Jonathan Magbie

Died While in Prison for Marijuana Possession: A Single Joint

December 3, 2008 -- Washington Post (DC)

D.C. Settles In Death Of Paralyzed Jail Inmate

By Del Quentin Wilber, Washington Post Staff Writer

The mother of a quadriplegic inmate who died in 2004 after suffering breathing problems at the D.C. jail has reached financial settlements with the District government and his care providers, her attorneys disclosed yesterday.

The settlements were reached in the controversial death of Jonathan Magbie, a 27-year-old Maryland man who was paralyzed from the neck down and used a mouth-operated wheelchair.

Magbie died four days into a 10-day jail sentence for possessing marijuana, which he said he used to ease the discomfort caused by his disability. The jail infirmary, where he was housed for several days, wasn't equipped with the ventilator he needed to breathe at night.

His death sparked several government investigations, which exposed major lapses in Magbie's care at the D.C. jail and Greater Southeast Hospital.

Attorneys for his mother, Mary R. Scott, declined to provide details of the financial settlement, which she reached with the city, private contractors and the insurance company that covered doctors at the hospital. The American Civil Liberties Union, which represented Scott, called the settlement "substantial" in a news release.

As part of the settlement, the District government changed the way officials screen and handle inmates with medical problems and disabilities, Scott's attorneys said.

"The family's concern was to make certain that, to the extent anyone can prevent it, that this terrible type of event never happens again," said Elizabeth Alexander, an ACLU lawyer who represented Scott. "A series of people dealt with this young man, and every single place where something could go wrong, it did go wrong."

Scott declined to comment through her attorneys. She filed a federal lawsuit in 2005 that accused the District government, Greater Southeast, three contractors and more than a dozen corrections officers, doctors and nurses of negligence in Magbie's death.

A spokeswoman from the D.C. government said she could not comment until looking into the matter. Greater Southeast is under new ownership and has been renamed United Medical Center. A spokeswoman for Corrections Corporation of America, which runs a portion of the D.C. jail where Magbie was held, declined to comment. Representatives of two other contractors did not return phone messages seeking comment.

Magbie's ordeal began Sept. 20, 2004, when D.C. Superior Court Judge Judith E. Retchin sentenced him to jail after he pleaded guilty to possessing marijuana. D.C. police found a gun and marijuana in Magbie's pockets in April 2003 after stopping a vehicle driven by a cousin of his. Magbie admitted buying the marijuana, records show.

Magbie's mother was furious that the judge did not give her son probation, the typical punishment for first-time offenders. Magbie, paralyzed since being hit by a drunk driver at age 4, had no criminal record. Retchin told a judicial commission that she sentenced Magbie to jail because he said he would continue to smoke marijuana to alleviate his pain. She also told the commission that she was unaware that he needed a ventilator to breathe at night. The commission cleared Retchin of wrongdoing.

Because of his condition, Magbie was supposed to be housed in the jail's infirmary, according to an investigation by the D.C. inspector general. Magbie was taken to a hospital for "respiratory distress" and returned to the jail infirmary, which didn't have a ventilator, the report said. Jail doctors did not perform a follow-up examination and did not always conduct daily rounds to check on patients, including Magbie, the report said.

Magbie ate and drank very little during the next few days, the report stated. On Sept. 24, 2004, he was having respiratory problems, and paramedics were called, the report said. They found him to be "unresponsive and very sweaty," and his undergarment was "saturated with urine," the report said.

Paramedics told investigators that the trip to the hospital was delayed by about 30 minutes because the jail staff would not allow them to leave without the proper paperwork and without a blood sugar test, the report said.

At the hospital, Magbie was "acutely ill," according to the report. He died that night.

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April 8, 2006 -- Washington Post (DC)

Column: Glossing Over Mistreatment In The Magbie Case

By Colbert I. King

Jonathan Magbie was a 27-year-old man who was paralyzed from the neck down as a result of a childhood accident. Although he had never been convicted of a criminal offense and although he required private nursing care for as much as 20 hours a day, Magbie was given a 10-day sentence in the D.C. jail in September 2004 by D.C. Superior Court Judge Judith E. Retchin for possession of a marijuana cigarette. He died in city custody four days later. His story has been the subject of several previous columns.

