In yesterday's front-page article about fatal neglect at the District's homes for the mentally disabled, nearly two paragraphs were dropped on Page A33 in some editions because of a production error. The complete story can be read on The Post's Web site, www.washingtonpost.com. The missing text, which dealt with the failure to do an autopsy on Fred Brandenburg, is as follows:

Reopening the case will be difficult. Brandenburg's body was released from the morgue and cremated without an autopsy. In an interview earlier this year, DHS official Frances Bowie, who until recently headed the department's developmental disabilities unit, explained why: Brandenburg's two sisters had refused to permit an autopsy. DHS officials said the sisters, who they said were Jehovah's Witnesses and whom they would not identify, had religious objections to the practice.

The Post located the sisters. One of them, Gloria Donovan, is a longtime member of All Saints Catholic Church in Manassas. The other, Juanita DeButts, worships and teaches Sunday school at the First Baptist Church of La Plata. "We're not Jehovah's Witnesses, and we were never asked about an autopsy," said Donovan, whose brother had just spent the Christmas holidays at her home. "It didn't happen.

The corpse measured 66 inches from blue toes to jutting ears. In a beige house on Tenley Circle, a dentist-entrepreneur lugged this cargo down the stairs into the basement and laid it to rest by the washer.

The body in plaid pajamas was that of a 57-year-old retarded ward of the District of Columbia. On the streets outside the city-funded group home where he had lived and died, kids sometimes called him Retard-O. Inside, he sweetened the hours by printing the name his mother gave him before she gave him up. Frederick Emory Brandenburg. He blanketed old telephone directories with that name, covered the TV Guides the home's staffers tossed aside. He glutted the flyleaves of his large-print Living Bible. The immensity of the effort made his hands shake, but the habit seemed as requisite as breath. In this way Brandenburg, whose thick-tongued words were mysteries to many, impressed the fact of his existence on his world.

In January 1997, that existence was obliterated by his caretakers.

In one of 14 group homes for which the city pays dentist Arthur Stubbs and his partner, Sheila Gaither, $6 million a year, Brandenburg was tranquilized in a staff mix-up, grew acutely ill and, surrounded by caretakers, slowly died without treatment. His body was washed, moved by Stubbs into the basement, and cremated without autopsy. The White Pages emblazoned with his name were dispatched to a trash can out back. His caretakers altered the time and circumstances of his death in records they submitted to the city, house documents show. Government officials who were supposed to ensure his safety kept evidence of wrongdoing from the police. And this summer, after The Washington Post asked questions, Brandenburg's city case manager shredded records on his death. Today, in the name of the privacy and dignity of the retarded, top city officials say they can't publicly acknowledge that a man named Fred Brandenburg was ever in their care.

This erasure of a life was not an exceptional event in what was supposed to be America's most compassionate and costly effort to deinstitutionalize the mentally retarded.

As the 1990s began, a historic reform moved the District's mentally disabled wards from a large, exurban asylum called Forest Haven into a web of small, privately run group homes and therapeutic programs in the heart of the city--programs funded by more than 1 billion public dollars. But in those intimate settings, a Post investigation has found, corporate misrepresentation and city complicity have concealed the facts of dozens of troubling deaths.

In 86 cases from 1993 through September 1999 in which The Post could ascertain a cause of death, it found documentary evidence in 34--more than one-third--of delayed treatment, neglect, falsifications in reports or other lapses.

Among the dead were:

* Profoundly retarded, elderly Calvin Nielson, fatally scalded in a home owned by a prominent developer. An aide left him alone in an overheating shower about which city inspectors had repeatedly complained.

* Herbert Scott, 43, whose decaying corpse was discovered by his caretakers only when the odor snaked under his door into a hallway.

* Antonio Silva, 16, who choked and died when counselors at his day program--the same program where 12 months earlier a boy died unattended in a hallway--couldn't locate paperwork they said they needed in order to suction his pneumonia-ridden lungs.

* Reginald Lovette, 28, who was strangled by his 250-pound roommate. For a year, his repeated pleas for protection had been disregarded by the convicted criminals who served as his group home counselors.

For these four cases, the city's Department of Human Services--the municipal custodian of D.C.'s retarded wards--produced, in seven months, exactly one record: a note from the organization that cared for Herbert Scott saying that his body had been found.

