Invisible Deaths The Fatal Neglect of D.C.'s Retarded Clockwise from top left: Sheila Payne, Fred Brandenburg, Desmond Brown, Gloria Davis, LaVon Green _____ Related Graphics _____ • Scores of Deaths, No Investigation • How the Dead Were Found _____ Live Online _____ Post Staff Writer Katherine Boo was "Live Online" on Dec. 6, answering your questions. • The Discussion _____ Previous Series _____ Invisible Lives: D.C.'s Troubled System for the Retarded • March 14: Forest Haven Is Gone, But the Agony Remains • March 15: Residents Languish; Profiteers Flourish • May 4: U.S. Probes D.C. Group Homes The Names of the Dead, 1993-99 Blue hyperlinks = photos; Brown hyperlinks = related documents. Josephine Gaines • Marjorie Haas • Earl Veit • Donzer Ray Fonville • Marie Dickens • Vernon Brown • Dora Mae Christian • Deborah Lynn Key • Theodore Turner • Ruth Mae Boaze • Richard Smallwood • Cheryl Ann Bush • Patrick Wyman Dixon • Robert Allen Watts • Nancy Williams • Joanne Marie Curtain • Alonzo Fouch • Helen Andrews • Calvin Nielson • Joyce King • Richard Julius Braddy • Joshua Brooks • Viola Tillyer • Ernest Durity • Kevin Paul Turner • Marguerite Spaulding • Brugiere Palmieri • Steven Vasquez • Cecil Gobble • Lee Robert Shipman • Isaac Lloyd Williams • Male, full name unknown • Daniel Bern • James Scott • Reginald Lovette • Antonio McCullers • Betty Tunstall • Lawrence P. Toney • Hazel Harris • Phyllis Mallory • Female, full name unknown • David Abney • Stephen Sellows • Dorothy Simmons • David Wyatt • Full name unknown • Peter Chipouras • Grace Marie Arnold • Antonio Silva • Eugene Robinson • John Wesley Hanna • Clara French • Levander Johnson • Unknown female • Male, full name unknown • Eduardo Echaves • Kenny Holmes • Female, full name unknown • Female, full name unknown • Emma Williams • Cassandra Cobb • James Henry Wilson • Henrietta Green • Kenneth Arnold Gavin • Denise Allison Smith • Steve Edward Moore • Melvin Seymore • Fred Brandenburg • Freddie Deperini • Francis Hanfman • Sheila Payne • Louis Parnell • Gloria Marie Davis • Roy Calloway • John Motika • Raynard Olds • Herbert Scott • Sara Walford Martin • Tony Snider • Helena Taylor • Male, full name unknown • Charles Rowley • Kermit Gleaton • Gary N. Thomas • William Hillery • Full name unconfirmed • Michael Gilliland • Full name unknown • Antonio Lucas • James Fairfax • Male, full name unknown • Lemeka Edon • Eleanor Gleason • James Smallwood • Full name unknown • Male, full name unknown • Margaret Marie Bicksler • Hilda Redman • LaVon Green • Christopher Lane • Thelma Goldberg • Henry Laker • Dennis Edward Jackson • Carlis Spears • Nannie Jones • Reginald Murray • Desmond Brown • Hazel Pinkney • A. Rowe • Geraldine Howell • Patrick Dutch • James Dean • Joseph Addison • Annie Williams • V. Bennett • Woman, full name unknown (City records regarding the mentally disabled contain a variety of spellings for certain names.)

A Legacy

A short story and an old one: In the 1980s, an entrepreneur named Weldon Ferguson opened a home for the retarded on 14th Street NW. In 1987, a doctor examining one of Ferguson's residents found evidence of what he termed "sexual violation." And in 1988, six retarded men who had lived at the home told a Channel 9 reporter that Ferguson had been molesting them in their bedrooms for years and that DHS officials had - also for years - ignored their pleas for help. The story aired, the police swept in, and Ferguson pleaded guilty to assault with intent to sodomize, for which he got a short suspended sentence.

The end. Almost.

One of the deaths for which DHS lost records was that of LaVon Green, who'd been among those who told a grand jury he'd been a victim of Ferguson's assaults. Channel 9 reported that Green contracted HIV while living at Ferguson's house. He died of complications from AIDS last year. Weldon Ferguson, who said in an interview he did not have HIV, was never ordered by the court to take an AIDS test.

Asked whether other former residents of Ferguson's house had died similarly, DHS spokesman Andrews said: "We can't find the answer. We just don't know."

They were unlikely money magnets, the refugees from Forest Haven, with their trash bags of clothes and stuffed animals. But as $1 billion flowed into D.C.'s group homes to pay for their care, charitable agencies were supplanted by entrepreneurs - in pronounced contrast to the situation in other states. To keep the new providers honest, DHS had a handful of social workers who had come to the city to be part of a nationally celebrated reform. But city officials acknowledge that much of the task of analyzing medical records and challenging the accounts of the new businesses was delegated to workers who had previously given sponge baths and spooned applesauce at Forest Haven.

