D.C. Mayor Adrian Fenty said “a feeling of horror” came over him after learning that a mentally disabled 65-year-old man languished in cockroach-infested squalor while the city’s bureaucracy missed one opportunity after another to step in.
Mr. Johnson (a pseudonym) died Feb. 23 at Providence Hospital, four days after falling into a diabetic coma. His death came more than two years after a nonprofit social worker first attempted to obtain D.C. government help for him.
Three city employees tied to Mr. Johnson’s case have been fired and more personnel actions are to come, Fenty said Friday. The mayor also released a report detailing the man’s seven-year history with the District, and offering 29 recommendations for reform.
“The government has failed one of our neighbors who needed our care and people will be held accountable for it,” said Fenty, who ordered his investigation about a week after University Legal Services released its own review of Mr. Johnson’s case.
The city’s report charges various D.C. agencies with inadequate record keeping, insufficient communication, poor responsiveness and scant visits with the client. The fundamental problem, the investigation found, “is that this individual’s urgent needs never translated into urgent action.”
Mr. Johnson’s circumstances are eerily similar to those of Banita Jacks, who is accused of murdering her four daughters in a Southeast row house. Johnson was failed by adult protective services. Jacks was virtually ignored by child protective services. In both cases, Fenty moved quickly to investigate failures, acknowledge mismanagement and fire staff — but not until after the victims’ deaths.
“Life is imperfect, and one of the things I’ve learned being in government for the first time, is that government is imperfect,” said interim Attorney General Peter Nickles.
A social worker with Family and Child Services of Washington, DC Inc., assigned to Mr. Johnson’s case, first tried to reach what is now the Department of Disability Services in October 2006. Three months later the social worker realized that the agency had moved and changed its phone numbers.
Mr. Johnson’s case was eventually referred to Adult Protective Services, due to the wretched condition of his home and his inability to care for himself. Emergency help from that arm of the government lasted only 50 days.
Follow-up attempts to get help from DDS were stifled by bureaucratic demands for evaluations, diagnosis and nonexistent documentation. Not until Nov. 1, 2007, was he approved for services. The response, the report determined, was “unacceptably sluggish.”
Recommendations for reform
Among the 29 suggestions for fixing adult protective services
— Ensure intake coordinator has face-to-face meeting with applicant within five days of assignment.
— Stop practice of intake case managers also carrying caseloads.
— Institute more rigorous performance reporting and data tracking.
