HOSPITAL FAULTED IN DEATH OF INMATE

Quadriplegic's Care Lacking, Probe Finds

The D.C. Department of Health has found that Greater Southeast Community
Hospital failed to provide adequate care to a quadriplegic jail inmate who
died in September after he was taken to the emergency room for severe
breathing problems.

The inmate, Jonathan Magbie, died Sept. 24 of acute respiratory failure,
raising questions about his medical care as well as why he was incarcerated
in the first place.

Magbie, 27, of Mitchellville, was serving a 10-day sentence after pleading
guilty in D.C. Superior Court to possession of marijuana, an offense that
rarely carries jail time for a first-time offender.

The Health Department's investigation focused on what happened after Magbie
arrived at the D.C. jail Sept. 20 and primarily on his treatment at the
hospital. The findings, released late yesterday in response to a Freedom of
Information Act request, represent the most comprehensive official
accounting of his death.

The hospital will be cited for violating local and federal regulations.
Last year, Greater Southeast was faulted by District hospital inspectors
for persistent problems with the quality of medical care. The city later
determined that the hospital had addressed deficiencies. "This was a tragic
incident," Gregg A. Pane, director of the Health Department, said in a
statement released with the report. Magbie's mother, Mary Scott, said last
night that she was pleased to see Greater Southeast held accountable but
that others shared in the blame for her son's death.

All knew, she said, that he had serious medical problems. "It's misconduct
on everyone's part," Scott said. "I still hold the judge responsible, the
jail responsible and the hospital responsible."

Hospital officials issued a statement saying they had not received an
advance copy of the report, but they defended the care they gave Magbie.
"We are confident that appropriate care was provided in this case, but
privacy rules prevent us from talking about specifics," the hospital
statement said. "We would welcome a fair and impartial review, but question
whether the District's conflict of interest in this matter allows it to be
fair and impartial."

Magbie, who was struck by a drunk driver at age 4, was paralyzed from the
neck down and his growth stunted.

But, helped by a settlement that paid him $30,000 a month, he tried to make
the most of his life. He traveled frequently, wore what he said was a
$7,000 watch and lived in what he called a mansion. Although he had never
before been accused of criminal wrongdoing, Magbie was known to keep rough
company, according to prosecutors, who said his name came up on a wiretap
of a suspect in a major drug-trafficking investigation. He was arrested in
April 2003 while riding with a cousin in his family's Hummer in Southeast
Washington. Police found cocaine, marijuana and a gun in the vehicle.

Magbie pleaded guilty to possession of marijuana, and probation seemed to
be the likely sentence.

But the judge, Judith E. Retchin, noting the gun in the car and Magbie's
insistence that he would continue to smoke marijuana because it made him
feel better, sentenced him to jail. Hours after he arrived at the D.C. jail
Sept. 20, he began having difficulty breathing.

Magbie told a jail nurse that he used a ventilator to help him breathe at
night, according to the Health Department's investigation, but the jail did
not have the equipment.

The jail's doctor had Magbie taken to Greater Southeast.

William Vaughn, a doctor in the hospital's emergency room, told Health
Department investigators that Magbie was brought to Greater Southeast
because he might need a ventilator. Vaughn initially planned to admit
Magbie but changed his mind after Magbie's condition improved, the
investigation found. He discharged Magbie back to the jail the next day
with instructions that Magbie could need nasal oxygen.

The Health Department said that the doctor erred by releasing Magbie
without addressing his ventilator needs at night.

Magbie never got a ventilator while at the jail.

The staff at the Correctional Treatment Facility, the medical jail annex
where Magbie was being held, was concerned when Magbie reappeared at the
jail, the Health Department investigation found.

Its chief medical officer, Malek Malekghasemi, told investigators that the
facility "should not have a patient that required a vent."

Malekghasemi said he called Retchin's chambers to find out why someone in
Magbie's condition would be in jail. The doctor wanted a court order to
have Magbie sent to the hospital but told investigators that the judge said
she could not take that action.

Magbie was returned to Greater Southeast on the morning of Sept. 24, again
with breathing problems.

The Health Department said it found "no documentation" that the nursing
staff kept doctors informed as his condition worsened. Medical records show
that a doctor was brought in at 5:40 p.m. when Magbie was in respiratory
distress; his breathing tube had become disconnected. Doctors reattached
the tube, but Magbie died within an hour.