Invisible Deaths The Fatal Neglect of D.C.'s Retarded Clockwise from top left: Sheila Payne, Fred Brandenburg, Desmond Brown, Gloria Davis, LaVon Green _____ From Sunday's Post _____ • Main Story: System Loses Lives and Trust • Graphic: Scores of Deaths, No Investigation • About This Project: How the Dead Were Found _____ Follow-Up Stories _____ • Williams Promises Accountability (Dec. 7) • D.C. Official Suspended in Probe of Homes (Dec. 9) _____ Online Extra _____ • Three Things You Can Do to Help _____ Live Online _____ Post Staff Writer Katherine Boo was "Live Online" on Dec. 6 and Dec. 9. • Dec. 6 Transcript • Dec. 9 Transcript _____ 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.)

District officials yesterday reopened two homicide cases and announced plans to revamp their oversight of 150 group homes for the mentally disabled in response to a Washington Post report that the city routinely fails to investigate when retarded residents die under questionable circumstances.

D.C. Department of Public Health Director Ivan C.A. Walks said he plans to set up a permanent interagency panel that will review records and circumstances relating to deaths of adults in District custody, including the mentally disabled and the elderly.

"I didn't realize things were this bad," said Walks, who became the city's chief health officer in September. "I'm not going to sit quietly and let other people not do their jobs. It's not going to happen."

The panel, Walks said, could be started in a matter of weeks and would include D.C. Chief Medical Examiner Jonathan L. Arden, Department of Human Services Director Jearline F. Williams and representatives of the police and fire departments and other agencies that have any role in handling such deaths. The city, he noted, has a panel that reviews deaths of foster children.

The District spends nearly $100 million a year in Medicaid and city funds to house, feed and look after the needs of about 1,190 mentally disabled residents. But responsibility for their well-being is split among numerous agencies – which have made virtually no effort to look into the actions of group home operators when residents die.

"We need to be much more aggressive about how we interact with the city's most vulnerable folks," said Walks, who said the fatality review committee would give the city a "single fixed point of accountability" to ensure that each agency responds properly when deaths occur.

Officials also promised to step up oversight of Medicaid fraud and abuse and to establish clearer regulations requiring group home operators to keep better records of injuries and unusual incidents.

However, earlier promises to reform the system have not yet been carried out. After a Post series in March on unchecked abuse in the homes, city officials said they would swiftly implement an existing law that allows the levying of stiff fines on homes that maltreat the retarded. The necessary paperwork remains to be done.

And this fall, as the mayor called reforming the group home system a key challenge on which his administration might be judged, city attorneys successfully moved in federal court to seal from the public the results of a Justice Department civil rights probe of those homes.

D.C. Executive Assistant Police Chief Terrance W. Gainer, who at the request of The Post examined police records on the deaths of two residents, said yesterday that he has assigned homicide detectives to complete the work that should have been done when those residents, Fred Brandenburg and James Scott, died.

"It's frightening and embarrassing that a city and an agency could let people down like this," said Gainer, who cautioned that the missing documentation and the age of the cases will make it difficult to determine whether criminal or administrative wrongdoing occurred. Scott died in 1994 and Brandenburg in 1997.

U.S. Attorney Wilma A. Lewis also said yesterday that the age of the cases and the lack of surviving evidence will hamper any follow-up investigation. She called the performance of the group homes "severe neglect bordering on possible criminal wrongdoing." But she stopped short of saying she will launch specific investigations and emphasized instead her commitment to help city agencies with theirs.

D.C. Mayor Anthony A. Williams (D) was traveling and unavailable for comment yesterday, but his chief of staff, Abdusalem Omer, said The Post article left him outraged.

"This government is broken," he said. "The culture in this government is in serious trouble, and this is what the mayor has been talking about since he came to office."

Omer added that the issue isn't money. The District has one of the most lavishly funded group home networks in the nation.

