting $6 million a year in public money
to care for the retarded. And none of the many city officials who knew
about the tranquilization, the slow death and the evidence of
corpse-tampering breathed a word to the family members whose names
Brandenburg had struggled to record beneath his own in the leaves of his
Living Bible.
"This is devastating." The voice of Brandenburg's sister
Gloria breaks. "They all told us Fred died in his sleep."
|
Invisible
Deaths
The Fatal Neglect of
D.C.'s Retarded
 Clockwise
from top left: Sheila Payne, Fred Brandenburg,
Desmond Brown, Gloria Davis, LaVon Green
|
|
(Page Two
of Three)
A
Commodity
It was meant to be a decade of recompense, with progressive laws
and ample funding marshaled to the mission. After Forest Haven, in
group homes from Cleveland Park to Capitol View, long-warehoused
individuals would realize their potential to live, learn and work
under the protection of their community's watchful eye. A Post
series in March chronicled how, when profit-minded entrepreneurs
flocked to a suddenly lucrative field, taxpayer-financed protections
succumbed to crasser interests. A muddy stretch of Section T in
Northeast's Glenwood Cemetery offers a useful vantage from which to
view the reform effort's least revocable failure.
Here, shadowed by sweet-faced marble angels and 19th-century
mausoleums, lie the District government's unmonied or unclaimed
dead: pressed-wood or aluminum coffins packed tight in narrow lots,
for reasons of municipal economy. A plastic disk numbered
"192" marks the grave of James Scott, a man whose December
1994 death has carved a particular trace in the minds of the
retarded men and women who survived him.
He passed the days as a food-service trainee at a for-profit
company, PSI, that runs the city's largest day program for the
retarded. He didn't say much, this bald 55-year-old with autistic
tendencies and off-brand sneakers, while packing tuna-on-white into
plastic wrap. He wasn't too much trouble, either, former counselors
recall, until the lunch time when his caretakers fatally injured
him.
As Scott's retarded peers watched, PSI therapists physically
"restrained" him after he became "agitated" and
threatened a program mate, according to reports staffers wrote at
the time. Their attempts at restraint dislocated his spine and
paralyzed him, according to reports that D.C. General physicians
wrote later. But after injuring him, PSI records show, staffers
attributed his "rag doll" stance and his guttural cries of
"Arm, arm!" to "behavioral hysteria."
Nearly two hours passed, PSI and ambulance records show, before
his caretakers dialed 911. Hospitalized in intensive care, Scott
died four weeks later. And one by one, the agencies that had been
assigned to protect him averted their gaze.
The police vowed to investigate a death that the medical
examiner's office, after an autopsy, classified as homicide. Five
years later, Assistant Chief Gainer examined the file and expressed
dismay: "This case got lost in never-never land."
DHS officials said, after Scott's death, that they would
investigate whether PSI was using excessive force on some of the
disabled people it receives $10 million a year to care for. But
court records show that DHS's chief overseer of day programs at the
time, Arnett Smith, was busy with private side deals with numerous
group home operators (including Stubbs, who hired Smith as a
consultant when he applied for public funding for his new group home
network). Smith, who declined to comment, was recently indicted on
federal conspiracy charges after The Post reported that he bought a
private home for another day program operator - a psychologist now
charged with Medicaid fraud - while he was supposed to be monitoring
her.
Reports of at least 18 other PSI injuries accumulated in
government files: a woman beaten with a baseball bat by counselors, for instance, and another woman injured, as Scott had
been, when staff members restrained her. The promised investigation
never materialized. "It appears we didn't do one," said
DHS spokeswoman Madelyn Andrews.
Each retarded ward has a court-appointed lawyer designated to
represent his interests. Records show that DHS officials didn't
locate Scott's. Each former resident of Forest Haven gets an extra
level of protection: a federal court monitor assigned to make sure
he gets the services the city has promised him. DHS didn't inform
the monitor of Scott's death until this September, five years after
the fact. And DHS delegated the task of notifying his relatives to
the owner of his group home, an entrepreneur named Carl Peterson who
had previously pocketed his clients' small disability checks, health
inspection records show. He would subsequently go to federal prison,
convicted of spending public funds meant for the retarded on go-go
dancers he called "group home consultants."
No relatives were found. No criminal charges or administrative
fines were levied against employees or officials of PSI. And the
city appropriated Scott's savings - the disability payments that
hadn't been stolen - to finance his funeral, which was held at a
mortuary owned by a DHS caseworker's husband. Scott helped pay as
well for his own interment beneath a numbered plastic disk.