Earlier this week Edward D. Reiskin, deputy mayor for public safety and justice, provided D.C. Council members David Catania (I-At Large) and Phil Mendelson (D-At Large), chairmen, respectively, of the council's Health and Judiciary committees, with the findings from the D.C. Department of Corrections (DOC) investigation into the care provided Magbie from Sept. 20 to Sept. 24, 2004.

Actually, to call the Corrections Department's report an "investigation" is like describing a BB gun as an AK-47. The eight-page document produced by the department's Office of Internal Affairs attempts to explain away a more extensive and highly critical investigation into Magbie's death that D.C. Inspector General Charles J. Willoughby conducted last October.

Willoughby's report and the lawsuit filed by the American Civil Liberties Union and two lawyers on behalf of Magbie's mother, Mary R. Scott, are more credible. They provide real insight into Magbie's neglectful treatment by the criminal justice system.

Now to the Department of Corrections "investigation." The findings were dutifully and uncritically transmitted to the council by Reiskin, who, incidentally, complained to lawmakers that "the investigation was hindered by legal advice provided to [the contractor medical staff] by its counsel not to release any information to DOC regarding this issue due to pending litigation."

That clampdown on salient information did not, however, stop Corrections from arriving on the scene after Willoughby completed his extensive investigation and producing an Internal Affairs document that exonerates or at least gives a virtuous appearance to many of the actions by staff and employees at the corrections facility where Magbie was confined. But even Corrections couldn't cover all the participants with whitewash.

In some cases, Corrections' critical findings were accompanied by recommended disciplinary actions that have all the harshness of a beating with a wet noodle.

Internal Affairs found:

There were instances in which Magbie's medical care was not documented. But the nurses culpable in the acts of omission couldn't be identified because the medical contractor, paid by the Corrections Department with D.C. tax dollars, wouldn't give access to the contractor's employees.

The associate medical director of the jail where Magbie was confined knew about Magbie's vulnerable medical condition and that he needed acute care immediately, but failed to notify higher-ups. The associate medical director, the report noted, resigned last October. Undeterred, Corrections bravely directed the medical contractor to "place a letter of reprimand in the doctor's Official Personnel File" and to determine "any other appropriate disciplinary action to be pursued against the doctor."

Correctional and medical staff provided written memos to the Corrections Department director stating that they never saw Magbie's cell door locked while he was in the unit. (It should have remained unlocked, because there was no way that Magbie, a quadriplegic, could reach the emergency button.) Corrections discovered information that contradicted the staff-written memos: Magbie's cell door had in fact been locked, in violation of doctor's orders. For their lying, Corrections fearlessly instructed the warden, disciplinary action was to be taken against the two officers and a disciplinary letter placed in the personnel file of each.

A physician in the Corrections facility housing Magbie told the inspector general that he was unaware of Magbie's return from Greater Southeast Community Hospital, where he had been taken as an emergency patient during his first night in jail. It turns out, the Corrections report noted, that the physician did see Magbie upon his return. That physician, thundered the Corrections report, "will no longer be permitted on DOC premises . . . this action is to take place posthaste."

As for the Corrections Department's decision to keep the ventilator-dependent Magbie confined for four days to the Correctional Treatment Facility, where no ventilator or appropriate medical care was available? The "investigation," done by Corrections staff and passed along by Reiskin, gave the rest of the nurses, physicians and staff a pass.

Judge Retchin? She was cleared by the Commission on Judicial Disabilities and Tenure.

Say this much for ol' D.C., it takes care of its own.

If justice is to be had in this case, it won't be found in D.C. agencies. Better to look to the U.S. District Court for the District of Columbia. That's where the Jonathan Magbie lawsuit is filed.

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January 25, 2006 -- Washington Examiner (DC)

Editorial: Crime And Punishment

One man confesses to raping a 7-year-old girl countless times and gets 60 days in jail from a Vermont judge who no longer "believes" in punishment. Another man, a quadriplegic in D.C., basically gets a death sentence for getting caught with a single marijuana joint. There's much to be said for judicial discretion, but this point spread is ridiculous. There no longer seems to be any national -- or rational -- standard in matters of crime and punishment.

