JONATHAN MAGBIE'S LAST HOURS

"Another inmate named Jason Foster and I were cleaning the floor around 11
or 11:30 at night when we noticed Jonathan was in his cell, and he was
sweating. He could barely talk," said Darryl Carter in a phone call from
the Youngstown, Ohio, jail where he is now assigned. Carter was describing
what he saw in a D.C. jail annex called the Correctional Treatment Facility
(CTF) on Sept. 23 -- Jonathan Magbie's last night on Earth. Magbie is the
27-year-old quadriplegic who was sentenced to 10 days in the D.C. jail on
Sept. 20 for simple possession of marijuana. Magbie used a ventilator at
night to sleep but was without it for five consecutive days. Magbie died on
Sept. 24 while in the city's custody.

Carter, a convicted felon, said he made sure Magbie got some water, then
went to the nurse on duty, named "Binka," and told him that Magbie needed
some help. "But Binka said, 'He's okay,' and never went to see him," Carter
said. A little later, Carter said, "Jonathan was making some noise with his
wheelchair, banging it into the door of his cell. . . . An officer named
Singly wanted to lock Jonathan's cell door, but I told her, 'Don't do that
because he can't push the button if he needs help.' " The officer locked
the door anyway, Carter said, and he didn't see her check on Magbie anymore.

Carter said he saw Magbie in the hallway the next morning. "Jonathan was
saying, 'You hear them calling me?' " Carter said. "I told him, 'Nobody's
calling you, Jonathan,' but Jonathan keep saying someone was calling him,"
Carter said. (In a second phone conversation on Wednesday evening, Carter
described Magbie's lips on the morning of Sept. 24 as "dry and whitish" and
said he was stuttering.) Carter said he was unable to stay around because
he was taken from the CTF for a scheduled court appearance. Friday morning,
Sept. 24, was the last time he saw Magbie alive.

At my request, the D.C. Corrections Department arranged for me to visit the
Correctional Treatment Facility on Thursday morning. Quite a reception
party was on hand.

Assembled in the administrator's office were Warden Fred Figueroa; Walter
Fulton, the CTF's program manager and public information officer; Lorella
Willis, the Corrections Department's health services administrator;
Patricia Wheeler, the Corrections Department's communications director; and
Jeremy Wiley, director of government relations for Corrections Corp. of
America, the private, for-profit company based in Nashville that operates
the CTF under a Corrections Department contract.

The CTF is no longer the drug and substance abuse treatment facility that I
visited years ago. Today it's a detention annex that houses the D.C. jail's
overflow of inmates. Currently 1,186 male and female inmates are imprisoned
in the medium-security facility on various felony and misdemeanor charges.
Some are pretrial inmates; a few are under the federal witness protection
program; others are awaiting transfer to a federal Bureau of Prisons
facility. The CTF also has an infirmary. It was into this world that
Superior Court Judge Judith Retchin sent the totally dependent Jonathan Magbie.

I asked to see where he was housed. Led by the warden, our party of six
went to the infirmary, a 37-cell facility with three dormitories and a cell
set aside for the suicidal.

It was clear why Darryl Carter said he warned against locking the door to
Magbie's cell. Although the room was equipped with an emergency button,
there was no way an inmate in Magbie's condition -- a wheelchair user with
upper and lower body paralyzed -- could reach it. Karen Yates, the officer
on duty during the tour, agreed. She said there were written instructions
to not lock Magbie's door, and she left it open during her tour of duty.

Yates volunteered that she recalled seeing Magbie on the Friday morning
before he was taken by ambulance to Greater Southeast Community Hospital,
where he later died. Asked about Magbie's condition at the time, Yates,
with the party of six looking on, said he was fine. She remembered hearing
Magbie say, "They're calling me" and "my sister's coming to get me" and
"I'm telling you, I'm leaving here." How and why he began experiencing
breathing problems on the morning of Sept. 24 -- as reported by the
Corrections Department -- Yates could not say. In response to my question
about his behavior, Yates said she was unqualified to make medical
judgments. She nonetheless maintained that in her view, Magbie was "fine"
on the morning of the day that he died.

But was he?

Could it be that the breathing difficulty inmate Carter observed was a sign
that Magbie was suffering from hypoxia, or lack of oxygen, and maybe
hypercarbia, which is an excess of carbon dioxide? With his breathing
diminished, Magbie's mental capacity could have been negatively affected,
hence the things that Carter and officer Yates heard him say on Sept. 24.
At least that's the thought of one anesthesiologist who has been following
this case in the media.

Clearly there were visual signs of Magbie's breathing difficulty; this
coupled with the condition of his lips, which, while not blue, were
"whitish," as described by Carter, may have suggested cyanosis, or a lack
of oxygen in his blood.