Although DHS officials told The Post earlier this year that many of the deaths had been investigated, a study of records shows that in the face of ample evidence of neglect, DHS hasn't investigated a single death of a retarded person since at least 1993. Only 14 received an autopsy--and six of those autopsies were left unfinished. Government officials routinely closed death cases on the basis of phoned-in or brief written accounts by group home and day-program officials--accounts that, The Post found, were frequently false.

Today, city records on many of those deaths have vanished. In April, using the Freedom of Information Act, The Post requested the records of all retarded persons who died in the city's care since 1993. In June 1999, DHS released heavily edited records documenting a total of 11 deaths. Pressed, DHS officials combed files and surveyed group home operators and by October had documented 69 dead. DHS Director Jearline F. Williams said last month that she could not explain why there were no records on 47 other deaths found by The Post.

Two days ago, DHS officials turned over death certificates that they said represented 114 deaths, at least 45 more than they had previously disclosed. Most of the details on the certificates had been whited out--giving no indication of who had died, where, how or under whose care.

Among public health researchers, fatalities of wards of the state are sometimes tagged "sentinel events": Like lifeless canaries in the pit of the mine shaft, they warn of perils that may await the living. But the D.C. government has for years resisted inquiry--by the press, by a federally funded advocacy group and even by the U.S. Department of Justice--into deaths within its taxpayer-funded network of care.

"We have a sacred trust to ensure the well-being of our most vulnerable clients," Mayor Anthony A. Williams said in July, after blind, retarded Patrick Dutch died of heat exhaustion when his caretakers forgot him for seven hours in a locked and stifling van. But the city's own records reveal a system that, buffered from public scrutiny, failed that trust.

The Post investigation used District medical examiners' records, DHS and Department of Public Health documents, funeral home and cemetery databases, Social Security death records and more than 200 interviews with retarded people and their caretakers, families and doctors to develop an accounting of who died and how.

In interviews, top officials of DHS, D.C. police, the health department and the medical examiner's office did not attempt to defend their agencies' handling of deaths among the retarded. "The system is broken," said Jearline Williams in response to The Post's findings. "The families of the dead have my sympathy, they have the District government's sympathy."

Williams and other agency heads said that, with the help of the District's inspector general and the U.S. Department of Health and Human Services, they were working frantically to initiate structural changes and investigate abusive contractors and negligent city employees. "We can't sit back and cover up things," said Williams. "It took a long time to get to this state, and it is going to take time to fix. But I promise that there will be radical changes, starting now, to ensure that those still in the group homes are safe. This will never happen again."

Some of the city's unrecorded dead lie in a Northeast cemetery: numbered discs, silted over, in rows by a chain-link fence. Others rest elsewhere, in unmarked group graves or plastic cartons. A tour of these shadowlands might begin with Fred Brandenburg. Although his body was cremated before burial, interviews and extant city records allow an account of his death to be exhumed.

At Forest Haven, where Brandenburg grew up, a child-size wheelchair is draped in reindeer moss. A stand of scrub oaks is shrouded in yellow steam, the off-venting of a nearby juvenile jail. If Brandenburg had died at this remote Laurel asylum in the final years before its court-ordered 1991 closing, the Justice Department would have sent in medical experts to find out why. A federal suit filed by residents' families had exposed so much medical neglect that Justice's civil rights division had joined the action, investigating every fatality.

But a 1997 death inside a D.C. Family Services house in Tenleytown--where the court rescue had eventually deposited Brandenburg--would be a far more secretive affair.

Stubbs, co-owner of D.C. Family Services, told The Post early last month that he was too busy to answer questions about Brandenburg's death, or other deaths in his homes, and did not return subsequent phone calls. His partner, Gaither, who is the company's executive director, also did not return repeated calls. Last week, Stubbs and Gaither, through their lawyer, declined to comment.

Employees observe that Stubbs doesn't often visit the 14 homes for the retarded that had helped him buy his own million-dollar home off Foxhall Road. But on Jan. 10, 1997, his presence was required.

For two years his company's nursing staff had failed to carry out a cardiologist's orders for medicating Brandenburg's long-standing heart condition, health department records show, while improperly medicating one of his housemates with Valium. On Jan. 8, Brandenburg, who was rarely sedated, was tranquilized, too. And something went wrong.

