An inquiry into the death last year of a 27-year-old quadriplegic inmate has concluded that D.C. Superior Court made only a "limited and uninformed" inquiry about the man's medical needs before ordering him to serve a 10-day sentence for marijuana possession.
But the investigation by the Commission on Judicial Disabilities and Tenure cleared the judge in the case, Judith E. Retchin, of judicial misconduct, concluding that she acted within the law and made an effort to ensure that a D.C. jail would be able to care for Jonathan Magbie.
The report cited "failures of communication among the participants in this tragic sequence of events."
The commission's report, released yesterday, is one of three official inquiries into Magbie's death Sept. 24. An earlier investigation by the D.C. Department of Health faulted Greater Southeast Community Hospital for failing to provide adequate care to Magbie after he was brought there from the jail. The Office of the Inspector General is examining the actions of the jail staff.
From the beginning, Magbie's family had focused its fury on the judge, who rejected probation -- a common sentence for a first-time misdemeanor offender -- and instead ordered him jailed for 10 days.
In a demonstration outside the courthouse in the days after Magbie's death, his mother, Mary Scott, called Retchin a killer and demanded her removal from the bench.
Retchin, a judge for almost 13 years and a top federal prosecutor before that, was interviewed by the commission, and the report provides the most extensive public account of her thinking in the case beyond what emerged in court transcripts.
The judge told the commission that she was leaning toward probation but reconsidered after Magbie told court investigators that he would continue to use marijuana because it alleviated the discomfort of his disability. Retchin said Magbie's attitude and the fact that he had been arrested with a gun -- a charge that was dropped as part of the plea -- convinced her that he should receive more than probation.
According to the commission, she and her staff made an error in trying to determine whether the jail could accommodate Magbie.
Retchin told her law clerk to find out from the chief judge's office whether the jail could care for a paraplegic. Magbie was almost a total quadriplegic, having slight use of one hand but otherwise paralyzed from the neck down.
According to the commission, a staff member in the chief judge's office who is the court's liaison with the jail incorrectly assumed that Magbie was a sentenced felon and faced at least a year in prison, which would have meant he was headed to a federal prison and not a D.C. jail. The result was that Retchin was told that the jail could accommodate Magbie.
Retchin told the commission that if she had known at the time about Magbie's acute medical needs, she would have come to a different decision, "a period of home confinement, rather than a jail term, would have far better served her sentencing objective," the report states, paraphrasing the judge.
Instead, Magbie, who was paralyzed at age 4 when he was struck by a drunken driver, was taken to jail in his motorized wheelchair.
Five days into his sentence, Magbie of Mitchellville died at Greater Southeast. It was his second trip to the hospital, having been taken there on his first day in jail. After the first hospitalization, a doctor at the jail tried unsuccessfully to have Magbie returned to the hospital, fearing that he would again need urgent medical care. But Magbie did not make it back to the hospital until the next day, when he was already in distress.
Greater Southeast has said Magbie received "appropriate care."
The commission found that the judge, court staff and Department of Corrections did not know at the time of Magbie's sentencing that his compromised respiratory system was "susceptible to swift deterioration requiring acute-care hospitalization."
Last night, Scott said Retchin should have known.
"If she wanted to know if they could accommodate him, she should have tried to find out what his needs were," Scott said. "How can you say someone's going to take care of you if you don't know what they need?"
The judge told the commission she did not know that Magbie regularly used a ventilator to help him breathe, especially when he was sleeping. He had not used one in court and his lawyer, Boniface Cobbina, made no mention of his needing a ventilator, which jail officials later said they were not equipped to administer.
In an interview yesterday, Chief Judge Rufus G. King III said the court had taken steps to improve the way it handles defendants with serious medical conditions. The medical alert forms that are completed for such defendants have been revised to require more information. Judges have been told that in the most serious cases, they should handle the inquiries directly, not leave them exclusively to court staff.
"It's definitely a lesson for all of us," King said.