Two More Deaths

Monday, April 23, 2007

A39-YEAR-OLD mentally ill man dies after a perfect storm of failures at St. Elizabeths Hospital. A 32-year-old woman with bipolar disorder who had never received a required mental assessment hangs herself in the D.C. Jail. Meanwhile, a judge determines that 650 people with mental disabilities are suffering because of the "wholly inadequate" job performed by the D.C. government. Each of these events occurred during Mayor Adrian M. Fenty's first 100 days in office. The blame may not be his, but the responsibility for fixing how the District deals with its mentally impaired is.

Even by the sorry standards of how the District has treated this vulnerable population, the recent cases -- involving different city agencies -- are alarming. The St. Elizabeths patient, Mark Harris, died of cardiopulmonary arrest when he became violent and a counselor restrained him. The Jan. 9 death has been ruled a homicide. An investigation showed a series of things gone wrong: no other staff available or willing to help; one oxygen tank locked in a closet that no one had a key to; another oxygen tank not working; and no defibrillator. The counselor used a form of restraint now deemed dangerous.

The story of Alicia Edwards, as told by the Legal Times, is equally chilling. Awaiting trial in the D.C. Jail for shoplifting, the woman was flagged as having mental health problems. The required in-depth exam was never done, and she hanged herself while alone in a cell March 31. Also troubling is that jail officials initially released false information about how she was being monitored. Investigations are underway by the Corrections Department and the D.C. Inspector General's Office.

The city has a long history of trying to improve health care and behavioral services for the mentally disabled. It is marked by lawsuits, court interventions and takeovers of agencies. Untold numbers of reform-minded administrators have come and gone. Millions have been spent. U.S. District Judge Ellen S. Huvelle, presiding over the 31-year-old class-action lawsuit brought by onetime residents of Forest Haven, cited this "tortured history" as she found the District in noncompliance.

It's now up to Mr. Fenty (D) -- with his trademark adherence to constituent service and accountability -- to turn things around. Judge Huvelle's reluctance to place the city's Department of Disability Services into a receivership makes sense since such efforts have not worked in the past. There needs to be an overhaul of dysfunctional city agencies and a change in a culture that thinks it's okay to treat with less respect those with more needs.

Mr. Fenty's designation of General Counsel Peter Nickles as his agent for change is to be commended. Mr. Nickles has a distinguished record of fighting for some of the city's most marginalized citizens. It's encouraging that Mr. Fenty is making additional resources available. And his appointment of St. Elizabeths director Patrick J. Canavan and retention of mental health director Stephen T. Baron have been applauded by advocates for the disabled.

These are all good steps, but it's time for results, and that's what Mr. Fenty should be concentrating on in his next 100 days. And the 100 after those.

© 2007 The Washington Post Company