That morning, a staff nurse gave him an injection of Ativan without the required doctor's orders, city records indicate. The nurse did so, group home records show, in the belief that another staffer would be taking him to a minor medical test that might frighten him. Brandenburg would not make it to any test. For the next two days, records show, Brandenburg couldn't stand without assistance and could barely open his eyes. He sweated and shook; staffers trying to make him eat saw bread fall from his lips, unchewed. But group home officials did not call a doctor or dial 911.

Nor did a health department inspector who happened to come to the house Jan. 8 for an annual survey of the home's quality of care. She found Brandenburg in a stupor on a back-room couch. The home's records indicate that staff members sought to hide the extent of his incapacity. They weren't successful. Over the next two days, records show, the inspector diligently documented Brandenburg's poor condition--and her discovery that the staff had lied to her about the circumstances surrounding the tranquilization. But she left the house without taking action to secure treatment for him.

Early the next morning, his stupor ended.

House logs and other records say that counselors checked Brandenburg every 15 or 30 minutes in the early hours of Jan. 10. Then at 5:30 a.m., his breathing suddenly grew labored, they said, so they dialed 911.

But ambulance records and staff interviews indicate that paramedics who arrived four minutes after the 911 call found a body already cold. Brandenburg had been dead for hours.

Police officers arrived soon after the paramedics, as they do for sudden deaths in private homes. Officers didn't note the discrepancy between house logs and a stiff corpse, records show. Nor did they learn of the tranquilization and the discrepancies surrounding it from health inspection officials who joined them at the house, records and interviews indicate. The subsequent police report would instead cite Elliot Gersh, a pediatrician under contract with the group home company. City records show that Gersh arrived at the house three hours after the 911 call and told officers what he would later record on Brandenburg's death certificate: that the 57-year-old had probably died of heart disease.

Gersh--who had examined Brandenburg the day before the drugging and described him in medical records as "alert, smiling" and recovered from a cold--said in an interview that health inspectors and group home officials hadn't informed him of the two days of sickness following tranquilization. He filled out the death certificate, he said, at the request of group home officials.

By law, bodies of those who die unexpectedly in private homes must be sent to the morgue for examination. To prevent evidence tampering, police are supposed to guard the body in the home until a medical examiner arrives. Gersh ordered the autopsy as required. But by noon--many hours before the pathologist appeared--police officers had departed the scene, group home records and interviews show.

In the interval, Stubbs appeared. With the help of a house counselor, group home records show, he moved Brandenburg's body from the scene of death, his second-floor bedroom, to the basement. At some point after the death, internal Family Services reports indicate, Brandenburg's body was washed, for unknown reasons.

"Totally inappropriate," said Chief Medical Examiner Jonathan L. Arden, who assumed his position last year. He reviewed the case at the request of The Post. The file was slim: Health inspectors had not passed on what they knew about the tranquilization and its aftermath. "This office should have been told," Arden said.

"I am outraged, hearing this," said Ivan C.A. Walks, the new director of the Department of Public Health, of his inspection unit's failure to intervene when the oversedation was discovered or to report what it knew to police after Brandenburg's death. "I can't defend these actions."

"We're going to have to reopen this investigation," said Executive Assistant Police Chief Terrance W. Gainer, who also examined police records at The Post's request.

Reopening the case will be difficult. Brandenburg's body was released from the morgue and cremated without an autopsy. In an interview earlier this year, DHS official Frances Bowie, who until recently headed the department's developmental disabilities unit, explained why: Brandenburg's two sisters had refused to permit an autopsy. DHS officials said the sisters, who they said were Jehovah's Witnesses and would not identify, had religious objections to the practice.

The Post located the sisters. One of them, Gloria Donovan, is a longtime member of All Saints Catholic Church in Manassas. The other, Juanita DeButts, worships and teaches Sunday school at the First Baptist Church of La Plata. "We're not Jehovah's Witnesses, and we were never asked about an autopsy," said Donovan, whose brother had just spent the Christmas holidays at her home. "It didn't happen."

Bowie today says she cannot recall the source of her information about the refused autopsy, and DHS Director Williams acknowledges that agency officials have no records to support their previous assertions. Williams also confirmed that this summer, after Post inquiries about the death, case manager Dwayne Franklin shredded his records on Brandenburg's death. On Nov. 4, Franklin was fired for the shredding.