Questioned recently by The Post, PSI President Elizabeth
Abramowitz responded in writing that Scott had not died of injuries
caused by her staff. After being told of autopsy and police reports,
Abramowitz said she was unable to discuss Scott's death or other
injuries at PSI because to do so would violate the privacy rights of
the retarded.
The realm of the retarded dead resounds with such silences in
part because of a 1978 law backed by well-intentioned advocates. In
mandating that the city keep extensive records on the health of its
retarded clients, the law stipulates that details of those records
be kept private to preserve dignity. The District cites that privacy
clause to withhold information about deaths - a policy that most
recently slowed a Justice Department civil rights investigation
sparked by The Post's March series. For months, District officials
refused on privacy grounds to turn over records to Justice and have
since obtained a temporary court seal to keep the results of the
federal investigation from the public.
The incomplete records District agencies released to The Post
suggest that the interests being protected weren't strictly those of
the retarded. Officials had inked out not just the names of the
disabled dead but the names of companies paid public money to care
for them, city caseworkers and health inspectors charged with
monitoring them - and occasionally even high-level government
officials. But the heavily blackened records are, in their own way,
revealing. They show that the failure to investigate deaths was a
systemic, multi-agency breakdown:
At DHS, the first line of defense for the retarded, caseworkers
filed away many cases suggestive of neglect - the middle-aged woman
who died of a urinary tract infection, for instance. But they did
refer several troubling cases to the agency's internal investigative
unit. The investigators were unable to document, after months of
inquiries, that they had done more than simply obtain death
certificates and close the files.
- The city's Medicaid office was assigned to investigate deaths
in the 80 percent of city group homes and day programs that
receive federal funds, a total of about $80 million a year. That
office was able to document two death investigations. The first,
from 1994, was a brief description of a scene of a murder. The
second was an investigation ordered by the mayor last summer,
after the highly publicized death of Patrick Dutch, who was left
for hours in the group home van. The investigation found that
the house manager and van driver "appeared not to remember
many of the details that might give someone a better
understanding why this tragedy happened."
- Inspectors at the Department of Public Health, charged with
making inquiries when suspicions are brought to their attention,
did a few death investigations, too. The record shows they
averaged one per year. When they found wrongdoing, they asked
the group home for "a plan of correction," as they did
in Brandenburg's case. They couldn't assess a fine - such as the
$100,000 penalty that can be levied on District nursing homes
for neglect - because the city's attorneys have never done the
administrative work needed to enforce an existing law that
allows monetary sanctions on group homes. Inspectors could have
referred death cases to the police. They haven't done so in more
than a decade.
A
Pattern
If individual cases are grim, the aggregate is startling.
While the exact number of retarded people who died since 1993 is
unknown, the 116 that The Post counted would give the District a
death rate far higher than that of similar jurisdictions.
The study of mortality among the deinstitutionalized retarded
is still in its academic infancy: Data sets are small,
government numbers vary in reliability, and medical issues
differ among populations. Still, the District has had more than
three times the number of deaths found in a roughly equivalent
New Jersey population and twice as many as found in a
Pennsylvania population. The District's death rate significantly
exceeds that of California's troubled group home system, where
University of California-Riverside faculty members have been
extensively researching mortality in community-based care.
"I wonder somewhat," said Wesley Vinner, a
high-functioning retarded man who grew up at Forest Haven.
"It's like we're dying left and right in programs that say
they protect us."
One reason, The Post found, is that city officials repeatedly
failed to recognize and correct disturbing patterns of neglect.
In 1990, when examining deaths at Forest Haven, Justice
Department investigators spotted one particularly alarming
trend: Residents were dying of aspiration pneumonia, which
sometimes occurs when the bedridden are fed inexpertly and
fluids build up in their lungs. A prominent D.C. law firm,
acting pro bono, sued the city on behalf of six dead Forest
Haven residents, alleging delayed and inadequate treatment. The
District settled for more than $1 million.
The Post, reviewing death certificates and hospital records,
identified 10 aspiration-related deaths since 1993 in group
homes scattered across the city. None of those deaths prompted
an investigation by city officials, records show.
Tony Snider, age 26. Sheila Payne, age 32. Steven Vasquez,
age 39. Midway down the aspiration death list is Gloria Davis, a
much-loved competitor in the ball-toss at the Special Olympics,
who died at age 33.