Is it possible that without a ventilator to help him breathe when he was
asleep, Magbie was becoming fatigued and beginning to decompensate with
regard to his ability to take in oxygen and get rid of carbon dioxide? If
so, that kind of condition, according to the medical expert, can become a
vicious cycle from which recovery is unlikely even with medical help. The
carbon dioxide builds up and the lack of oxygen leads to a mentally dulled
person who then breathes less, which leads to more carbon dioxide and less
oxygen. The heart tries to overcome things, but it eventually starts to
fail -- a vicious cycle and a downward spiral toward death.

The Corrections Department said it gave Magbie nasal oxygen as prescribed
by physicians at Greater Southeast Community Hospital, where he was sent on
the night of Sept. 20 when he began to have breathing difficulties and
first told them he used a ventilator at night. Wrote another physician who
did not treat Magbie: "Nasal oxygen for a quadriplegic is an absurd
recommendation. You can blow all the oxygen in the world up someone's nose
but, if they can't move their chest adequately to breathe the oxygen in, it
will be futile. Mr. Magbie almost certainly died from lack of oxygen, so
nothing of note is likely to show up in any autopsy report." A vicious
cycle and downward spiral toward death.

Where do things stand?

Yesterday Corrections Department officials identified the nurse and the
officer cited by Carter as medical nurse Alexander Ebiringa and
correctional officer Patricia Singley. I informed Corrections Department
spokesman Bill Meeks about Carter's allegations and requested an
opportunity to interview the nurse and officer. I received this e-mail:
"The Department of Corrections is very emphatic that the cell where inmate
Jonathan Magbie was housed was not locked at any time. The warden . . . has
interviewed at least six of the correctional and medical staff that was on
duty during that period. All staff members interviewed emphatically denied
and have submitted written statements to the fact that Magbie's cell was
never locked on the evening of Sept. 23, 2004, and the morning of Sept. 24
or at any time."

The D.C. Health Department's Philippa Mezile said yesterday that the
investigation of Magbie's death, completed Oct. 22, is still under review
in the department.

Beverly Fields, chief of staff to the D.C. chief medical examiner, said
yesterday that Magbie's death was due to "acute respiratory failure
following dislodgement of tracheotomy tube placed for treatment of
respiratory insufficiency due to remote upper cervical spinal cord injury
with quadriplegia due to blunt impact trauma. The manner of death was
accidental."

A physician who's had an upsetting experience with the Superior Court wrote
to me: "Anyone at all familiar with the care of quadriplegics knows that
sentencing Mr. Magbie to 10 days in jail was a probable death sentence. In
settings where medical issues are raised [Judge Retchin's office was
advised of the possible adverse medical consequences of her sentencing of
Magbie], the Court always has an obligation to act to preserve life and
health. While the Court will undoubtedly almost always object to having
Court decisions questioned or objected to by those outside the purview of
the Court, it is the height of arrogance, of which I believe there is an
abundant supply in the Superior Court, to assume that judicial decisions in
arenas with which the Court is supremely incompetent are, nonetheless,
infallible."

So I called Judge Retchin's chambers and spoke with her yesterday. The
judge said she had consulted with the court's ethics counselor and was
advised that the code of judicial ethics prevented her from speaking about
the Magbie case. However, she did say on the record, "Everyone on my end
thinks his death was terribly tragic" and an outcome "that no one
intended." Judge Retchin, I should note, is held in high regard by mutual
associates.

Where to go from here? As one reader wrote, Magbie's death should not be
regarded by the court and public as simply an aberration for which there is
nothing in need of fixing. Jonathan Magbie was more victim than
perpetrator. If the court and Corrections Department staff involved in this
reprehensible tragedy fail to undertake a substantial revaluation of their
approach to people at significant disadvantage, and no one is held
accountable, then Jonathan Magbie's death will have been in vain.

Was it?

And then this. When sentencing Magbie on Sept. 20, Judge Retchin said she
had assurances that the jail could accommodate Magbie's needs. But wait a
minute. In response to my request, the D.C. Superior Court sent me at 4:09
p.m. yesterday a copy of a transcript of a July 20 bench conference that
Judge Retchin had with Magbie's attorney, Boniface Cobbina, and Charles
Stimson, assistant U.S. attorney. Judge Retchin asked Stimson why the
government was offering Magbie a guilty plea to a misdemeanor and was
dismissing all other counts of his indictment.

Stimson spelled out the government's reasons, and then said this to Judge
Retchin: "So, with all those things in mind, that's why we did what we did,
and I think it's a fair offer, and I think both sides got something. I
would also say, talking to the jail, that they can't accommodate Mr. Magbie
because when he was arrested, they actually had to take him in an ambulance
to the hospital to be catheterized because he gets catheterized every four
or six hours sometimes. So, you know, these were all part of our
considerations."

That was three months before Judge Retchin sent Magbie to jail. Oh, my goodness.