In September 2004, D.C. Superior Court Judge Judith Retchin sentenced 27-year-old Johnathan Magbie to 10 days in the D.C. Jail for his first offense, a misdemeanor. Magbie, who was paralyzed from the neck down in a drunken driving accident when he was 4, never made it out alive.

During a four-day period, Magbie -- who had a tracheotomy, a pulmonary pacemaker, and required a ventilator to breathe at night and smoked pot to ease the pain of a bone infection -- was allegedly parked overnight in a locked infirmary cell. He could not reach the emergency button to call for help. While in the District's custody for less than a week, he reportedly became dehydrated, contracted pneumonia and died during an acute respiratory crisis.

"I'm not saying he shouldn't have been punished," his mother, said Mary Scott. "I just don't think it should have cost him his life." Last fall, she filed a $100 million lawsuit against the city for negligence. Seeing as Magbie weighed 130 pounds when he went to jail, and only 90 pounds when he died, she has a pretty good case.

The real crime here is that neither the clueless judge, the supremely inattentive corrections officers or the equally incompetent health care workers at Greater Southeast Community Hospital have yet been punished for their part in Magbie's untimely and unnecessary death.

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September 30, 2005 -- Austin Chronicle (TX)

Meddling Federal Lawmakers Share Blame In Senseless Medi-Pot Death

By Jordan Smith

The mother of a quadriplegic man who died last year while in the custody of the Washington, D.C., Department of Corrections filed suit on Sept. 20 against individuals working for the jail and a local hospital for failing to provide adequate medical care in violation of federal laws -- including the Eighth Amendment's ban on cruel and unusual punishment.

Still, medi-pot advocates argue that there's at least one party -- the U.S. Congress -- notably absent from the lawsuit, even though federal lawmakers share equal responsibility for 27-year-old Jonathan Magbie's death.

Indeed, if Congress hadn't meddled with the will of D.C. voters by threatening to withhold money from the city's budget (which is supported entirely by federal appropriation) as a result of voters' attempt to enact a medi-pot law, Magbie might still be alive today.

Magbie, paralyzed from the neck down after a car wreck when he was 4 years old, died on Sept. 24, 2004, four days into a 10-day sentence for simple possession of a single marijuana cigarette; it was his first criminal offense.

Although it was within D.C. Superior Court Judge Judith Retchin's discretion to sentence Magbie to probation only, she imposed the 10-day sentence in response to Magbie's assertion that he would probably continue to use marijuana because the herb made him "feel good," and helped ease painful symptoms of his paralysis and associated medical conditions, The Washington Post reported last year.

"As long as [smoking marijuana is] against the law," Retchin reportedly replied, "you're not permitted to do it, Mr. Magbie." Retchin's 10-day punishment turned into a death sentence for Magbie, who was incapable of moving without the aid of a motorized, chin-operated wheelchair and required a tracheotomy tube, pulmonary pacemaker, and, at night, a ventilator in order to breathe.

Additionally, Magbie was at a high risk for contracting pneumonia and had a history of osteomyelitis, a kind of bone infection -- among other medical problems with which his jailers would have to contend -- -- needs that critics say Retchin should have known the District jail could not meet.

During the four days he was in jail, Magbie's health quickly deteriorated, and he was transferred multiple times between the Correctional Treatment Facility (run by the often-criticized private prison operator Corrections Corporation of America) at the D.C. Central Detention Facility and the Greater Southeast Community Hospital.

He was having a hard time taking in enough oxygen, he contracted pneumonia, and was nearly unable to eat, according to the lawsuit filed last week by his mother, Mary Scott. And since Magbie had difficulty speaking above a whisper, he was forced to move his wheelchair around in order to get the attention of his incarcerators. The movement apparently irritated the jailers, reported the Post.

On Sept. 23, they locked him inside an infirmary cell, without access to any kind of panic button, and did not check on him until the next morning, according to the lawsuit.

Magbie died at 6:40pm on Sept. 24. Scott is seeking more than $100 million in damages for the civil rights violations that she alleges caused her son's death.

While Judge Retchin was cleared of any misconduct for her decision to send Magbie to jail, medi-pot advocates say federal lawmakers should not get a similar pass.

Back in 1998, District voters overwhelmingly approved a medi-pot initiative, with nearly 70% of voters in favor of a measure that would have protected patients like Magbie from criminal prosecution.