Profoundly retarded people such as Davis can't articulate
pain, which is one reason their caretakers, the good ones, are
remarkable to watch. They develop a hyper-perception that lets
them scent an infection, read pain in the blinking of an eye.
Davis, nonverbal and nonambulatory since birth, had been placed,
after Forest Haven, in what was supposed to be a bastion of such
sensitivity. The Astor Place SE group home where she lived is
one of 34 in the District owned or managed by Voca, a division
of a Louisville-based corporation, and supported by $25 million
a year in federal funds. Its direct-care workers earn as much as
$12 an hour, and its foyers are fresh from the broom. But
troubling deaths happened in Voca's homes, too.
One evening in 1997, the company's records show, Gloria Davis
started spewing mucous from her nose and mouth - the hallmark of
a major aspiration. Davis alerted caretakers to her distress the
only way she could - by shaking her bed. This cry for help was
heard at 10 p.m., house records show. But her caretakers didn't
dial 911. They dialed group home administrators. Records show
that a series of conversations ensued - about the fact that
Davis was struggling to breathe, that "the situation was
getting worse," that an ambulance should be called. But 70
minutes passed before anyone actually called one. Too late. Davis arrived at the hospital a few
minutes before midnight and was declared dead.
Voca's initial accounts of the evening understated by 40
minutes the interval between Davis's distress signal and the
call to 911, company records show. Cleveland Corbett, vice
president of Voca, said that the inaccuracy was an inadvertent
error on the part of harried caretakers and that he
"wouldn't second-guess the staff's judgment" on the
70-minute delay.
A month after Gloria Davis's death, at a home run by Voca in
Northeast, 42-year-old Raynard Olds had a seizure so propulsive
that his head left a hole in his bedroom wall. His neck was
critically injured on impact. A caretaker came immediately to
find him on the floor, fully conscious. I can't get up, Olds
explained. Ambulance records show he didn't arrive at the
hospital for an hour and a half after his violent fall. He died
a month later from his injuries. Voca's Corbett described the
time lapse between injury and hospitalization as
"appropriate given the professional judgments
involved."
Kenny Holmes, who lived in a Voca home three blocks from
Olds's, also had to wait for care. He swallowed three small
plastic bags while his counselor enjoyed a "fish and
bread" dinner.
Profoundly retarded, Holmes interpreted the world through his
mouth, like an infant, but with the dangerous coordination of an
adult. He swallowed whole corncobs, ate his own shoelaces.
Unable to speak, he couldn't call for help when help was
required. That's why Voca was paid $90,000 in public funds per
year to keep him safe.
One August night, caretaker Linda Bowers settled in with her
dinner on the couch.
According to an account she wrote of the evening - an account Bowers described in an interview with
The Post as accurate - when Holmes emerged from his bedroom and
obtained her attention, she sent him back inside and continued
eating. He retreated but then came out again. Go back to your
room, she told him more firmly, not leaving her meal. Again he
did as he was told. Back in his room, he finally got her
attention - by issuing a great and stomach-turning gurgle,
turning blue and thrashing on the floor. Bowers panicked and
neglected to perform the Heimlich maneuver she had been trained
to do, Voca records show. When Holmes got to the hospital, there
was little to be done. He was declared dead of asphyxiation.
Voca's "discharge summary" to DHS omitted Holmes's attempts to obtain
Bowers's attention and said Bowers called an ambulance 40
minutes before ambulance records show she did. Corbett called
Bowers a caring employee and said, "I believe the staff
provided the information as they knew it at the time."
If Holmes had died five blocks east, in Maryland, the
government would have sent a registered nurse to the scene to
interview staff. A physician would have scoured his medical
file, and a University of Maryland professor of pharmacology
would have studied the drugs he had been taking - their adequacy
and interactions. By governor's fiat, Maryland's state health
department investigates every death in group homes except those
of residents who have been diagnosed as terminally ill.
If Holmes had died in Delaware, the questioning of staff
would have been led by a state long-term care official who is a
former FBI investigator.
If Holmes had died in Missouri, his group home might now be
shuttered. Four months after Holmes's death, a retarded man in a
St. Louis facility swallowed rubber gloves and choked to death
in his bedroom as a caretaker sat nearby. State officials
conducted a months-long investigation, identified systemic
shortcomings and closed the home.
But Kenny Holmes died in the District of Columbia. Voca
executives carried out the only review done on his death.
