Bleak House : As patients died one by one, a Washington D.C. home for the mentally retarded became one of the nation's most deadly institutions. Eventually, Forest Haven was closed, but questions linger about how the nation cares for those entrusted to its protection.

Murray Waas is a Washington-based investigative reporter. He wrote this story as a fellow at the Alicia Patterson Foundation. Jesse Drucker and Jason Serman provided research assistance

During the early morning hours of Aug. 8, 1989, two detectives were summoned to the grounds of Forest Haven, Washington, D.C.'s institution for the mentally retarded "to investigate the report of a dead body." At the scene, they discovered the "body of a B/M (black male) . . . lying on his right side in his bed in a fetal position . . . ." Their report further related: "He was wearing a hospital gown and white socks with red stripes. . . . There was what appeared to be dried blood on his mouth."

The body was identified as that of Arthur Harris, a severely retarded young man known to his family and friend as Arkie, who had spent more than 17 years institutionalized at Forest Haven.

Not long before his death, Arkie's family had celebrated his 22nd birthday at Forest Haven, 300 acres of wooded, campus-like grounds located outside Washington in suburban Laurel, Md. In one of the 22 cottages, many with pleasant-sounding names like Athelia, Dogwood and Camelia, they ate ice cream and cake and snapped photographs. But when it came time for them to go home, Arkie's older sister, Brenda, did not want to leave. For reasons she could never explain, she was filled with fear and despair as she said goodby to her brother. "We said we got to go, but she just stood there," recalls their mother, Gloria Mae Harris. "So I waited about a half an hour for her, and I went back in the ward and she's laying in the crib with him. She said, 'Mom, I don't want to let Arkie go.' I said, 'Honey, he's OK, nobody's going to hurt him here.' So she looked back and she busted out crying and she went right back and held him again. That's when I said 'Brenda, come on,' 'cause I was trying to be strong for her. But she kept crying and soon we both ended up crying, and I went back there and I said, 'He's fine.' She looked at him and said, 'I love you Arkie.' And he just took his hand to her face. She said, 'I feel better now.' "

But Arthur Harris would soon become one of at least 10 Forest Haven residents who, during a two-year period, died of complications related to aspiration pneumonia, an infection that can be caused by entry of food into the lungs when patients are fed while they are lying down instead of sitting up.

Those deaths, says John Dunne, the assistant attorney general for civil rights during the Bush Administration, constitute the deadliest known example of institutional abuse in recent American history. "Based on our various investigations around the country" says Dunne, "there was no other institution of any kind in America where so many people died from abuse and neglect over such a short period of time."

The ultimate death toll at Forest Haven may never be known. The problem dates back at least 20 years, according to city records and interviews, when the population of the facility averaged more than 1,300. Yet the Justice Department and city only began to monitor deaths there between May, 1989, and March, 1991, while the institution was in the process of closing and roughly 200 residents remained. "There is nothing to indicate that there was a dissimilar rate prior to that," says Joseph Tulman, a law professor at the District of Columbia School of Law who worked on behalf of Forest Haven residents. "What we discovered in 1991 was only the tip of the iceberg."

Social problems such as homelessness, street crime and drugs generate headlines, but less public attention has been focused on the often life-threatening conditions facing people living in prisons, mental hospitals, institutions for the mentally retarded and public nursing homes. Especially threatened are those left behind at institutions such as Forest Haven, forgotten as communities debate whether to maintain such facilities or to close them.

Mary Bray, an occupational therapist who has investigated conditions at facilities for the mentally retarded as an expert for the Justice Department and advocacy groups, says that Forest Haven is hardly unique and residents all across the country are still in danger of dying of aspiration pneumonia.

"Over 200,000 people in institutions who are immobile and rely on others for eating are at risk. Others such as the mentally retarded, high-risk infants, children and adults with developmental disabilities are also at risk," says Bray. "Part of the problem is that the parents and relatives of a good number of these people have long since forgotten them. So there is no one to make sure they are not neglected or abused."

The Justice Department and private advocacy groups have sued state governments in Pennsylvania, Connecticut, Oregon, Tennessee, Oaklahoma and many other states for violating the constitutional rights of mentally retarded residents of state-run institutions. In a number of cases, lawsuits have charged that residents had died unnecessarily from aspiration pneumonia.