In an interview, Franklin, who had been rated "excellent" in a job evaluation this year, admitted destroying some documents and otherwise not acting on what he considered obvious and suspicious inconsistencies surrounding Brandenburg's death. But Franklin said that DHS officials, fearing bad publicity, were making him a scapegoat for doing what superiors consistently encouraged case managers to do: "hush up problem deaths and other screw-ups."

"Sad to say, our division didn't care who died or when or how, so they didn't give us the tools to investigate," Franklin said. "The truth is that the agency was sloppy from the top on down, and clients paid for it in illnesses, rapes and deaths."

The city delivered another client to Brandenburg's empty bed, records show. Stubbs and Gaither kept collecting $6 million a year in public money to care for the retarded. And none of the many city officials who knew about the tranquilization, the slow death and the evidence of corpse-tampering breathed a word to the family members whose names Brandenburg had struggled to record beneath his own in the leaves of his Living Bible.

"This is devastating." The voice of Brandenburg's sister Gloria breaks. "They all told us Fred died in his sleep."

It was meant to be a decade of recompense, with progressive laws and ample funding marshaled to the mission. After Forest Haven, in group homes from Cleveland Park to Capitol View, long-warehoused individuals would realize their potential to live, learn and work under the protection of their community's watchful eye. A Post series in March chronicled how, when profit-minded entrepreneurs flocked to a suddenly lucrative field, taxpayer-financed protections succumbed to crasser interests. A muddy stretch of Section T in Northeast's Glenwood Cemetery offers a useful vantage from which to view the reform effort's least revocable failure.

Here, shadowed by sweet-faced marble angels and 19th-century mausoleums, lie the District government's unmonied or unclaimed dead: pressed-wood or aluminum coffins packed tight in narrow lots, for reasons of municipal economy. A plastic disk numbered "192" marks the grave of James Scott, a man whose December 1994 death has carved a particular trace in the minds of the retarded men and women who survived him.

He passed the days as a food-service trainee at a for-profit company, PSI, that runs the city's largest day program for the retarded. He didn't say much, this bald 55-year-old with autistic tendencies and off-brand sneakers, while packing tuna-on-white into plastic wrap. He wasn't too much trouble, either, former counselors recall, until the lunch time when his caretakers fatally injured him.

As Scott's retarded peers watched, PSI therapists physically "restrained" him after he became "agitated" and threatened a program mate, according to reports staffers wrote at the time. Their attempts at restraint dislocated his spine and paralyzed him, according to reports that D.C. General physicians wrote later. But after injuring him, PSI records show, staffers attributed his "rag doll" stance and his guttural cries of "Arm, arm!" to "behavioral hysteria."

Nearly two hours passed, PSI and ambulance records show, before his caretakers dialed 911. Hospitalized in intensive care, Scott died four weeks later. And one by one, the agencies that had been assigned to protect him averted their gaze.

The police vowed to investigate a death that the medical examiner's office, after an autopsy, classified as homicide. Five years later, Assistant Chief Gainer examined the file and expressed dismay: "This case got lost in never-never land."

DHS officials said, after Scott's death, that they would investigate whether PSI was using excessive force on some of the disabled people it receives $10 million a year to care for. But court records show that DHS's chief overseer of day programs at the time, Arnett Smith, was busy with private side deals with numerous group home operators (including Stubbs, who hired Smith as a consultant when he applied for public funding for his new group home network). Smith, who declined to comment, was recently indicted on federal conspiracy charges after The Post reported that he bought a private home for another day program operator--a psychologist now charged with Medicaid fraud--while he was supposed to be monitoring her.

Reports of at least 18 other PSI injuries accumulated in government files: a woman beaten with a baseball bat by counselors, for instance, and another woman injured, as Scott had been, when staff members restrained her. The promised investigation never materialized. "It appears we didn't do one," said DHS spokeswoman Madelyn Andrews.

Each retarded ward has a court-appointed lawyer designated to represent his interests. Records show that DHS officials didn't locate Scott's. Each former resident of Forest Haven gets an extra level of protection: a federal court monitor assigned to make sure he gets the services the city has promised him. DHS didn't inform the monitor of Scott's death until this September, five years after the fact. And DHS delegated the task of notifying his relatives to the owner of his group home, an entrepreneur named Carl Peterson who had previously pocketed his clients' small disability checks, health inspection records show. He would subsequently go to federal prison, convicted of spending public funds meant for the retarded on go-go dancers he called "group home consultants."