Bowers, those officials concluded, required a training session
in "calmness." She remains a caretaker with the
company, about which Corbett can say accurately, "The city
has never had a problem with us about deaths."
A
Public Threat
Breast cancer. Massive cardiac events. The complex medical
conditions associated with Down syndrome. Some deaths The Post
found were inevitable, and a few - at the nonprofit Kennedy
Institute, at the for-profit Metro Homes - were thoroughly, even
mournfully, documented by group home officials. But some of the
deaths that weren't, like that of Helen Andrews, had
consequences that resonated beyond group home doors.
Eating her morning Cheerios, climbing a single flight of
stairs - even the basics seemed to tax her. Languid outings with
her day program sometimes left her gulping for air, which was
discomfiting to a 70-year-old with good manners. The
high-functioning Andrews lived in a caring home run by the
nonprofit Black Leadership and Christ's Kingdom Society, whose
staffers regularly delivered her to the internist with whom it
contracted for residents' care. Group home records show that in
April 1994, Fumikazu Kawakami, observing that Andrews had been
"deteriorating significantly" for six months,
diagnosed her condition: She was suffering from arthritis and
depression.
Twelve days after he wrote her a prescription for an
antidepressant called Zoloft, records show, she was dead of
treatable, contagious tuberculosis.
Kawakami did not return a reporter's phone calls. City
officials turned over to The Post a single document on Andrews's
death, after inking out every fact but the date and the cause of
death: "Tuberculous."
TB deaths, rarities in the metropolitan area, tend to make
headlines and inspire mass testings, as the pernicious airborne
bacteria can be passed to others in as little time as it takes
an elevator to go from the first floor to the fifth.
Fortunately, the vast majority of those infected can be cured
with a low-cost course of antibiotics - if they learn they've
been exposed.
"I'm appalled," said Tom Wilds, president of St.
John's Community Services, where, until she grew too weak to
attend, Andrews was in a day program with a dozen other retarded
people. "Our clients and staff were exposed, and I am just
learning this now?"
|
|
Invisible
Deaths
The Fatal Neglect of
D.C.'s Retarded
Clockwise
from top left: Sheila Payne, Fred Brandenburg,
Desmond Brown, Gloria Davis, LaVon Green
|
The
Names of the Dead, 1993-99
Blue
hyperlinks = photos; Brown hyperlinks =
related documents.
Josephine
Gaines • Marjorie Haas • Earl Veit •
Donzer
Ray Fonville • Marie Dickens
• Vernon Brown • Dora Mae Christian
• Deborah Lynn Key • Theodore Turner
• Ruth Mae Boaze • Richard Smallwood
• Cheryl Ann Bush • Patrick Wyman
Dixon • Robert Allen Watts • Nancy
Williams • Joanne Marie Curtain •
Alonzo Fouch • Helen Andrews • Calvin
Nielson • Joyce King • Richard Julius
Braddy • Joshua Brooks • Viola Tillyer
• Ernest Durity • Kevin Paul Turner
• Marguerite Spaulding • Brugiere
Palmieri • Steven Vasquez • Cecil
Gobble • Lee Robert Shipman • Isaac
Lloyd Williams • Male, full name unknown
• Daniel Bern • James Scott •
Reginald Lovette • Antonio
McCullers • Betty Tunstall
• Lawrence P. Toney • Hazel Harris •
Phyllis Mallory • Female, full name
unknown • David Abney • Stephen
Sellows • Dorothy Simmons • David
Wyatt • Full name unknown • Peter
Chipouras • Grace Marie Arnold •
Antonio Silva • Eugene Robinson • John
Wesley Hanna • Clara French • Levander
Johnson • Unknown female • Male, full
name unknown • Eduardo Echaves • Kenny
Holmes • Female, full name
unknown • Female, full name unknown •
Emma Williams • Cassandra Cobb • James
Henry Wilson • Henrietta Green •
Kenneth Arnold Gavin • Denise Allison
Smith • Steve Edward Moore • Melvin
Seymore • Fred Brandenburg • Freddie
Deperini • Francis Hanfman • Sheila
Payne • Louis Parnell • Gloria Marie
Davis • Roy Calloway • John Motika •
Raynard Olds • Herbert Scott • Sara
Walford Martin • Tony Snider • Helena
Taylor • Male, full name unknown •
Charles Rowley • Kermit Gleaton • Gary
N. Thomas • William Hillery • Full
name unconfirmed • Michael Gilliland •
Full name unknown • Antonio Lucas •
James Fairfax • Male, full name unknown
• Lemeka Edon • Eleanor Gleason •
James Smallwood • Full name unknown •
Male, full name unknown • Margaret Marie
Bicksler • Hilda Redman • LaVon Green
• Christopher Lane • Thelma Goldberg
• Henry Laker • Dennis Edward Jackson
• Carlis Spears • Nannie Jones •
Reginald Murray • Desmond Brown •
Hazel Pinkney • A.