Last November, a federal judge ruled that the State of Tennessee had violated the constitutional rights of mentally retarded residents of a state institution known as the Arlington Developmental Center. Among other things, the judge ruled that it was "virtually conceded by the state of Tennessee that psychiatric and psychological services were virtually nonexistent." Medical care, he found, was "below any minimum standard and well below the medical malpractice standard." A Justice Department expert in the case estimated that at least 25 residents of the institution had died of aspiration pneumonia, and that many of those deaths could have been prevented.

Karen Green McGowan, also a Justice Department expert witness, says that the extent of the problem across the country has never even been exposed: "Someone dies of aspiration pneumonia and they (state authorities) will say they died of heart failure or respiratory arrest or that they stopped breathing. Everybody who dies has stopped breathing or their heart has stopped. And so the real cause of death is often not identified. What we have here are quiet little murders. They're killed one day at a time because people don't pay attention and then no one finds out the real cause of death."

Some experts say they believe that the story of Forest Haven is an example of what is to come, as municipal and state budgets become tighter, institutions face overcrowding and understaffing, and the public's attention is focused elsewhere.

WHEN ARTHUR HARRIS DIED, ONLY A HANDFUL OF FAMILY AND PEOPLE who knew him attended his funeral. The city that had been responsible for his care during his life concluded it was too expensive to pay for a tombstone, so his grave is designated only by a numbered metal disk.

Arthur Harris' death was the result of inaction by representatives of the government of the District of Columbia, the federal judiciary, the medical profession, advocacy groups and law enforcement.

The city was warned repeatedly over a 15-year period about the abuse and neglect of patients at Forest Haven, and specifically that aspiration pneumonia was killing them. But despite the warnings and a court order to improve conditions, the city government did nothing until it was too late.

Justice Department civil rights attorneys presented evidence eight times over a period of 18 months to federal district Judge John Pratt, who was enforcing the court order, that Forest Haven patients were dying because of improper mealtime practices and substandard medical care. But Pratt did nothing.

The medical profession was also indifferent. One physician, according to city documents, provided substandard care to five Forest Haven residents who died of aspiration pneumonia. Another was allowed by the Maryland medical licensing board to continue practicing at the facility even after it suspended his license and declared that his continual practice of medicine would pose a "grave risk and imminent danger to the health, safety and welfare of the citizens of Maryland." Justice Department and city documents say he later provided inappropriate care to Forest Haven residents who died.

After most of the deaths, the U.S. Park Police, which had jurisdiction because Forest Haven is located on federal park land, were called to investigate. With their daily mission of policing the nation's national parks, they had little experience at probing institutional abuse or medical negligence. And so the cops did nothing.

Forest Haven is now closed, its doors shut on Oct. 14, 1991. But the story has not ended. Retarded citizens continue to die as a result of abuse and neglect by the city government--in city-run group homes and in a municipal nursing home.

A multimillion-dollar civil suit alleging wrongful death filed by the families of six Forest Haven residents is scheduled to begin Monday in a District of Columbia Superior Court. And perhaps there will finally be answers to the lingering questions about how so many people over so many years could have died at the institution, and how even though so many powerful people in the community knew what was going on at Forest Haven, nothing was done to stop the dying.

IMPROPER MEALTIME PROCEDURES CAN KILL IN A NUMBER OF WAYS, EX-Mary Bray, the occupational therapist. "There is a valve we all have called the epiglottis," she says. "The epiglottis opens and closes depending on whether you're breathing or eating. Under normal circumstances, the epiglottis closes off when you're drinking or eating, and it prevents food from going down in the lung," which eventually can be fatal.

"But if you're fed lying down, or too quickly, or a combination of the two, the epiglottis does not function properly, the consequence of which is food lodging in your throat or going down into your lungs," she says. If food or fluid builds up in the lungs, the result can be a fatal infection or asphyxiation caused when so much scar tissue builds up around the foreign material that the lungs can no longer function. Other times, as the person coughs repeatedly, trying to expel the food, he can choke to death.

