A D.C. regulatory agency never created a file or properly acted on a complaint of dangerous conditions at an illegal rooming house on Kennedy Street in Northwest Washington and stopped pursuing the case two days before a fire killed two occupants, an independent investigation has found.

Because a formal process was not followed, housing investigators and others did only cursory checks of the property, failed to follow up with the D.C. police officer who made the complaint, and then aborted their inquiry “without appropriate documentation and approval,” an outside consulting firm hired by the District concluded.

The report was made public Friday, 10 weeks after the Aug. 18 fire at 708 Kennedy St. NW killed Fitsum Kebede, 40, and Yafet Solomon, 9, who lived in separate rooms in the basement of the rowhouse in Brightwood Park. The renters, mostly Ethiopian immigrants, lived in tiny rooms, some no bigger than a queen-size bed, and shared kitchens and bathrooms.

Kevin Donahue, the District’s deputy mayor for public safety, said the report lays bare “painful details” documenting “nine critical moments” when employees in the city’s Department of Consumer and Regulatory Affairs (DCRA) and the fire department could have taken action but didn’t.

“There was an abundance of missed opportunities,” Donahue said. “Had one or more of those been acted upon, we would have had a chance to take action prior to the fire. When the investigation into that house was closed out, it closed out any opportunity to identify and remediate the problems.”

D.C. officials had put four housing employees and two fire officials on leave after an early assessment of the response to the complaint. Donahue declined Friday to comment on their status, but he said the report will be used to decide whether formal discipline is warranted.

Authorities have said a litany of code violations in the unlicensed rooming house, including interior locked doors and gates, “contributed to the deaths.” A criminal investigation continues, and authorities have not determined how the fire started, though court documents show they were testing a laptop computer and power cord found in Kebede’s room. Court documents say the house was not wired to account for its many occupants.

The fatal fire prompted an outpouring of grief in the District and focused attention on substandard housing for the poor and immigrants who often cannot afford anything else. It also raised questions about the District’s ability to police its housing stock amid an influx of residents into the rapidly gentrifying city.

An investigation by The Washington Post in September documented a series of mistakes and miscommunications that allowed the house and its owner to escape regulatory oversight.

The audit report by the D.C.-based firm Alvarez & Marsal notes that there are only a dozen housing inspectors monitoring compliance in the District, and none require formal training on issues specific to the city. Instead, the report says, new hires take a generic course and learn by shadowing other inspectors, sometimes limited to a single inspection.

The report also says the DCRA and the police and fire departments lacked “clear communication channels” for collaborating and following through on housing complaints. Police have since added directives to formalize the way officers forward complaints to housing and fire inspectors.

The report concludes that Officer Ernie Davis’s March 22 email to employees at the DCRA and the fire department about the urgent problems he saw at 708 Kennedy St. fell into a void.

“Despite the MPD Officer’s persistence, contacting six different DCRA employees on five occasions over the course of three months, no DCRA employee ever entered the case” into a program launched six months earlier to track inquiries and complaints.

Davis’s email contained a subject line of “serious code violations” and a single sentence about a problem at an unrelated property on 14th Street NW. The body of the email did not mention the Kennedy Street house, though his attached police report gave a scathing critique.

Investigators with the audit firm spelled out in meticulous detail how Davis’s emails traveled through DCRA employees but never made it into a formal process, which prevented the complaint from being tracked and from being reviewed by supervisors.

A housing investigator did visit the Kennedy Street property but photographed only the front and could not document attempts to enter. The investigator said he visited the property three times, but Donahue said he can only prove one. The report says the investigator did not enter his observations into any formal file and that “at no point” did he attempt to contact Davis, who had twice emailed the DCRA to make sure the agency was taking action.

One housing investigator told auditors that a case file was made but was lost when his office had to move to another location. Around the same time, a DCRA manager was promoted, and a field worker was moved into the office to cull an “overwhelming caseload.”

Cases that had been considered dormant were suspended and later closed. Some of those “cases” were not cases at all but ones that had been started informally and could be shut down without raising a flag with superiors or creating a notation in any file.

They included the rowhouse at 708 Kennedy St. NW.