Rowe • Geraldine Howell •
Patrick Dutch • James Dean • Joseph
Addison • Annie Williams • V. Bennett
• Woman, full name unknown
(City
records regarding the mentally disabled
contain a variety of spellings for certain
names.)
|
|
|
(Page
Three of Three)
A
Legacy
A short story and an old one: In the 1980s, an entrepreneur
named Weldon Ferguson opened a home for the retarded on 14th
Street NW. In 1987, a doctor examining one of Ferguson's residents
found evidence of what he termed "sexual violation." And
in 1988, six retarded men who had lived at the home told a Channel
9 reporter that Ferguson had been molesting them in their bedrooms
for years and that DHS officials had - also for years - ignored
their pleas for help. The story aired, the police swept in, and
Ferguson pleaded guilty to assault with intent to sodomize, for
which he got a short suspended sentence.
The end. Almost.
One of the deaths for which DHS lost records was that of LaVon
Green, who'd been among those who told a grand jury he'd been a
victim of Ferguson's assaults. Channel 9 reported that Green
contracted HIV while living at Ferguson's house. He died of
complications from AIDS last year. Weldon Ferguson, who said in an
interview he did not have HIV, was never ordered by the court to
take an AIDS test.
Asked whether other former residents of Ferguson's house had
died similarly, DHS spokesman Andrews said: "We can't find
the answer. We just don't know."
A
Culture
They were unlikely money magnets, the refugees from Forest
Haven, with their trash bags of clothes and stuffed animals. But
as $1 billion flowed into D.C.'s group homes to pay for their
care, charitable agencies were supplanted by entrepreneurs - in
pronounced contrast to the situation in other states. To keep the
new providers honest, DHS had a handful of social workers who had
come to the city to be part of a nationally celebrated reform. But
city officials acknowledge that much of the task of analyzing
medical records and challenging the accounts of the new businesses
was delegated to workers who had previously given sponge baths and
spooned applesauce at Forest Haven.
Some of those new case managers cared deeply about clients
they'd watched grow up, but DHS officials had a vested interest in
never training them to investigate deaths. These officials had
weathered blistering criticism for conditions at Forest Haven and
then, under court-imposed deadline, had personally chosen the
group home operators who would supplant the asylum. If these new
homes were found wanting, where would the residents go?
Today, the impulse to extenuate the circumstances of death is
quickened by a fear of liability. As city officials note, some
low-income families see a death by scalding or by broken neck as
an opportunity for windfall litigation. Because retarded people
have little lost-earning potential, big settlements are rare.
Still, one mother contacted by The Post about her son, who died
this year, asked "America to know my pain" and a
reporter to find her a lawyer. She last visited her son, she later
noted, in 1989.
DHS's unwillingness to investigate is facilitated by a city
agency that should be the last bulwark of accountability: the
medical examiner's office. Many jurisdictions require an autopsy
on all deceased public wards who did not have documented organic
diseases. D.C.'s Chief Medical Examiner Arden previously worked in
New York City, where autopsies are performed on approximately 90
percent of retarded wards. The District has no such policy
mandates. Only one in 13 got a completed autopsy, The Post found.
In several cases, bodies sent to the morgue were left unexamined,
without explanation, by city pathologists.
"If you're going to point fingers, point here," said
Arden. "We didn't investigate when we should have. We didn't
do right by these men and women."
Then again, the vast majority of the retarded dead never
arrived at the morgue in the first place. City records show that,
even when signs of neglect had been documented, DHS officials
consistently failed to request autopsies for retarded people
without families - people for whom the agency served as the de
facto "next of kin."
And sometimes, as with a woman named Betty Tunstall, they
closed the file with even fewer formalities.
A Loss
As the decade began, Tunstall embodied the transforming promise
of the group home system. Today, hers is a life twice lost.
