The D.C. Department of Health has found that Greater Southeast Community Hospital failed to provide adequate care to a quadriplegic jail inmate who died in September after he was taken to the emergency room for severe breathing problems.
The inmate, Jonathan Magbie, died Sept. 24 of acute respiratory failure, raising questions about his medical care as well as why he was incarcerated in the first place. Magbie, 27, of Mitchellville, was serving a 10-day sentence after pleading guilty in D.C. Superior Court to possession of marijuana, an offense that rarely carries jail time for a first-time offender.
The Health Department's investigation focused on what happened after Magbie arrived at the D.C. jail Sept. 20 and primarily on his treatment at the hospital. The findings, released late yesterday in response to a Freedom of Information Act request, represent the most comprehensive official accounting of his death.
The hospital will be cited for violating local and federal regulations. Last year, Greater Southeast was faulted by District hospital inspectors for persistent problems with the quality of medical care. The city later determined that the hospital had addressed deficiencies.
"This was a tragic incident," Gregg A. Pane, director of the Health Department, said in a statement released with the report.
Magbie's mother, Mary Scott, said last night that she was pleased to see Greater Southeast held accountable but that others shared in the blame for her son's death. All knew, she said, that he had serious medical problems. "It's misconduct on everyone's part," Scott said. "I still hold the judge responsible, the jail responsible and the hospital responsible."
Hospital officials issued a statement saying they had not received an advance copy of the report, but they defended the care they gave Magbie.
"We are confident that appropriate care was provided in this case, but privacy rules prevent us from talking about specifics," the hospital statement said. "We would welcome a fair and impartial review, but question whether the District's conflict of interest in this matter allows it to be fair and impartial."
Magbie, who was struck by a drunk driver at age 4, was paralyzed from the neck down and his growth stunted. But, helped by a settlement that paid him $30,000 a month, he tried to make the most of his life. He traveled frequently, wore what he said was a $7,000 watch and lived in what he called a mansion.
Although he had never before been accused of criminal wrongdoing, Magbie was known to keep rough company, according to prosecutors, who said his name came up on a wiretap of a suspect in a major drug-trafficking investigation.
He was arrested in April 2003 while riding with a cousin in his family's Hummer in Southeast Washington. Police found cocaine, marijuana and a gun in the vehicle.
Magbie pleaded guilty to possession of marijuana, and probation seemed to be the likely sentence. But the judge, Judith E. Retchin, noting the gun in the car and Magbie's insistence that he would continue to smoke marijuana because it made him feel better, sentenced him to jail.
Hours after he arrived at the D.C. jail Sept. 20, he began having difficulty breathing. Magbie told a jail nurse that he used a ventilator to help him breathe at night, according to the Health Department's investigation, but the jail did not have the equipment. The jail's doctor had Magbie taken to Greater Southeast.
William Vaughn, a doctor in the hospital's emergency room, told Health Department investigators that Magbie was brought to Greater Southeast because he might need a ventilator. Vaughn initially planned to admit Magbie but changed his mind after Magbie's condition improved, the investigation found. He discharged Magbie back to the jail the next day with instructions that Magbie could need nasal oxygen.
The Health Department said that the doctor erred by releasing Magbie without addressing his ventilator needs at night. Magbie never got a ventilator while at the jail.
The staff at the Correctional Treatment Facility, the medical jail annex where Magbie was being held, was concerned when Magbie reappeared at the jail, the Health Department investigation found. Its chief medical officer, Malek Malekghasemi, told investigators that the facility "should not have a patient that required a vent."
Malekghasemi said he called Retchin's chambers to find out why someone in Magbie's condition would be in jail. The doctor wanted a court order to have Magbie sent to the hospital but told investigators that the judge said she could not take that action.
Magbie was returned to Greater Southeast on the morning of Sept. 24, again with breathing problems. The Health Department said it found "no documentation" that the nursing staff kept doctors informed as his condition worsened.
Medical records show that a doctor was brought in at 5:40 p.m. when Magbie was in respiratory distress; his breathing tube had become disconnected. Doctors reattached the tube, but Magbie died within an hour.
Staff writers Nicole Fuller and Cheryl W. Thompson contributed to this report.