Some of those new case managers cared deeply about clients they'd watched grow up, but DHS officials had a vested interest in never training them to investigate deaths. These officials had weathered blistering criticism for conditions at Forest Haven and then, under court-imposed deadline, had personally chosen the group home operators who would supplant the asylum. If these new homes were found wanting, where would the residents go?

Today, the impulse to extenuate the circumstances of death is quickened by a fear of liability. As city officials note, some low-income families see a death by scalding or by broken neck as an opportunity for windfall litigation. Because retarded people have little lost-earning potential, big settlements are rare. Still, one mother contacted by The Post about her son, who died this year, asked "America to know my pain" and a reporter to find her a lawyer. She last visited her son, she later noted, in 1989.

DHS's unwillingness to investigate is facilitated by a city agency that should be the last bulwark of accountability: the medical examiner's office. Many jurisdictions require an autopsy on all deceased public wards who did not have documented organic diseases. D.C.'s Chief Medical Examiner Arden previously worked in New York City, where autopsies are performed on approximately 90 percent of retarded wards. The District has no such policy mandates. Only one in 13 got a completed autopsy, The Post found. In several cases, bodies sent to the morgue were left unexamined, without explanation, by city pathologists.

"If you're going to point fingers, point here," said Arden. "We didn't investigate when we should have. We didn't do right by these men and women."

Then again, the vast majority of the retarded dead never arrived at the morgue in the first place. City records show that, even when signs of neglect had been documented, DHS officials consistently failed to request autopsies for retarded people without families - people for whom the agency served as the de facto "next of kin."

And sometimes, as with a woman named Betty Tunstall, they closed the file with even fewer formalities.

As the decade began, Tunstall embodied the transforming promise of the group home system. Today, hers is a life twice lost.

After Forest Haven, where she had lived since the Truman administration, Tunstall was placed in a Southeast group home owned by a company called We Care, whose director was a former aide to Marion Barry. We Care received $154,000 per client per year, one of the highest Medicaid rates in the country. After Chapter 11 bankruptcy reorganization, six settled sexual harassment suits against its director and allegations of misspent funds, the organization has been renamed Individual Development Inc. and is chaired by David Wilmot, one of Barry's longtime personal attorneys. "I don't know what those guys were doing, frankly," said Wilmot, who said his homes, which are managed by Voca, now provide excellent care.

There was a robust cocaine trade in Betty Tunstall's new front yard, former staffers recall. Nonetheless, deinstitutionalization would suit her.

Nonverbal, said the Forest Haven records.

"Pork chops and fries," Betty Tunstall said one night at the sight of her favorite dinner, rendering her caretakers bug-eyed at the stove.

After 40 years, Tunstall was pushing boundaries, finding words. "Look," she demanded, as she turned on the house radio by herself. She mastered the essential pronoun of communal living: "mine." This was the miracle that reformers had worked to witness - what they dreamed their legacy would be.

For five years now, this miracle has been buried in an unmarked plot in Prince George's County that even the cemetery director gets lost trying to find. How Tunstall got there, DHS records do not say. She was interred at age 50 but never officially declared dead. City officials shelved her case without a death certificate.

It's illegal in the District to bury a person without certifying death. "Very unusual," said Urbane Bass, head of D.C.'s vital records agency. "It's a crime." Also a mystery. What happened to the $70 monthly disability checks that, Social Security Administration records show, group home administrators kept receiving in her name for months after her unrecorded death?

It would be easy, given cases such as Brandenburg's and Tunstall's, to paint life inside group homes in the hue of Clockwork Orange. The reality is subtler: an incremental coarsening of sensibility. Take the big white house on Maple Street NW - the one with Christmas garlands bedecking the portico - where lived gentle, 28-year-old Reginald Lovette.

Lovette's roommate, a 250-pound retarded man named Bernard Eaton, had his grievances, as roommates do. He thought Lovette touched his television, snored too loudly, got preferential treatment from the staff. Eaton sometimes registered his protests by attacking Lovette while he slept (See Document). When Lovette was awake, police documents show, Eaton frequently attempted to strangle him.

Lovette, who city records say had come into government care after a violent childhood with a psychotic father, repeatedly asked staff members to shield him from what they would later describe as "constant abuse." But Lovette was left to share a room with Eaton. And DHS left uninvestigated a series of reports by the home's neighbors. Residents were wandering the streets, confused and unattended. Residents were in the back yard, chilled and naked, with none of their caretakers in sight.

And then one night just before Christmas 1994, Eaton succeeded in an act he'd been edging toward all year. He strangled Lovette with a baby-blue bedsheet.

Police reports describe the battleground: bed and nightstand askew, pillow gory, body in checkered pajamas splayed on floor. The scene comported with what Eaton confessed. Not long after midnight, he had a prolonged fight with Lovette before getting the sheet to strangle him. But the employees in the home - charged with checking hourly on Lovette and his housemates - didn't rush to the rescue. Police and health department records show they were missing in action all night and didn't find Lovette's body until after 7 a.m., by which time rigor mortis had set in. After discovering the killing, health inspection records show, staffers did nothing. Only when a member of the morning shift appeared 20 minutes later did someone decide to call the police.