Improper feeding and lack of movement can also cause potentially fatal gastrointestinal conditions, including one known as volvulus, in which the intestines become so twisted that they may eventually, in the words of one physician, "resemble an entangled telephone cord." The inability of the intestines to function can, in turn, cause the crowding of other nearby body organs, internal hemorrhaging or asphyxiation if the intestines pressure the diaphragm.

Almost all of the 10 Forest Haven residents who died from complications related to improper feeding died in these ways, according to reports prepared by experts retained by the civil rights division of the Department of Justice and in internal reviews by the District of Columbia. Yet aspiration pneumonia need hardly be fatal. Only because the conditions went untreated, the medical reviews concluded, did the residents die.

ARTHUR HARRIS WAS 5 YEARS OLD WHEN HE WENT TO LIVE AT FOREST HAVEN in 1973. For the first years of his life, Arkie had seemed like any other little boy, except that he was developing a bit more slowly.

"He was a happy child, always smiling; it's just that he wasn't performing like my other children when they were born," Gloria Harris recalls. But she soon began to notice problems with Arkie, which she reassured herself at first were not serious. When he started to walk and play and tried to keep up with his two older sisters, his left leg would always drag, slowing the little boy down. And his left arm seemed to be "always in a clench."

When Arkie was 2, doctors told Harris that her son was mentally retarded, and she kept him at home, where he continued to receive medical treatment and therapy. "They prescribed glasses for him because his eyes, the left side would always go nearly in the corner," says Harris. "They were just cute little glasses. They had very thick lenses. And we used to always mess with them 'cause we'd have to put them on him. And then he would always with his right hand take them off."

When Arkie was 5, a social worker warned Harris that her son would "have the strength of 20 men" when he was a teen-ager and be impossible to control. And not long after that, Arkie went to live at Forest Haven, taking only his clothes and a few stuffed animals, including his favorite, a green alligator. During her first visit to her son, Gloria noticed the alligator was missing. "They said it probably got knocked on the floor and the cleanup man probably put it in the trash, and I've never seen the alligator since."

Three years later, as a movement toward removing the retarded from institutions swept the nation, the now-defunct Antioch Law School filed the class-action lawsuit that eventually led to Forest Haven's closing. The lawsuit, Evans, et al. vs. Washington, charged that the constitutional rights of residents were violated because they were victims of inhumane treatment. The Justice Department joined the suit two years later as a co-plaintiff. Betty Evans, mother of Joy Evans, the name plaintiff in Evans. vs. Washington, later provided a sworn affidavit to Judge Pratt. "Dogwood, the cottage where Joy lived, was a veritable snake pit," she wrote. "I once witnessed a nurse open the cottage door only to find 80 half-clad screaming women come running to the door; the nurse quickly closed it shut."

She also described the constant physical abuse her daughter had been subjected to: "The more simple injuries ranged from chipped teeth to scratches, lacerations and bruises all over her body. . . . On one occasion we found Joy's entire back raw." The Evanses were later to learn the injury was the result of "urine burns from being restrained on a rubber sheet."

On June 14, 1978, the plaintiffs and the city agreed to settle the case, signing a consent decree ordering that Forest Haven would be closed and its residents moved to community group homes. In the meantime, they would no longer be subjected to "acts of physical or psychological abuse" and would receive proper "medical, dental, and health related services." (The consent decree came too late for Joy Evans, who had died at Forest Haven, at the age of 18, in July, 1976.)

Buried in the lengthy court order was the following promise by the city government: "No class member shall be fed in a position less than the maximum upright position consistent with his or her capabilities or handicaps."

Contacted 15 years later, Bob Catz, the attorney who initiated the Evans vs. Washington case and drafted the consent decree, explains: "There were a large number of people who were dropping dead like flies. What was happening was that way back then they were dying from being fed lying down, which caused them to eventually choke on their food. It was common knowledge. So we put the language in to require them to be fed sitting up." Unknown to Catz, however, aspiration pneumonia deaths continued.