Before the ballots could be counted, however, then-U.S. Rep. Bob Barr, R-Ga., added an amendment to the district appropriations bill to strip city funding if officials attempted to "enact or carry out" any local initiative to legalize or reduce the criminal penalties for "possession, use, or distribution" of pot (or any other illegal drug).

A federal district judge tossed the so- called Barr Amendment a year later, ruling it was unconstitutional, but the measure was reinstated by the federal appeals court in 2002, which to date has made it impossible for district residents to protect seriously ill marijuana users like Magbie.

"Because Congress intervened to block the democratic rights of District voters, Jonathan Magbie went to jail and died for simply trying to ease his pain," said Aaron Houston, director of government relations for the D.C.-based Marijuana Policy Project. "Magbie's agonizing death was completely unnecessary."

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September 17, 2005 -- Washington Post (DC)

Justice For A 'Death Of Neglect'

By Colbert I. King

Next Tuesday marks the first anniversary of 27-year-old Jonathan Magbie's final encounter with the D.C. government. It will be no cause for celebration.

It was on Sept. 20, 2004, that D.C. Superior Court Judge Judith Retchin sentenced Magbie, a quadriplegic since an accident at age 4, to 10 days in the D.C. jail. His crime? Possession of marijuana.

Five days after falling into the hands of the D.C. government, Magbie was dead. He died a horrible death. It was preventable. But nobody in the system cared.

Looking down from her bench, Retchin saw a first-time offender. He controlled his wheelchair with a mouth-operated device. He could breathe only with a battery-controlled pulmonary pacemaker. At night he needed the assistance of a respirator. He could have been sentenced to home detention, where he would have had round-the-clock attention. Instead, Retchin, apparently upset when Magbie refused to swear off weed, which helped him get through a miserable existence, sent him to that taxpayer-supported hellhole near the Anacostia River known as the D.C. jail.

What happened to Magbie at the jail and at Greater Southeast Community Hospital, where his life ended five days later, shouldn't happen to a dog. In fact, it doesn't happen to dogs and cats in the custody of decent and caring people. But Magbie had no one in his corner except his mother, Mary Scott, and she could not join him in jail. In the intervening 12 months, the continuum of players responsible for Magbie's last days on Earth has never had it so good.

Retchin's handling of the Magbie case was reviewed by the D.C. Commission on Judicial Disabilities and Tenure: It gave her grace, and she was subsequently rewarded with a renewed assignment to the court's coveted criminal docket so that more Retchin-style justice can be meted out to the criminal-minded.

Odie Washington, director of the Corrections Department, which runs the D.C. jail, retired with full honors and words of praise from the mayor. And Greater Southeast Community Hospital, which treats the District's sick inmates under a lucrative D.C. government contract, continues to collect D.C. checks, courtesy of city taxpayers.

The only person made to pay for the mistreatment of Jonathan Magbie has been Magbie himself. But perhaps not for long.

On the anniversary of his imprisonment, attorneys retained by Magbie's mother will file a lawsuit in U.S. District Court against the D.C. government and the hospital charging them with medical malpractice and violations of the D.C. Human Rights Act, the Americans With Disabilities Act and the constitutional prohibition against cruel and unusual punishment.

Magbie's lawyers are no slouches. Two of them, Donald Temple and Ed Connor, successfully sued the Eddie Bauer clothing store chain in 1997 for falsely imprisoning and defaming three young black men on suspicion of shoplifting. The federal jury required the company to pay $1 million.

Temple and Connor are joined by the American Civil Liberties Union's Eighth Amendment specialists in prisoners' rights, Elizabeth Alexander and Arthur Spitzer. Together they have done the job that the D.C. inspector general's office and the mayor's office told me they would do -- but did not. Magbie's lawyer found out what happened to him during those five fateful days a year ago. And they want to tell that story to a federal judge and jury.

Among the evidence they will present is an affidavit and medical opinion from Jerry S. Walden, a prison medicine expert and former chief medical officer at the U.S. penitentiary in Terre Haute, Ind. After a review of records from the D.C. jail and Greater Southeast Community Hospital, interviews with various sources and a look at the pertinent medical literature, Walden concluded that "Jonathan Magbie died a death of neglect."

