If individual cases are grim, the aggregate is startling. While the exact number of retarded people who died since 1993 is unknown, the 116 that The Post counted would give the District a death rate far higher than that of similar jurisdictions.

The study of mortality among the deinstitutionalized retarded is still in its academic infancy: Data sets are small, government numbers vary in reliability, and medical issues differ among populations. Still, the District has had more than three times the number of deaths found in a roughly equivalent New Jersey population and twice as many as found in a Pennsylvania population. The District's death rate significantly exceeds that of California's troubled group home system, where University of California-Riverside faculty members have been extensively researching mortality in community-based care.

"I wonder somewhat," said Wesley Vinner, a high-functioning retarded man who grew up at Forest Haven. "It's like we're dying left and right in programs that say they protect us."

One reason, The Post found, is that city officials repeatedly failed to recognize and correct disturbing patterns of neglect.

In 1990, when examining deaths at Forest Haven, Justice Department investigators spotted one particularly alarming trend: Residents were dying of aspiration pneumonia, which sometimes occurs when the bedridden are fed inexpertly and fluids build up in their lungs. A prominent D.C. law firm, acting pro bono, sued the city on behalf of six dead Forest Haven residents, alleging delayed and inadequate treatment. The District settled for more than $1 million.

The Post, reviewing death certificates and hospital records, identified 10 aspiration-related deaths since 1993 in group homes scattered across the city. None of those deaths prompted an investigation by city officials, records show.

Tony Snider, age 26. Sheila Payne, age 32. Steven Vasquez, age 39. Midway down the aspiration death list is Gloria Davis, a much-loved competitor in the ball-toss at the Special Olympics, who died at age 33.

Profoundly retarded people such as Davis can't articulate pain, which is one reason their caretakers, the good ones, are remarkable to watch. They develop a hyper-perception that lets them scent an infection, read pain in the blinking of an eye. Davis, nonverbal and nonambulatory since birth, had been placed, after Forest Haven, in what was supposed to be a bastion of such sensitivity. The Astor Place SE group home where she lived is one of 34 in the District owned or managed by Voca, a division of a Louisville-based corporation, and supported by $25 million a year in federal funds. Its direct-care workers earn as much as $12 an hour, and its foyers are fresh from the broom. But troubling deaths happened in Voca's homes, too.

One evening in 1997, the company's records show, Gloria Davis started spewing mucous from her nose and mouth - the hallmark of a major aspiration. Davis alerted caretakers to her distress the only way she could - by shaking her bed. This cry for help was heard at 10 p.m., house records show. But her caretakers didn't dial 911. They dialed group home administrators. Records show that a series of conversations ensued - about the fact that Davis was struggling to breathe, that "the situation was getting worse," that an ambulance should be called. But 70 minutes passed before anyone actually called one (See Document). Too late. Davis arrived at the hospital a few minutes before midnight and was declared dead.

Voca's initial accounts of the evening understated by 40 minutes the interval between Davis's distress signal and the call to 911, company records show. Cleveland Corbett, vice president of Voca, said that the inaccuracy was an inadvertent error on the part of harried caretakers and that he "wouldn't second-guess the staff's judgment" on the 70-minute delay.

A month after Gloria Davis's death, at a home run by Voca in Northeast, 42-year-old Raynard Olds had a seizure so propulsive that his head left a hole in his bedroom wall. His neck was critically injured on impact. A caretaker came immediately to find him on the floor, fully conscious. I can't get up, Olds explained. Ambulance records show he didn't arrive at the hospital for an hour and a half after his violent fall. He died a month later from his injuries. Voca's Corbett described the time lapse between injury and hospitalization as "appropriate given the professional judgments involved."

Kenny Holmes, who lived in a Voca home three blocks from Olds's, also had to wait for care. He swallowed three small plastic bags while his counselor enjoyed a "fish and bread" dinner.

