The Washington Post
Monday, March 15, 1999; Page A9

Over the years, there has been a lessening in the level of public interest and response when a mentally retarded ward of the District dies. In the past three years, 53 mentally retarded group home residents have died, but only three of these deaths have received even cursory investigation by the Department of Health. The Department of Human Services refused to release further information about the other 50 deaths, citing privacy concerns. Who these people are, where they died and whether care was a factor remains a public mystery.

That stands in stark contrast to the way such deaths were probed at the beginning of the decade, when mentally retarded wards were housed at Forest Haven, a large asylum run by the District. Concerned about conditions there, Justice Department lawyers and medical consultants cataloged conditions surrounding virtually every death from 1989 to 1991, concluding that substandard medical care contributed to at least eight deaths at Forest Haven. The findings helped bring about the closing of Forest Haven in 1991 and a city settlement of $1 million to relatives of those who died there. Today, the Health Department investigates the death of a retarded ward only when it perceives something unusual after reading "incident reports" about the circumstances of death, which are usually written by the operator of the group home or day treatment program where the ward died. In one case where suspicious circumstances were found, health officials requested an autopsy from the District's medical examiner. But no autopsy was performed. The medical examiner's office says it was never made aware of the details of the death.

Even when the Department of Health finds that poor medical treatment is involved in a retarded person's death, it cannot fine the group home operator. It can only refer the case to the U.S. attorney's office for criminal prosecution or to the District corporation counsel's office for civil action. In the last decade, not a single case has been referred.