There were, Walden said, many parts to the failure to take Magbie's health seriously. "Certainly the tracheostomy accident [Magbie's tracheostomy was misaligned, shoved back in, and not tied to maintain a correct position] could have been prevented and happened while being monitored.

"His pneumonia [noted during the initial jail examination] was essentially undiagnosed and untreated. Despite the early X-ray and the sputum production, no one sent a sputum specimen and started treatment. All this was complicated by his nutritional status." (Magbie weighed 130 pounds at jail intake on Monday, Sept. 20. Five days later, at his autopsy exam, he weighed 90 pounds).

"He had been in the emergency room on day one [rushed from the jail to Greater Southeast and returned the next day] and had fluid and sugar deficits noted. No one cared that he wasn't eating or measured his fluid intake after."

Although Magbie needed a respirator and made that fact known on his first day at the jail, he was never given one during his five days in custody. "There were no physicians consult nor pulmonary consult performed while in the jail. He was monitored by license practical nurses. No RN [registered nurse] or PA [physician's assistant] or doctor followed him or was even consulted about" drastic changes in his condition.

Disaster struck on Sept. 24, his last day at the jail -- and in this world. The lawsuit will detail what happened that day.

None of this will soften the blows that Magbie received from the D.C. government. None of this will bring him back or end the weeping and sorrow in his family. But Magbie deserves justice. This is an opportunity. We are obliged to try.

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November 21, 2004 -- The Washington Post (DC)

Who Judges The Judge?

By Colbert I. King

Drop by the H. Carl Moultrie building on Indiana Avenue NW on any given day and watch as Superior Court judges mete out justice to people in orange prison jumpsuits who have failed to do right by their fellow citizens. But how about when the criminal justice system renders an injustice itself -- one so egregious that it results in a tragic death and an irrevocable shattering of lives of family and friends? What happens when the upright does wrong?

Make no mistake about it, Superior Court Judge Judith Retchin knew what she had on her hands when she sentenced 27-year-old quadriplegic Jonathan Magbie on Sept. 20 to 10 days in jail for simple possession of marijuana. Why she decided to incarcerate Magbie, totally dependent, unable to breathe reliably on his own -- and a first-time offender -- remains an unanswered question that court officials would just as soon see go away. It won't. It can't. The power of government took Jonathan Magbie off the streets. The power of government put him behind bars. And Magbie was in the government's custody when he died.

Magbie's disability was no mystery to Retchin.

Three months before he was sentenced, Magbie was called by Retchin to a status hearing at which he was expected to plead guilty. Retchin said she wanted truthful answers. To make certain Magbie could be prosecuted for any false statement, she told him she was going to ask the court clerk to place him under oath. "Do you understand, Mr. Magbie?" Retchin asked. "Yes," Magbie said.

"Mr. Magbie," asked Retchin, "are you able to raise your right hand to take an oath?"

"No," he said. Retchin then told Magbie, "Listen to what the court clerk is saying. I understand because of your physical limitations you won't be able to raise your right hand, but you still will be under oath if you agree after she gives you the oath." Magbie, five feet tall, his growth stunted since the accident that left him paralyzed at age 4, seated in the motorized wheelchair that he operated with his chin, swore to tell the truth, the whole truth and nothing but the truth.

After that there was no way Magbie's condition could have slipped Retchin's mind. Three times, Charles Stimson, the assistant U.S. attorney prosecuting the Magbie case, saw fit to give the judge a reminder.

"Before I go forward," Stimson told Retchin in open court, "I would like the record to be clear that Mr. Magbie is in a wheelchair. As I understand it from numerous discussions with [Magbie's lawyer], he's a quadriplegic. And that should be very clear on the record at this point before I go forward and the court makes further inquiry."

Retchin merely thanked Stimson and moved on to accept Magbie's guilty plea.

Stimson kept trying to get it through Retchin's head that Magbie was no threat. During a confidential bench conference, Stimson cited Magbie's condition as a reason why the government did not want to take the case to trial or to send him to jail. Stimson told Retchin that "the jury appeal to a person in a wheelchair . . . is very high because he can't do anything for himself." Moments later, Stimson explained: "We felt that if we took this to trial, the jury would acquit Magbie because he can't really do much."

But nothing could stop Retchin from treating Magbie as a danger to society.

