A SEARING PORTRAIT OF ABUSE

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.