After Forest Haven, where she had lived since the Truman
administration, Tunstall was placed in a Southeast group home
owned by a company called We Care, whose director was a former
aide to Marion Barry. We Care received $154,000 per client per
year, one of the highest Medicaid rates in the country. After
Chapter 11 bankruptcy reorganization, six settled sexual
harassment suits against its director and allegations of misspent
funds, the organization has been renamed Individual Development
Inc. and is chaired by David Wilmot, one of Barry's longtime
personal attorneys. "I don't know what those guys were doing,
frankly," said Wilmot, who said his homes, which are managed
by Voca, now provide excellent care.
There was a robust cocaine trade in Betty Tunstall's new front
yard, former staffers recall. Nonetheless, deinstitutionalization
would suit her.
Nonverbal, said the Forest Haven records.
"Pork chops and fries," Betty Tunstall said one night
at the sight of her favorite dinner, rendering her caretakers
bug-eyed at the stove.
After 40 years, Tunstall was pushing boundaries, finding words.
"Look," she demanded, as she turned on the house radio
by herself. She mastered the essential pronoun of communal living:
"mine." This was the miracle that reformers had worked
to witness - what they dreamed their legacy would be.
For five years now, this miracle has been buried in an unmarked
plot in Prince George's County that even the cemetery director
gets lost trying to find. How Tunstall got there, DHS records do
not say. She was interred at age 50 but never officially declared
dead. City officials shelved her case without a death certificate.
It's illegal in the District to bury a person without
certifying death. "Very unusual," said Urbane Bass, head
of D.C.'s vital records agency. "It's a crime." Also a
mystery. What happened to the $70 monthly disability checks that,
Social Security Administration records show, group home
administrators kept receiving in her name for months after her
unrecorded death?
A
Killing
It would be easy, given cases such as Brandenburg's and
Tunstall's, to paint life inside group homes in the hue of
Clockwork Orange. The reality is subtler: an incremental
coarsening of sensibility. Take the big white house on Maple
Street NW - the one with Christmas garlands bedecking the portico
- where lived gentle, 28-year-old Reginald Lovette.
Lovette's roommate, a 250-pound retarded man named Bernard
Eaton, had his grievances, as roommates do. He thought Lovette
touched his television, snored too loudly, got preferential
treatment from the staff. Eaton sometimes registered his protests
by attacking Lovette while he slept . When Lovette was awake,
police documents show, Eaton frequently attempted to strangle him.
Lovette, who city records say had come into government care
after a violent childhood with a psychotic father, repeatedly
asked staff members to shield him from what they would later
describe as "constant abuse." But Lovette was left to
share a room with Eaton. And DHS left uninvestigated a series of
reports by the home's neighbors. Residents were wandering the
streets, confused and unattended. Residents were in the back yard,
chilled and naked, with none of their caretakers in sight.
And then one night just before Christmas 1994, Eaton succeeded
in an act he'd been edging toward all year. He strangled Lovette
with a baby-blue bedsheet.
Police reports describe the battleground: bed and nightstand
askew, pillow gory, body in checkered pajamas splayed on floor.
The scene comported with what Eaton confessed. Not long after
midnight, he had a prolonged fight with Lovette before getting the
sheet to strangle him. But the employees in the home - charged
with checking hourly on Lovette and his housemates - didn't rush
to the rescue. Police and health department records show they were
missing in action all night and didn't find Lovette's body until
after 7 a.m., by which time rigor mortis had set in. After
discovering the killing, health inspection records show, staffers
did nothing. Only when a member of the morning shift appeared 20
minutes later did someone decide to call the police.
Health inspectors subsequently arriving on the scene noted a
tangential oddity: There was no food in the house for the
residents to eat. As the group home's owner, Samelia Green, would
later explain to inspectors, the staff supervisor had probably
falsified grocery store receipts and pocketed the cash meant to
finance a week of clients' meals.
Who exactly were Lovette's caretakers in the house on Maple
Street? A check of District and Maryland criminal records
indicates that they included a convicted cocaine dealer, a
convicted crack dealer and a twice-convicted thief and crack user
who had just been released from jail.
To care for the retarded in, say, Florida, one must pass a
criminal background check, secure an FBI clearance and attest in
writing to exacting standards of moral character. The District
recently put a similar law on its books, but city administrators
have yet to do the necessary paperwork to enforce it. No effective
curb on criminal caretakers. No trace of a response to panicked
neighbors. No protection for a young man in bed. And after
Lovette's killing, little change.