"There are enough resources," Omer said. But if more are needed to protect vulnerable citizens, he said, "we'll just have to find them."

The Post tallied 116 deaths in the D.C. group home system from 1993 through September 1999 – 47 more than the Department of Human Services (DHS) had been able to document. Of the 86 cases in which The Post could find a cause of death, there was documentary evidence in 34 cases of delayed treatment, neglect, falsifications in records or other lapses.

Although D.C. Department of Human Services officials had previously asserted that deaths were regularly investigated, they were unable to document a single review going back to 1993.

Government officials and outside professionals who deal with the system said yesterday's article left no room for excuses.

"We really do need to stop killing people," said Kathy Patterson, chairwoman of the D.C. Council's government operations committee. "The circumstances described [in The Post] are simply unacceptable."

"If the mayor fails to act vigorously and successfully, then I think the U.S. Congress should do so," said Eunice Kennedy Shriver, co-founder of the Special Olympics and a longtime activist on behalf of the mentally retarded. "This is a national, not just a local, disgrace."

U.S. Rep. Thomas M. Davis III (R-Va.), chairman of the House Government Oversight subcommittee on the District, said the mayor and D.C. financial control board Chairwoman Alice M. Rivlin will be questioned about the group homes at a Jan. 21 hearing that could influence Congress's thinking on whether the control board should be phased out.

"I'm not trying to threaten control over this incident, but when members see this, they ask, 'Is the city really ready for self-governance?'‚" Davis said. "Tony [Williams] has just been there a year, but if he ever needed a mandate to really take control, this is it."

Medicaid pays for most of the group home system for the mentally disabled, but there has been little but finger-pointing among the many Health Department and Human Services officials involved, said former Medicaid director Paul Offner.

"It's going to require closing down a number of these group homes for the mentally retarded," Offner said, "and it's going to be expensive."

Brandenburg, who had a heart condition, died in 1997 after a group home nurse gave him a tranquilizer injection without the required doctor's orders. He was incapacitated for two days before workers at a home run by D.C. Family Services, a private company, called paramedics. After his death, the group home's staff and officials falsified reports and moved and washed the body, the home's records indicate.

Human Services official Frances Bowie told The Post in March that an autopsy was not performed on Brandenberg's body because his two sisters refused to grant permission. Bowie's staff said the sisters, whom they would not identify, were Jehovah's Witnesses and had religious objections to an autopsy.

The Post located Brandenberg's sisters, one a Baptist and the other a Catholic; each said no city or group home official ever asked about an autopsy. Human Services officials now acknowledge they have no evidence to support their previous assertions that the women blocked an autopsy.

A lawyer for the owners of the home, Arthur Stubbs and Sheila Gaither, did not respond yesterday to a call for comment.

Scott was fatally injured in 1994 when group home workers "restrained" him, dislocating his spine and paralyzing him. Nearly two hours passed before caretakers called 911. Scott died a month later. His death was classified a homicide by the medical examiner, but police never investigated.

Gainer said he is working with the U.S. attorney's office to "piece together" the Scott case.

So far, the conditions in the group homes have not become the subject of much litigation even though would-be lawyers want to sign up clients.

Last spring, Patrick Malone, a Washington attorney with a disabled son, assembled a group of volunteer lawyers willing, at no charge, to represent retarded men and women who had been abused in District group homes. But Human Services officials, Malone said, have thus far thwarted the attorneys' efforts by saying that the abused clients aren't mentally competent enough to hire lawyers.

Donna Thornton was one of several retarded men and women around the city yesterday who said they want to believe what the politicians are saying.

"I can't even find the words," said Donna Thornton, a retarded woman in the District government's care whose friends were among those who died. "No one was watching. I do hope it can get better, but right now I am just sad."

Staff writer Katherine Boo will host an online discussion at 1 p.m. today.

Staff writers Darryl Fears and Cheryl W. Thompson contributed to this report.