D.C. Cleansed Group Home Death Reports
Saturday, August 5, 2006
The District government has altered reports concerning deaths of mentally retarded residents of the city's group homes, deleting damaging information before the documents were turned over to court officials and others who review the cases.
The deletions, discovered by a federal court monitor, included information that described serious case-management failings; delays in obtaining consent for medical procedures; concerns about health care; concerns about autopsy findings and procedures; and problems getting information needed to complete the death investigations.
One report was changed to remove several sentences critical of a case manager's oversight, including a complaint that he had visited the resident only once in eight years. The case manager still works for the Mental Retardation and Developmental Disabilities Administration, according to the court monitor, Elizabeth Jones.
Jones's interim report about the deletions, filed in U.S. District Court this week, comes at a critical time for the D.C. government. A federal judge is weighing a request to have the troubled agency placed in court receivership, a move that city officials say would derail their efforts to improve operations.
Jones frequently has faulted the city for the care and oversight of roughly 2,000 mentally retarded wards, most of whom live in group homes. In November, she said a pattern of neglect led to four deaths since late 2004, and she warned that other lives were in danger.
In her latest report, Jones says the city also deleted some recommendations from the investigative contractor, the Columbus Organization, that urged the mental retardation agency to change policies or practices to avoid future harm to group home residents, many of whom also have physical disabilities.
"Recommendations for improved health practices were not considered," she writes.
Jones first raised concerns about altered reports in June, after discovering that parts of one death report had been deleted. She then asked that original copies of 19 death investigations be sent to her to compare against copies circulated by the District.
Of those reports, she says in her court filing, eight had significant deletions. The deleted material deprived oversight bodies -- including the court, a fatality review committee and the D.C. Council -- of information they needed to protect and improve services for disabled residents, she says. The information also was withheld from plaintiffs in a long-standing federal lawsuit over the District's care.
D.C. officials said the death reports are edited to ensure quality and to correct typographical and grammar errors -- not to alter any findings.
They said yesterday that changes that appear to be substantive were made when the Incident Management and Investigations Unit, which reviews the reports, was part of the Department of Human Services.
In October, that unit was put under the control of the city's mental retardation administrator, who reports directly to Brenda Donald Walker, the deputy mayor for family issues.