3 D.C. Workers Dismissed in Death

Aid for Retarded Man Held Up, Pleas Ignored, Officials Say

Washington Post Staff Writer
Saturday, November 1, 2008; Page B01

Three city employees have been let go after an investigation found that a mentally retarded man living in a cockroach-infested apartment had been denied disability services for more than two years before his death, even as a social worker pleaded for him to get assistance.

Mayor Adrian M. Fenty (D) and Acting Attorney General Peter J. Nickles yesterday announced the findings of the investigation into the case, which was made public by University Legal Services. The report detailed "a bureaucratic struggle that would end in tragedy."

The man, identified only by the pseudonym "Mr. Johnson," was hit by a bus when he was a toddler and left mentally disabled. His mother cared for him during the next five decades of his life. After she died in 1993, social workers and an AARP volunteer tried desperately to help Johnson receive the medical attention he needed.

But according to the report, requests to the Department of Disability Service (DDS) were routinely ignored or bogged down in red tape.

Johnson, who had an IQ of 45, had diabetes, hypertension, skin cancer and prostate problems. His contacts with city agencies date to 2001, but most of the early records have been lost or misplaced, the report says.

The bureaucratic morass began in earnest in late 2006, when a social worker under contract to the city visited him and was appalled by his health and living conditions.

"Over the next 11 months, government agencies fought through issues of eligibility, diagnoses and documentation, missing several opportunities to meet his needs along the way," the report said. "All the while, Mr. Johnson's ability to self-care deteriorated."

The social worker spent three months trying to reach the city agency tasked with helping disabled people, not realizing it had moved. When she got the right phone number, no one returned her call. When she went to the agency in person, she was told Johnson was already "in the system" and mistakenly assumed he would be taken care of. Months later, she sent a new application for services, but it was put on hold because it lacked a copy of his Social Security card and a psychological assessment completed before he was 18.

In August 2007, the social worker left a message with a DDS case manager saying Johnson was in crisis. The case manager eventually agreed to visit him five weeks later, but never showed up and did not cancel or reschedule the visit.

Johnson was finally ruled eligible for assistance in November 2007, but early in February he was still being assessed. That month, he slipped into a diabetic coma and died.

Nickles said that new safeguards would ensure that others in the same situation would be visited more quickly and provided assistance. He said that if Johnson were alive today, his case would be treated differently.

"None of the employees who previously worked on this case will be working at intake," he said. "They've been replaced with new employees who have been trained and who are now implementing new processes and enforcing standards."

Identities of the three employees let go were not released. Nickles said one employee left voluntarily, one was fired and the third was a "private matter."

Additional inquiries will determine whether other employees should be disciplined, Fenty said.

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