Nov. 25, 1974 - March 29, 1995
Everyone called her Mia. She was removed from her home at age 3 after her mother allegedly physically abused her, and she received a diagnosis of cerebral palsy and retardation. But her prognosis was good. As a teenager, she was described as "charismatic and engaging."
After 17 foster care placements in 17 years, Mia died in her sleep at age 20 in a ward for the hearing impaired at St. Elizabeths Hospital, even though she had no hearing problems.
Xermia's "tragic life and death suggest the most callous form of systematic institutional neglect," wrote Judith Meltzer, the federal monitor of the D.C. Child and Family Services Agency, in a 1998 study of child deaths.
From 1978 to 1986, Xermia lived in four foster homes. By her 13th birthday, she had been moved 11 times. She lived in psychiatric hospitals and treatment centers in New Jersey, Maryland and Texas. But Mia's records contained no explanation for the moves and no sign that social workers were monitoring her.
In 1990, Mia was sent temporarily to St. Elizabeths. Then she was moved to a treatment center in Florida. By 1992, she was having psychiatric problems. Still, she had "no active advocate or case manager," Meltzer found. Two years later, she returned to St. Elizabeths. A social worker requested that she be examined for sleep apnea, a condition that causes people to stop breathing while asleep, according to Meltzer's report. St. Elizabeths agreed to do the exam but never did.
In the end, Xermia was placed in a St. Elizabeths ward for the deaf, even though she had no hearing problems. A doctor said the ward had a skilled staff, but Mia's social worker objected, arguing that Mia needed verbal communication.
A judge ruled in February 1995 that Mia should be transferred. Meltzer said she never was. A month later, Mia died of "questionable natural causes in a placement that was acknowledged to be inappropriate to her needs," Meltzer wrote.
A spokeswoman for St. Elizabeths declined to comment, citing confidentiality.
"The lack of overall management of this child's life and the apparent disregard for her future is heartbreaking," Meltzer concluded.
Dec. 10, 1975 - June 13, 1995
Donnell was found unconscious in his bed in a city-run nursing home one month after the U.S. Justice Department filed a lawsuit, charging that "dangerous" and "grossly deficient" medical practices at the facility led to the deaths of 37 residents in less than three years.
A death certificate lists Donnell's cause of death as cardiopulmonary arrest, but no autopsy was conducted on the retarded teenager.
He was born in 1975 to a 17-year-old mother. At 2, Donnell stopped breathing while playing. He was taken to the hospital and received a diagnosis of spinal meningitis. He was in a coma for four months, resulting in extensive brain damage.
In 1983, when Donnell was 7, he was taken away from his mother after a doctor at Howard University Hospital reported her suspicions that Donnell was intentionally overmedicated with phenobarbital. He was placed in D.C. Village, a nursing home of last resort for poor children, the elderly and the retarded. Donnell spent the next 12 years at the home near the Blue Plains sewage treatment plant in Southwest.
Donnell, still a ward of the District, was not visited by city social workers for seven years.
After his death, an agency report noted "very little involvement" by social workers and "large gaps in the documentation."
In its 1995 lawsuit, the Justice Department contended that poor medical practices at D.C. Village were placing residents in "imminent danger of infection, potential loss of limb . . . and even death." The lawsuit alleged that poorly trained staff ignored the needs of residents, who were living in squalid conditions, kept in restraints and given inappropriate medication.
"Within its walls, 269 of the District's most vulnerable and defenseless residents . . . lived in such conditions of filth and abuse that even basic needs were often neglected," a court-appointed monitor of D.C. Village wrote in 1997.
A year after Donnell died, then-Mayor Marion Barry closed D.C. Village.