Death of Disabled Ward Detailed

By Karlyn Barker
Washington Post Staff Writer
Friday, June 16, 2006

A mentally retarded ward of the D.C. government died last summer after receiving poor care in a group home and at two hospitals -- one of which tried to put a feeding tube in his stomach even though the organ had been removed years earlier.

The man, according to a previously secret report on his death, received scant and sometimes misguided medical attention as his health deteriorated in the Southeast Washington home. Once hospitalized, the report says, he was given inappropriate treatment for his condition and was later transferred to another hospital, where doctors were not summoned until it was too late.

The document was among a dozen reports concerning deaths of mentally retarded wards obtained last week by the D.C. Council. The report sheds new light on one of the more recent deaths of a group home resident -- to a point.

It does not name the group home operator or the hospitals that delivered the questionable treatment. That and other information was blacked out before the reports were given to D.C. Council member Adrian M. Fenty (D-Ward 4).

Fenty's copies were significantly redacted because city attorneys say certain information might identify the deceased, in violation of privacy laws. Yet excerpts from these same reports, with only the decedents' names and birth dates redacted, were recently filed in federal court by an advocacy group, providing a detailed, who-did-what account of the deficient care.

"It seems that the concern of the District is to protect the District and to protect the potential wrongdoers," said Sandy Bernstein, legal director of University Legal Services, whose group obtained its own set of reports and filed the excerpts in its role of representing plaintiffs in a 30-year-old lawsuit against the city. The group is seeking a court takeover of the mental retardation agency.

Fenty, who chairs the council's Human Services Committee, criticized the decision to black out sections of the reports that went to the council, saying it is frustrating to read about poor care and not be able to see who is at fault.

"This is being directed by policymakers who don't want the public to know what's happening," he said.

Based on the report and the unredacted excerpts filed in court, here is what occurred:

The man, 41, died last June. He lived at a group home run by Community Alternatives of D.C. The home staff, among numerous mistakes, "failed to adequately assess and monitor" his declining health and fed him prune juice against doctor's orders because it didn't have suppositories for his constipation. When he was rushed to a hospital, no one from the home went with him.

At Greater Southeast Community Hospital, doctors operated to put a feeding tube in his stomach -- unaware that he had received a total gastrectomy at the same hospital three years earlier. He was transferred to Providence Hospital to have a feeding tube placed in his small intestine. He arrived in poor shape, the report says, but was not seen by a doctor for nearly nine hours, and by then he was dying.

All deaths of group home residents are investigated by an independent contractor, which files a detailed report with the city's Fatality Review Committee. The reports are not public, but the man's death was among four cited last fall by a court monitor, who said the residents died because they did not receive timely and competent health care.

Marsha H. Thompson, whom Mayor Anthony A. Williams (D) fired last week as head of the Mental Retardation and Developmental Disabilities Administration, said she sent a copy of the death report to Greater Southeast and told an agency supervisor to file a complaint with the city's hospital review board. She said that she learned in April that her order "was ignored" and that she then sent separate letters to the hospitals.

Officials at Greater Southeast and Providence declined to comment. A spokeswoman for Community Alternatives, the group home operator, said that the man "thrived" for years in the home despite being in fragile health and that he died from a condition that developed after weeks in the hospital. Community Alternatives has since ceased operations in the city.

A House committee has scheduled a hearing today on the mental retardation agency, and a federal judge has set June 29 for a hearing on the receivership request.

The agency serves about 2,000 mentally retarded people, most of whom live in about 360 city-contracted group homes. The council enacted emergency legislation this spring to make public all reports on deaths and serious incidents.

Fenty said the continued redaction of death reports violates the new law and makes it impossible to learn who is responsible in cases of death, neglect and abuse. But a city official said the council was told it could have unredacted reports for oversight purposes -- if it would promise not to give them to The Washington Post and other media.

A Fenty aide confirmed the offer but said the council thought the public had a right to know how tax dollars are being spent and how service providers are performing.

The Post has a pending lawsuit against the District to obtain copies of group home death investigations with the identities of the deceased deleted.

© 2006 The Washington Post Company