Well, you might ask, didn't the police find Magbie and his co-defendant, Bernard Beckett, seated in a Hummer, a $50,000 to $70,000 vehicle, in a Southeast D.C. neighborhood? And didn't the police search Magbie and find $1,502 at the time of his arrest? Wasn't a gun in the car?

True, but that's not the whole truth. What the police may have suspected was a case of drug dealers in a luxury vehicle purchased through ill-gotten gains was anything but.

Beckett was Magbie's cousin and driver as well as a resident in Magbie's home. The Hummer was in the name of Magbie's brother. The gun was placed on Magbie by Beckett, at Magbie's request when the cops pulled them over. Magbie's lawyer, Boniface Cobbina, told Retchin that the gun was in the car for protection because Magbie and his family lived in a community with a high number of vehicle thefts.

The $1,502 on Magbie? It was unrelated to criminal activity. Magbie happened to be loaded. He was receiving about $30,000 a month in income as a settlement in compensation for his injuries, according to his attorney Cobbina. The money was invested very wisely by Magbie's mother, who, Cobbina told Retchin, gave him "at least $10,000 in cash, so that he can spend it as he wants to."

Even the prosecution acknowledged that Magbie was a young man of means. Stimson informed Retchin at the bench conference, "Mr. Magbie is trying to live sort of the fast life or as fast as he can while being confined to a wheelchair, and he has various nicknames out in the street which aren't relevant to this, but our opinion is that he likes to share his money to feel important but that he's not involved in selling drugs on the street, he's not involved in drug running." Yes, he hung out with some questionable characters and liked having them around, Stimson said, "because it made him feel important."

And, as reported two columns ago, three months before Retchin jailed Magbie, Stimson advised her that Magbie had medical needs that the jail couldn't accommodate.

So why was the judge determined to put him behind bars, which, as some have contended, amounted to a death sentence?

Being a Superior Court judge means never having to admit you are wrong -- that is unless you are answering to the D.C. judicial tenure and disabilities commission, which reviews the conduct of judges. That's not likely to happen with Judge Retchin, however. Magbie's not wired to anybody important in Washington.

And, sure, he died while in custody of the D.C. Department of Corrections. But the jailers aren't worried either. Their boss, Mayor Anthony Williams, is too busy with other things such as bringing the monied and baseball back to town. Besides, what's all this fuss about another black man dying? It happens all the time.

Update: Yesterday Gregg Pane, director of the D.C. Health Department, said his department's report on Magbie's death was being sent to Greater Southeast Community Hospital, where he died, for comment. Greater Southeast, according to a letter from City Administrator Robert C. Bobb to D.C. Council member Kathy Patterson, has been presented with a "Statement of Deficiencies and Plan of Correction." The District is also, Bobb said, "reviewing the city's contracted relationship with Greater Southeast Community Hospital."

The city administrator's office advised that a letter concerning the circumstances of Magbie's death was being sent to his mother, Mary Scott, but that the contents could not be disclosed.

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November 6, 2004 -- The Washington Post (DC)

Jonathan Magbie's Last Hours

By Colbert I. King

"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.

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October 30, 2004 -- The Washington Post (DC)

How (and Why) Did Jonathan Magbie Die?

By Colbert I. King

With important national and local elections on Tuesday, and with a city in turmoil over baseball stadium financing, why return for a fourth consecutive week to the case of Jonathan Magbie, the 27-year-old quadriplegic who was sentenced by Superior Court Judge Judith Retchin to 10 days in the D.C. jail for simple possession of marijuana? After all, Magbie's dead and buried. Why keep his story alive?

Maybe it's because Jonathan Magbie didn't die the way so many other men of his age and race meet death in the nation's capital: by being gunned down or stabbed in the streets. He didn't lose his life in a house fire or an automobile accident, although it was a car crash at age 4 that left Magbie paralyzed from the neck down, unable to breathe on his own sometimes, and dependent on others for the rest of his life.

On Sept. 20 a judge took Jonathan Magbie away from the people who cared for him and placed him in the hands of the D.C. government. When he died on Sept. 24, Jonathan Magbie was this city's captive under lock and key, unable to fend for himself or live as he wished.

