Magbie Experiences Respiratory Distress at [Correctional Treatment Facility] September 24.

[District Fire and Emergency Medical Services] paramedics arrived at approximately 9 a.m. During an interview, one stated that they found Magbie 'unconscious, very sweaty, and sitting at a 45-degree angle in his wheelchair.' His diaper was saturated with 'very dark' urine and his catheter drainage bag was filled with 'tea-colored urine.' One of the paramedics stated . . . that it appeared that 'Magbie had not been cleaned for several days.' His pupils were fixed and dilated. Paramedics could not get Magbie to respond verbally to a 'pain stick' or to ammonia.

Both paramedics stated that the CTF physician they consulted upon arrival informed them that Magbie probably had been in this state for several hours before being noticed. . . . They assessed his vital signs as unstable and determined that he needed to be transported to the hospital immediately. . . . The paramedics stated that they were delayed approximately 20-30 minutes because CTF officials would not let them leave before transport paperwork had been completed and Magbie's blood sugar level had been taken. [CTF physicians denied this when interviewed.]

The paramedics could not get their stretcher into Magbie's cell, and the medical staff did not know how to operate his wheelchair in order to move it into the hallway. Consequently, Magbie was lifted out of his chair and taken out of the room to the stretcher.

One paramedic stated that while they were trying to move Magbie out of the CTF as quickly as possible, a correctional officer was trying to handcuff Magbie.

-- Excerpt from "Special Report: Quality of Care Issues Related to the Custody of Jonathan Magbie," October 2005, by the Office of the Inspector General, Government of the District of Columbia.

This is the 12th column to be written about Jonathan Magbie, a 27-year-old man who was paralyzed from the neck down at age 4 after being struck by a drunk driver. Magbie lived at home with his mother, needed private nursing care at least 20 hours a day and was totally dependent upon others because he couldn't use any of his limbs. He got around in a motorized wheelchair that he operated with his mouth, and his breathing was aided by a tracheotomy tube and an implanted diaphragmatic pacemaker.

Of all the accounts obtained and reported about Magbie's treatment while in custody of the D.C. government, this IG report, which I obtained from a confidential D.C. government source, contains, by far, the most horrifying and disgusting details. It documents incompetence, neglect and dishonesty. And it describes the unforgivably slovenly behavior directed toward Magbie once Superior Court Judge Judith Retchin so inexplicably turned over a quadriplegic to the D.C. Department of Corrections on Sept. 20, 2004.

And why?

Because Magbie pleaded guilty to the possession of marijuana found in his vehicle, which was being driven at the time by his cousin. Magbie, purchaser of the weed, was a first-time offender. Retchin, who the record shows was fully aware of Magbie's incapacitation, nonetheless sentenced him to 10 days in the D.C. jail, to be followed by probation and the payment of a $50 victim's assessment.

The city got its hands on Magbie on Monday. By Friday, he was dead.

We now know the truth -- or as much as can be learned without a public trial with witnesses forced to testify under oath -- thanks to City Administrator Robert Bobb, who refused to accept an obscenely weak investigative report by the D.C. Health Department's Health Regulation Administration that was issued a few months after Magbie's death.

The IG's 64-page report should be a must-read for Retchin, Superior Court Chief Judge Rufus King and all other judges and magistrates who sentence men and women to the custody of the D.C. Corrections Department. The correctional officers and medical staff who handled -- or, more accurately, mishandled -- Magbie are still in place, drawing their paychecks.

Phil Mendelson (D-At Large), chairman of the D.C. Council's Judiciary Committee, which oversees Corrections, and David Catania (I-At Large), chairman of the Health Committee, which oversees the Health Department, must also read this report. The agencies under their jurisdiction make a mockery of the council's vaunted oversight.

Oh, yes -- the bureaucracy can produce written policies and procedures that make them appear as models of efficiency, as the IG report notes. But noncompliance, as in Magbie's case, is the rule. Those departments are, in truth, peppered with full-strength, trifling workers who get by doing next to nothing, all on the taxpayers' dime. The problem is that most of their supervisors, quality-wise, aren't much better.

This much we now know, thanks to Mr. Bobb and the IG:

* The D.C. jail could not provide Magbie with the ventilator he advised both the jail and Greater Southeast Community Hospital that he needed. Magbie was taken to Greater Southeast the first night of his incarceration because of respiratory distress, but the hospital nonetheless sent him back; Greater Southeast staffers "knew there was no ventilator at the jail," the IG reported. No rationale for that decision could be documented.

* The CTF and the D.C. jail, despite Retchin's representation in court, were not prepared to accommodate Magbie's medical needs.

* The CTF's nurses did not follow doctor's orders, properly document their care or give the full range of treatment and care ordered and required.

* There is no documentation that CTF physicians made daily rounds, no physician progress notes for two days of Magbie's incarceration, no up-to-date information on his health, progress, changes or needs.

* There is no Health Department oversight of the CTF and jail medical operations, thus allowing both to function "at higher risk for undetected, systemic problems and medical errors that could affect inmate care and health," the report says.

The detailed description of their noncompliance is enough to make the blood boil.

The IG lacked authority to investigate the Superior Court's officers and employees involved with Magbie. Too bad. The court will never tell on itself. So we may never learn the fate of the medical-alert form that Magbie's lawyer filled out about his client's condition as Magbie was taken off to jail after sentencing.

The IG report said a Superior Court official stated that a court employee gave the form to two contract correctional officers who took custody of Magbie. The correctional officer who received the court paperwork stated, however, that it did not contain a medical-alert form on Magbie.

We don't have an independent evaluation of actions by Superior Court judges, officers or employees, who by law are above the city's reach. Don't count on any help from the D.C. commission that oversees judicial conduct and is chaired by William Lightfoot, a personal-injury lawyer and former politician. I'd rather turn to the three blind mice.

Maybe with the Superior Court's congressional protector, Rep. Tom DeLay (R-Tex.), occupied with his own problems, Capitol Hill will review the court's actions both before and after Magbie's death. Otherwise, the public and Magbie's family will be treated with the contempt that court officials reserve for inquiring minds in the press.

Finally, I would urge a close reading of the IG's page of contradictory statements -- a list of conflicting testimony by witnesses with direct knowledge of the events involving Magbie. Truth, unfortunately, is still taking a beating.

But the tragic and unnecessary death of Jonathan Magbie may have one saving grace: We've finally got the goods on a rotten system.