A retarded 21-year-old District man who died in an overheated seclusion room at St. Elizabeths Hospital in January was "the victim of a systematic death" and was accorded inadequate treatment by a staff "almost completely without training, education or understanding" of his condition, according to a report released yesterday by D.C. Del. Walter Fauntroy.

Emory Lee, who had Downs syndrome, epilepsy, obesity and heart problems, was found dead Jan. 18 in the locked seclusion room where he had been confined on and off for three days.

D.C. public health officials ruled in March that Lee died during a seizure. The report issued yesterday, which was prepared by the staff of the House District Committee, says that Lee was not given anticonvulsant drugs despite his medical history.

"Of the 40 staff interviewed at St. Elizabeths Hospital," the report says, "less than five had had any formal or continuing education in the treatment of the psychiatric disorders of a profoundly retarded, Downs syndrome patient . . . . Almost all respondents stated they had no idea of what to do with Emory other than to treat him like every other patient on the ward and expect him to respond as the others responded."

While the report says there is no evidence of deliberate maltreatment, it questions actions of staff members at D.C. General Hospital, who apparently paid little attention to Lee's medical records, and at St. Elizabeths, who, the report says, falsified observation charts.

St. Elizabeths authorities have disciplined 18 employes in the Lee investigation, members of Fauntroy's staff said yesterday.

The report recommends that St. Elizabeths conduct an audit of the use of seclusion rooms for "dual diagnosed" (retarded/psychotic) patients and that it set up "a full and complete education process" for staff members involved with those patients.

During its investigation, the committee staff discovered that one St. Elizabeths staff member, who made 33 observation entries on Lee's chart, made only nine visits. Another was discovered to have been drinking on duty.

Lee, who had lived with his mother and attended St. John's Child Development Center, was at St. Elizabeths for only a few days of testing. Patricia Smith, Fauntroy's press secretary, said yesterday that the St. John's staff had prepared "an extensive briefing packet" on Lee's medical history and that the packet had been "hand-carried with Emory Lee to D.C. General." But, Smith said, when Lee was transferred to St. Elizabeths, "the packet did not follow."

According to the staff report, Lee's medical records specified that Emory needed "to be admitted to D.C. General Hospital or St. Elizabeths Hospital (locked ward) for reevaluation of his anticonvulsant medication."

However, the report says, the psychiatrist on duty at D.C. General telephoned the St. Elizabeths emergency room asking to have Lee admitted for psychiatric, not medical, reasons. "The need to have his anticonvulsant medications was not discussed."

The staff report released by Fauntroy follows investigations by the District medical examiner's office; the D.C. police department; the National Institute of Mental Health, which certifies the hospital, as well as St. Elizabeths itself.

All concluded that Lee died of his medical condition. However, according to the report issued yesterday, the medical examiner's office was not told of the false documentation.

The office of U.S. Attorney Joseph E. diGenova has said it also will investigate Lee's death.