How and why did he die? That question, at least to me, is every bit as important as the outcome in the battleground states on Tuesday. A human being entrusted to our government lost his life. He was arrested, prosecuted and restrained from freedom in our name. Did we the people, through our government, contribute in any way to his death? The performance of this city's criminal justice system is no less important than that of the D.C. Sports and Entertainment Commission, on which Mayor Anthony Williams and other city officials lavish such rapt attention.

And so the late Jonathan Magbie still tops my agenda. So does the mystery of his death.

Will we ever know?

Last week Chief Judge Rufus King III of the D.C. Superior Court pledged to "determine what went wrong" in Magbie's case ["Judge King Responds," letters, Oct. 22]. But when asked if the judge would make public his findings after meetings with Corrections Department officials about the jail's capacity to handle different medical conditions, Superior Court spokeswoman Leah Gurowitz said in an e-mail: "The Chief Judge will make any changes in Superior Court practice and procedure that are found necessary to assist the jail in assessing and treating those committed to its custody." Apparently it's going to take more than a prying journalist to find out what the court did or failed to do with regard to Jonathan Magbie.

But answers are needed.

Why did Judge Retchin not take action when Malek Malekghasemi, associate medical director of the Correctional Treatment Facility (CTF), where Magbie was housed, called Judge Retchin's law clerk on the day after his sentencing to say that Magbie should not be in jail, given the nature of the sentence and his overall medical condition? Did the court have a responsibility to act after receiving information from a competent medical authority, especially information that contradicted her earlier understanding of the jail's ability to accommodate Magbie?

Who advised Judge Retchin's law clerk that the jail could accommodate, as a court official described Magbie, "a paralyzed wheelchair-bound defendant"? The Corrections Department sent me this statement on Thursday: "For the record, the Department of Corrections (DOC) had no conversation with anyone from the Superior Court regarding the housing of a person confined to a wheelchair prior to the sentencing of Mr. Magbie. The DOC was not aware of Mr. Magbie, or his condition, prior to his arrival at the Central Detention Facility [D.C. jail], following his sentencing in Superior Court, on September 20, 2004. However, the judges of the U.S. District Court and the Superior Court, and their staffs, routinely communicate with the DOC through the DOC's General Counsel's Office."

So who gave Judge Retchin assurances, which she stated in open court, that the jail could accommodate Magbie's needs? Was Judge Retchin ever advised that Magbie needed a ventilator at night to breathe? The Corrections Department maintains that it does not provide ventilator services in any of its facilities, and would have said so if asked. A review of all court transcripts related to Magbie will, of course, settle that question. But will that happen?

Did the Corrections Department provide the appropriate level of care needed for Magbie while he was at the CTF? The department maintains that it did. But department staff members learned from Magbie-after he began experiencing breathing problems on his first night in incarceration and before he was transported by ambulance to Greater Southeast Community Hospital-that he used a ventilator at night to assist his breathing when he slept. Yet for three nights at the CTF, he was never supplied with one or sent to a facility where a ventilator was available. The Corrections Department says it followed oral and written instructions from Greater Southeast's medical staff for Magbie's care, namely, to provide him with nasal oxygen as needed. Did the hospital provide appropriate instructions, given Magbie's medical condition? Did the Corrections Department take into account the concerns of its associate medical director?

Who will answer these questions?

The D.C. Health Department's investigation into Magbie's death, started Sept. 28, was completed on Oct. 22, according to Philippa Mezile of the department's communications staff. A report is expected next week. Mezile said that after a review by physician Robert Vowels, senior deputy director for D.C. environmental health administration, and the department's general counsel, the report will be made public, subject to further review by the city's attorney general (formerly the corporation counsel). The investigation included interviews with hospital and jail staff members and a review of hospital and jail records, Mezile said.

Did investigators also interview other inmates housed in the CTF infirmary with Magbie, I asked? No, Mezile said, because the Health Department lacks regulatory authority over the Corrections Department except for environmental and sanitation issues. Suppose, she was asked, that there are inmates with stories to tell about Magbie's treatment, as Magbie's family has heard; shouldn't authorities want to know? The question remains unanswered.

Five weeks later, we do not know how and why Magbie died.

On Tuesday, I asked Beverly Fields, chief of staff to the city's chief medical examiner, about Magbie's cause of death. "It's pending," Fields said. "Pending what?" I asked. "Just pending," she said.