Profoundly retarded, Holmes interpreted the world through his mouth, like an infant, but with the dangerous coordination of an adult. He swallowed whole corncobs, ate his own shoelaces. Unable to speak, he couldn't call for help when help was required. That's why Voca was paid $90,000 in public funds per year to keep him safe.

One August night, caretaker Linda Bowers settled in with her dinner on the couch.

According to an account she wrote of the evening (See Document) - an account Bowers described in an interview with The Post as accurate - when Holmes emerged from his bedroom and obtained her attention, she sent him back inside and continued eating. He retreated but then came out again. Go back to your room, she told him more firmly, not leaving her meal. Again he did as he was told. Back in his room, he finally got her attention - by issuing a great and stomach-turning gurgle, turning blue and thrashing on the floor. Bowers panicked and neglected to perform the Heimlich maneuver she had been trained to do, Voca records show. When Holmes got to the hospital, there was little to be done. He was declared dead of asphyxiation.

Voca's "discharge summary" (See Document) to DHS omitted Holmes's attempts to obtain Bowers's attention and said Bowers called an ambulance 40 minutes before ambulance records show she did. Corbett called Bowers a caring employee and said, "I believe the staff provided the information as they knew it at the time."

If Holmes had died five blocks east, in Maryland, the government would have sent a registered nurse to the scene to interview staff. A physician would have scoured his medical file, and a University of Maryland professor of pharmacology would have studied the drugs he had been taking - their adequacy and interactions. By governor's fiat, Maryland's state health department investigates every death in group homes except those of residents who have been diagnosed as terminally ill.

If Holmes had died in Delaware, the questioning of staff would have been led by a state long-term care official who is a former FBI investigator.

If Holmes had died in Missouri, his group home might now be shuttered. Four months after Holmes's death, a retarded man in a St. Louis facility swallowed rubber gloves and choked to death in his bedroom as a caretaker sat nearby. State officials conducted a months-long investigation, identified systemic shortcomings and closed the home.

But Kenny Holmes died in the District of Columbia. Voca executives carried out the only review done on his death. Bowers, those officials concluded, required a training session in "calmness." She remains a caretaker with the company, about which Corbett can say accurately, "The city has never had a problem with us about deaths."

Breast cancer. Massive cardiac events. The complex medical conditions associated with Down syndrome. Some deaths The Post found were inevitable, and a few - at the nonprofit Kennedy Institute, at the for-profit Metro Homes - were thoroughly, even mournfully, documented by group home officials. But some of the deaths that weren't, like that of Helen Andrews, had consequences that resonated beyond group home doors.

Eating her morning Cheerios, climbing a single flight of stairs - even the basics seemed to tax her. Languid outings with her day program sometimes left her gulping for air, which was discomfiting to a 70-year-old with good manners. The high-functioning Andrews lived in a caring home run by the nonprofit Black Leadership and Christ's Kingdom Society, whose staffers regularly delivered her to the internist with whom it contracted for residents' care. Group home records show that in April 1994, Fumikazu Kawakami, observing that Andrews had been "deteriorating significantly" for six months, diagnosed her condition: She was suffering from arthritis and depression.

Twelve days after he wrote her a prescription for an antidepressant called Zoloft, records show, she was dead of treatable, contagious tuberculosis.

Kawakami did not return a reporter's phone calls. City officials turned over to The Post a single document on Andrews's death, after inking out every fact but the date and the cause of death: "Tuberculous."

TB deaths, rarities in the metropolitan area, tend to make headlines and inspire mass testings, as the pernicious airborne bacteria can be passed to others in as little time as it takes an elevator to go from the first floor to the fifth. Fortunately, the vast majority of those infected can be cured with a low-cost course of antibiotics - if they learn they've been exposed.

"I'm appalled," said Tom Wilds, president of St. John's Community Services, where, until she grew too weak to attend, Andrews was in a day program with a dozen other retarded people. "Our clients and staff were exposed, and I am just learning this now?"

Next Page

Page One | Two | Three