In July, 1986, the District of Columbia Association of Retarded Citizens, which had been appointed by the court to monitor conditions at Forest Haven, asked an expert in developmental disabilities to submit a proposal for training Forest Haven staff to feed patients properly. The proposal, with a modest budget of $24,698, called for assessing the aspiration risk for each resident and training workers at the facility. But the expert, Karen Green McGowan, says she was told later that the proposal was turned down when the city said it had no funds for such a program.

Without that training, many well-intentioned workers fed residents improperly out of sheer ignorance. "Nobody ever instructed them that it was wrong to feed the residents lying down," says Bray, the occupational therapist. "The sad thing is that many of the workers were the only people in the world who cared about many of the clients."

I observed that mix of care and ignorance when I visited the institution in 1990. A nurse lovingly washed a profoundly retarded boy, holding him in her hands, cleaning him, singing to him. ("From what you read in the newspapers, you'd think we're all monsters," she good-naturedly scolded me.) Later, while I still looked on, she fed the boy while he was lying down.

But even had there been proper training, a number of workers and medical personnel say that staffing levels at Forest Haven were so low that it still would have been all but impossible to feed residents in a responsible way.

When she visited her son at mealtime, Gloria Harris wondered why the staff did not sit up Arkie in his bed but spoon-fed him bits of food while he was lying down. At home, she had taken care to prop him up with pillows. But she was not one to question the staff procedures, often watching as a single worker attended a roomful of hungry residents. "I knew the nurses had their hands full," she says.

Kathy Senior, a social worker who volunteered at Forest Haven, recalls that "it would take me 20 to 30 minutes to properly feed one (resident). A lot of workers were required to feed eight or 10 residents in that time. And it's made quite clear to them that they'll lose their job if they don't get all their people fed."

A constant source of wonderment for Harris was why her son was kept in a crib even as an adult. "But I figured that was the way Forest Haven procedures were."

It was difficult for Brenda to see her brother that way, says Harris. "When Arkie got to be 11 or 12, she could not stand to leave him there, and I remember when I took here there, she wouldn't want to leave. . . . She said, 'Somebody gonna hurt my brother.' I'd say, 'No. He'll be fine.' And she'd look back and she'd just bust out crying."

On their final visit, Harris recalls, "We brought him half a sheet cake and had his name put on, put 'Happy Birthday Arkie' on it. There were a couple of children that came down there. We were having a ball with giving him ice cream and cake."

Harris knew Arkie was happy that day: Arkie and Brenda blew out the candles on the cake together. Then Arkie "turned around and patted Brenda's face, like that," Harris says, imitating her son's mannerism, "and that would show he's happy."

Later, when Gloria had trouble persuading Brenda to leave, it was only after Arkie once again patted her on the face that she agreed to go.

Around the time of that final goodby, early 1989, the original target date for Forest Haven's shutdown had come and gone, with 252 residents remaining. Medical care and living conditions were so bad that the federal Health Care Financing Administration had taken the unusual step of cutting off $8 million in Medicaid funding for Forest Haven. The city, which could have continued the funding for months simply by appealing the decision, took no action to recover the money. And now, without this substantial funding, conditions deteriorated.

By now the civil rights case had been turned over to Joe Tulman. An intense, soft-spoken, bearded man of 40, Tulman was stunned by reports of inhumane conditions at Forest Haven. Convinced that the residents needed more forceful advocacy, Tulman called the Justice Department's civil rights division, where attorney Laurie Weinstein, alarmed about the Medicaid cutoff, recommended that the department become re-involved.

Among her first actions was to arrange a tour of Forest Haven with Dr. Robert Kugel, an expert on medical care of the retarded, who concluded in a report that "medical care and practice at Forest Haven . . . expose residents to unreasonable risks of harm."

Two months later, on May 2, 1989, Sheila Dabney, 39, a profoundly retarded Forest Haven resident, died suddenly, the first of three deaths over the next few months. Medical records indicated that the cause of death was related to either aspiration pneumonia or an infected bedsore that had gone untreated for such a long time that the infection had spread and killed her. John Schneider, a 60-year-old resident, was the next to die, and a city report concluded that "aspiration may have been a factor in the demise of the patient."

Four days later, on Aug. 8, 1989, Arthur Harris died, and the Justice Department asked Kugel to investigate. He concluded that Arkie had suffered from symptoms related to aspiration pneumonia since 1986, but no aggressive action had been taken to correct the problem.