Health inspectors subsequently arriving on the scene noted a tangential oddity: There was no food in the house for the residents to eat. As the group home's owner, Samelia Green, would later explain to inspectors, the staff supervisor had probably falsified grocery store receipts and pocketed the cash meant to finance a week of clients' meals.

Who exactly were Lovette's caretakers in the house on Maple Street? A check of District and Maryland criminal records indicates that they included a convicted cocaine dealer, a convicted crack dealer and a twice-convicted thief and crack user who had just been released from jail.

To care for the retarded in, say, Florida, one must pass a criminal background check, secure an FBI clearance and attest in writing to exacting standards of moral character. The District recently put a similar law on its books, but city administrators have yet to do the necessary paperwork to enforce it. No effective curb on criminal caretakers. No trace of a response to panicked neighbors. No protection for a young man in bed. And after Lovette's killing, little change.

Eaton, who under D.C. law could not be held responsible for the homicide because of his mental deficiencies, went to live with his mother in Northeast

Samelia Green, who declined to comment, continued collecting her public money. Felons went on caring for the survivors. And DHS officials didn't supply a single record on the case.

Desmond Brown's fingers curled inward like rams' horns. His slender torso was a permanent L. He was retarded. He was blind. And what of it? He cranked his favorite Santana tape and decided he could dance on his knees. If fate had played a trick on him, he seemed to get the joke. Among so many limits, said his presence, there may still be so much life.

Two years after city and group home officials concealed the truth of the death of Fred Brandenburg, 38-year-old Desmond Brown was in another home owned by dentist Arthur Stubbs.

One rainy day in January, Brown, who had cerebral palsy, got wet. In city files, there is one version of what happened next: a 10-sentence memo, titled "Investigation," by Stubbs's partner, Sheila Gaither (See Document). It says Brown came down with a cold but quickly recovered. When his "cold symptoms" returned a week later, group home officials whisked him to the hospital.

City records and the accounts of his group home and day program caretakers provide a painful counter-narrative. From late January to late February 1999, Brown's care supervisor, Patricia Thorpe, repeatedly petitioned superiors to give the "sick," "unresponsive" Brown treatment stronger than Sudafed. "He was distressed, and I felt we shouldn't take chances," Thorpe said in an interview. But company officials declined to take Brown to a doctor.

"They'd say, he's fine, just give him soup, give him water," recalled Genevieve Ruffin, a veteran aide at Brown's group home and one of four DCFS staffers who noted that dialing 911 without authorization can get a person fired. "When Desmond couldn't eat, they said it was a 'behavior problem,'‚" Ruffin said. "I mean, even I could tell by looking at him - it was pneumonia."

As Brown was wasting away, residents of other DCFS homes were hurting, too. Health inspectors found that one woman had been improperly treated for respiratory distress, two others had been repeatedly and improperly tranquilized, and many more weren't getting medical treatments that had been ordered by their doctors. Meanwhile, crucial day-to-day care was being handled by a crew of minimally trained welfare recipients. DHS had given Stubbs and Gaither a multimillion-dollar contract to help D.C. welfare mothers find jobs. Until it was discovered that a DHS official involved in awarding the contract lived in a home owned by Stubbs, the deal gave the dentist and his partner a double windfall: bonuses from their welfare-reform contract for placing workers in jobs and tax credits at the group homes for hiring welfare recipients. Somewhere near the bottom of the incentive structure ranked the life of one Desmond Brown.

"Saving money, saving money: That's all we heard," said Thorpe, who eventually took a job in the Maryland group home system.

Brown couldn't negotiate a similar exit.

"Step out!" he'd regally gesture when his guardians irked him - a stylish cover for a physical fact: Brown himself was trapped. He grew sicker, until one Friday night his labored breathing and shaking left his caretakers almost as distraught as he was. But as with Brandenburg, the problem was kept inside the house. Sweat poured off Brown's emaciated body, records and interviews show. He tore at his clothes in anguish. He gasped for air. But DCFS supervisors decided that he didn't require the services of a doctor. Brown was "doing fine" that Friday evening, says the brief DCFS "investigation." He was desperately ill, say interviews and city records. In the house ledger, Ruffin and a co-worker detailed more than Brown's unremedied suffering. They recorded his horrified recognition.

"I am dying," a retarded man informed his caretakers. "I am going to die."

It was as if, in that moment on the last night he ever spoke, the blind man could see what lay ahead. The Saturday morning when Gaither granted permission to take him to Providence Hospital. The emergency tracheotomy. The immediate dispatch to intensive care, where yellow ghosts attended in isolation gear. The silvery balloon for his 39th birthday, hovering above a tangle of plastic tubes. And then a casket crammed alongside 11 other caskets in a single cemetery plot.

Like so many others failed by the government that promised to save them, Desmond Brown in the end received a group grave with a plastic marker.

On that marker, another joke Brown might have gotten. No name, just the digits 137. A number, as if someone were counting.