Eaton, who under D.C. law could not be held responsible for the
homicide because of his mental deficiencies, went to live with his
mother in Northeast
Samelia Green, who declined to comment, continued collecting
her public money. Felons went on caring for the survivors. And DHS
officials didn't supply a single record on the case.
A
Prophecy
Desmond Brown's fingers curled inward like rams' horns. His
slender torso was a permanent L. He was retarded. He was blind.
And what of it? He cranked his favorite Santana tape and decided
he could dance on his knees. If fate had played a trick on him, he
seemed to get the joke. Among so many limits, said his presence,
there may still be so much life.
Two years after city and group home officials concealed the
truth of the death of Fred Brandenburg, 38-year-old Desmond Brown
was in another home owned by dentist Arthur Stubbs.
One rainy day in January, Brown, who had cerebral palsy, got
wet. In city files, there is one version of what happened next: a
10-sentence memo, titled "Investigation," by Stubbs's
partner, Sheila Gaither. It says Brown came down with
a cold but quickly recovered. When his "cold symptoms"
returned a week later, group home officials whisked him to the
hospital.
City records and the accounts of his group home and day program
caretakers provide a painful counter-narrative. From late January
to late February 1999, Brown's care supervisor, Patricia Thorpe,
repeatedly petitioned superiors to give the "sick,"
"unresponsive" Brown treatment stronger than Sudafed.
"He was distressed, and I felt we shouldn't take
chances," Thorpe said in an interview. But company officials
declined to take Brown to a doctor.
"They'd say, he's fine, just give him soup, give him
water," recalled Genevieve Ruffin, a veteran aide at Brown's
group home and one of four DCFS staffers who noted that dialing
911 without authorization can get a person fired. "When
Desmond couldn't eat, they said it was a 'behavior
problem,'‚" Ruffin said. "I mean, even I could tell by
looking at him - it was pneumonia."
As Brown was wasting away, residents of other DCFS homes were
hurting, too. Health inspectors found that one woman had been
improperly treated for respiratory distress, two others had been
repeatedly and improperly tranquilized, and many more weren't
getting medical treatments that had been ordered by their doctors.
Meanwhile, crucial day-to-day care was being handled by a crew of
minimally trained welfare recipients. DHS had given Stubbs and
Gaither a multimillion-dollar contract to help D.C. welfare
mothers find jobs. Until it was discovered that a DHS official
involved in awarding the contract lived in a home owned by Stubbs,
the deal gave the dentist and his partner a double windfall:
bonuses from their welfare-reform contract for placing workers in
jobs and tax credits at the group homes for hiring welfare
recipients. Somewhere near the bottom of the incentive structure
ranked the life of one Desmond Brown.
"Saving money, saving money: That's all we heard,"
said Thorpe, who eventually took a job in the Maryland group home
system.
Brown couldn't negotiate a similar exit.
"Step out!" he'd regally gesture when his guardians
irked him - a stylish cover for a physical fact: Brown himself was
trapped. He grew sicker, until one Friday night his labored
breathing and shaking left his caretakers almost as distraught as
he was. But as with Brandenburg, the problem was kept inside the
house. Sweat poured off Brown's emaciated body, records and
interviews show. He tore at his clothes in anguish. He gasped for
air. But DCFS supervisors decided that he didn't require the
services of a doctor. Brown was "doing fine" that Friday
evening, says the brief DCFS "investigation." He was
desperately ill, say interviews and city records. In the house
ledger, Ruffin and a co-worker detailed more than Brown's
unremedied suffering. They recorded his horrified recognition.
"I am dying," a retarded man informed his caretakers.
"I am going to die."
It was as if, in that moment on the last night he ever spoke,
the blind man could see what lay ahead. The Saturday morning when
Gaither granted permission to take him to Providence Hospital. The
emergency tracheotomy. The immediate dispatch to intensive care,
where yellow ghosts attended in isolation gear. The silvery
balloon for his 39th birthday, hovering above a tangle of plastic
tubes. And then a casket crammed alongside 11 other caskets in a
single cemetery plot.
Like so many others failed by the government that promised to
save them, Desmond Brown in the end received a group grave with a
plastic marker.
On that marker, another joke Brown might have gotten. No name,
just the digits 137. A number, as if someone were counting.
Staff researchers Alice Crites and Heming Nelson contributed to
this report.
© 1999 The Washington Post Company
|
|