The first thing you notice when you read the D.C. Health Department's report into the death of 27-year-old quadriplegic Jonathan Magbie is that several critical pieces of information have been blacked out. The second thing that becomes obvious is that while the Health Department correctly points an accusing finger at Greater Southeast Community Hospital for giving Magbie substandard care, the report gives the medical staff at the Corrections Department a pass, even though the jail's doctors failed to make it clear to the hospital that Magbie could not be properly cared for at the Correctional Treatment Facility. Third, the report raises as many questions as it answers. And finally, you can't help wishing that Superior Court Judge Judith Retchin would read the report too, because there is no way on earth that a human being in Magbie's condition, and a first-time offender found guilty of simple possession of marijuana, should have been sent to a place such as the D.C. jail.
This week I turned to two sets of practiced eyes to review the Health Department's report. These health experts -- one in Washington, the other in Virginia -- reached similar conclusions about the quality of care provided at Greater Southeast. It was poor. But they also said that a failure of communication between the hospital and the jail contributed to the tragedy, as did the decision to incarcerate him in the first place.
Now for the report.
Let's start with salient aspects of Magbie's physical state in the days immediately preceding and at the time of his death, which occurred Sept. 24 while he was under the jurisdiction of the Department of Corrections.
On Sept. 20 Retchin sent to jail a man who had a high spinal cord disruption leading to no -- or limited -- use of his arms and no use of his legs. He had a permanent tracheotomy; was ventilator-dependent at least part of the time, especially when tired or sleeping; had partial diaphragm paralysis requiring the use of a diaphragm pacer; had a permanent indwelling stomach tube and a permanent indwelling urinary catheter, and contracture of the muscles and tendons.
What other conditions were present at the time of death?
Magbie had heart disease, asthma, chronic obstructive lung disease, low blood pressure, low blood sugar and pressure (or bed) sores. He also had a probable urinary tract infection leading to sepsis (or the absorption of microorganisms into the bloodstream), and probable pneumonia in his left lung.
Magbie was severely ill when he was released from the hospital and returned to the Corrections Department on Sept. 21. According to the report, his white blood count was abnormal -- but the result was blacked out. Rale and wheezing -- a possible indicator of asthma, pneumonia or heart failure -- had been heard during his hospital examination. But the report did not include any lab results or the result of a portable chest X-ray that Magbie had been given.
The Health Department was also silent on why the initial plan to admit Magbie to the hospital on Sept. 21 was changed to discharge him back to the Corrections Department. Also unanswered is the question of whether Magbie's problems, as documented in the hospital's emergency department on Sept. 21, had been fully disclosed to Corrections Department medical staff -- and if not, why. And if the Corrections Department had been informed, why did it take him back? The Health Department report did not address those critical questions.
There are other mysteries, too.
On Sept. 24, the day he died, Magbie was found unresponsive at the jail and was returned to the hospital's emergency room and given lab and X-ray tests. But the results of the chest X-ray, urine toxicity test and white blood count were blacked out in the Health Department report. Part of the urinalysis was blacked out, too. Why? Did the chest X-ray and white blood count show he had significant pneumonia?
And why was the urine drug screen result also blacked out? A possible clue: Page 11 of the report contains this entry at the time of his second and final admission to Greater Southeast on Sept. 24: "1:20 pm: Disposition time: Clinical impression: Altered mental status, Multi-substance abuse, Pneumonia, Urinary tract infection-Urospesis."
"Multi-substance abuse"? Yes, drugs. Magbie, the report shows, was given Narcan, which is a reversal agent for narcotics.
Which raises the question: What kind of recent narcotic substance would Magbie have had in his system, since at the time of the test he had already been in the custody of the Corrections Department for four days? As a quadriplegic, Magbie surely couldn't have taken anything by himself. There are no answers in the Health Department report.
Finally, there's the cause of death. The chief medical examiner attributed it to dislodgement of Magbie's tube. Who dislodged it, when and where? And what happened to the inner cannula, the device to be connected to a tracheotomy tube that helps a patient breathe? The report doesn't say, except to note that when emergency medical services staffers were ready to transport Magbie to the hospital on the morning of Sept. 24, "the EMS could not connect the oxygen to the tracheotomy tube, it would not connect. The [Correctional Treatment Facility's chief medical officer] stated he cut some tubing from another product and attached the tubing into the tracheotomy so the patient could receive oxygen." At that point, Magbie was unconscious at the jail and the inner cannula tube was missing.
And the Health Department considers this case closed?