No relatives were found. No criminal charges or administrative fines were levied against employees or officials of PSI. And the city appropriated Scott's savings--the disability payments that hadn't been stolen--to finance his funeral, which was held at a mortuary owned by a DHS caseworker's husband. Scott helped pay as well for his own interment beneath a numbered plastic disk.

Questioned recently by The Post, PSI President Elizabeth Abramowitz responded in writing that Scott had not died of injuries caused by her staff. After being told of autopsy and police reports, Abramowitz said she was unable to discuss Scott's death or other injuries at PSI because to do so would violate the privacy rights of the retarded.

The realm of the retarded dead resounds with such silences in part because of a 1978 law backed by well-intentioned advocates. In mandating that the city keep extensive records on the health of its retarded clients, the law stipulates that details of those records be kept private to preserve dignity. The District cites that privacy clause to withhold information about deaths--a policy that most recently slowed a Justice Department civil rights investigation sparked by The Post's March series. For months, District officials refused on privacy grounds to turn over records to Justice and have since obtained a temporary court seal to keep the results of the federal investigation from the public.

The incomplete records District agencies released to The Post suggest that the interests being protected weren't strictly those of the retarded. Officials had inked out not just the names of the disabled dead but the names of companies paid public money to care for them, city caseworkers and health inspectors charged with monitoring them--and occasionally even high-level government officials. But the heavily blackened records are, in their own way, revealing. They show that the failure to investigate deaths was a systemic, multi-agency breakdown:

* At DHS, the first line of defense for the retarded, caseworkers filed away many cases suggestive of neglect--the middle-aged woman who died of a urinary tract infection, for instance. But they did refer several troubling cases to the agency's internal investigative unit. The investigators were unable to document, after months of inquiries, that they had done more than simply obtain death certificates and close the files.

* The city's Medicaid office was assigned to investigate deaths in the 80 percent of city group homes and day programs that receive federal funds, a total of about $80 million a year. That office was able to document two death investigations. The first, from 1994, was a brief description of a scene of a murder. The second was an investigation ordered by the mayor last summer, after the highly publicized death of Patrick Dutch, who was left for hours in the group home van. The investigation found that the house manager and van driver "appeared not to remember many of the details that might give someone a better understanding why this tragedy happened."

* Inspectors at the Department of Public Health, charged with making inquiries when suspicions are brought to their attention, did a few death investigations, too. The record shows they averaged one per year. When they found wrongdoing, they asked the group home for "a plan of correction," as they did in Brandenburg's case. They couldn't assess a fine--such as the $100,000 penalty that can be levied on District nursing homes for neglect--because the city's attorneys have never done the administrative work needed to enforce an existing law that allows monetary sanctions on group homes. Inspectors could have referred death cases to the police. They haven't done so in more than a decade.

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. 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--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" 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?"

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. 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. 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.

Staff researchers Alice Crites and Heming Nelson contributed to this report.

THE NAMES OF THE DEAD,

1993-99*: Josephine Gaines Majorie 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 unknown 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 Patrickk Dutch James Dean Joseph Addison Annie Williams

V. Bennett Female, full name unknown

*City records regarding the mentally disabled contain a variety of spellings for certain names.

Scores of Deaths, No Investigations

After searching its files for seven months, the D.C. Department of Human Services, the municipal custodian of D.C.'s retarded wards, was able to document that 69 of approximately 1,190 retarded individuals in its residential care system died between January 1993 and September 1999. A Post investigation identified 47 additional wards who died during that time. The Post also found evidence of delayed treatment, neglect, falsification of circumstances or other lapses in 34 cases -- well over one-third.

116 DEATHS identified by the Post investigation

69 NUMBER OF DEATHS the Department of Human Services documented by November.

8 AUTOPSIES COMPLETED by the D.C. medical examiner

0 INVESTIGATIONS DOCUMENTED by the Department of Human Services

NOTE: Studies of the mortality of the mentally retarded in community programs have found that a surge in the death rate is common in the first year after deinstitutionalization. In order to provide the least inflated analysis of death in the District in the 1990s, The Post studied deaths that occurred from January 1993, 14 months after the closing of Forest Haven, to September 1999.

For More Information

To see additional documents gathered by The Post, go to www.washingtonpost.com/metro. Katherine Boo will host an online discussion, at www.washingtonpost.com, at 1 p.m. tomorrow.