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System Loses Lives and Trust
By Katherine Boo Washington Post Staff Writer Sunday, December 5, 1999; Page A1 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:
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 (See Document). 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. An Erasing 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 (See Document). 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 (See Document). 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." © 1999 The Washington Post Company
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Post Staff Writer Katherine Boo was "Live Online" on Dec. 6, answering your questions.
Gold Medal for Public Service:
"Awarded to The Washington Post, notably for the work of Katherine Boo, that disclosed wretched neglect and abuse in the city’s group homes for the mentally retarded, which forced officials to acknowledge the conditions and begin reforms."