Although the city would repeatedly argue before Judge Pratt that nothing was wrong with medical care at Forest Haven, it had been monitoring care at the facility and had concluded in many instances that treatment was even worse than the Justice Department was alleging.

A city-sponsored peer review of the medical care Arkie received noted that he had apparently had many episodes of vomiting in the three months prior to his death. "The vomiting was so severe that (Harris) had dehydration," the report said, and at various times he was admitted to the hospital or Forest Haven's infirmary. His medical records show that between February, 1988, and August, 1989, he was sent to D.C. General Hospital at least seven times to be treated for symptoms associated with improper feeding, such as upper gastrointestinal bleeding, vomiting and aspiration pneumonia.

"Vomiting appeared controlled . . . but on June 28, 1989 . . . there was continued vomiting including a large amount of dark brown material. . . . On July 17, 1989, nurses' notes show (ashen) color, bluish lips, rapid pulse. . . . (This) suggests shock probably due to a massive GI (gastrointestinal) hemorrhage."

But Kugel, in his report to the Justice Department, concluded that despite all this, Arkie could have still been saved on the last day of his life if someone had called 911 and rushed him to a hospital.

A police report shows that more than six hours passed between the time medical personnel believed Harris' life was in danger and an ambulance arrived.

At 6:30 on the morning of Aug. 8, 1989, the report related, a nurse checked on Arkie and "noticed that Harris had vomited." At 8:30, the same nurse checked once more and Arkie vomited again, an event that did not alarm the nurse, who explained to the detectives "that any time Harris was moved he would vomit."

Arkie was finally examined an hour later by a Forest Haven physician who waited nearly two hours before writing "an order to have Harris taken to D.C. General Hospital." The nurse, the report says, contacted a local ambulance service "to arrange transportation" but was told they could not send an ambulance until 3 p.m. At 1 in the afternoon, the nurse again called the ambulance, and asked if "they could not make the transport sooner."

Around that time, the nurse noticed that Arkie was "choking and in some respiratory distress." She rolled him onto his side then noticed that "vomit (which) consisted primarily of blood and mucus . . . gushed from mouth and nose."

CPR was attempted, but proved futile. By the time the ambulance arrived, Arthur Harris was long dead.

Gloria Harris only learned about her son's death by happenstance, from a relative whose daughter worked at the facility. Panicked, Harris called the institution, eventually reaching a social worker. "She said, 'Mrs. Harris, I have bad news for you. I regretfully have to say he passed at 1:35 p.m.,' " Harris recalls. "My son could have died and nobody told me for months."

After the funeral, the nurse gave Harris Arkie's belongings: "There was a new pair of camouflage fatigues and two little stuffed animals. I told her that the clothes were not his, that I had never seen Arkie wear them. And those are not the stuffed animals I gave him. And I said, 'This is all his belongings?'; she told me 'yes.' And I still have it all in the same bag and a picture of him they gave him. I just left it in a plastic bag up in my closet."

The city paid for Arkie's burial at the Harmony Memorial Park cemetery in suburban Maryland. There, in the Garden of Eternal Rest, his grave is marked by a small metal disk engraved with four numbers, one in each corner, each signifying a different grave. Arkie's number, 174, in the upper right corner of the disk, indicates that his wooden coffin is buried in the area above and to the right of the marker.

Shortly after the burial, the Justice Department filed a motion with Judge Pratt relating that "Dr. Kugel discovered that the medical records of all three deceased residents revealed an absence of appropriate medical care."

Armed with such evidence, the attorneys prepared for a hearing in federal court, where they would seek a contempt ruling and fines against the city for neglecting to obey the consent decree. They were confident that the dying would finally come to an end.

THE COURT DATE SOON CAME. BUT LAURIE WEINSTEIN, THE JUSTICE DEPARTMENT civil rights attorney, hardly had the chance to make her case. Judge Pratt told attorneys for both sides that he had decided to review the matter in another 120 days, telling them to try to work it out on their own.

Weinstein rose to object, but the judge was in no mood to listen. "Thank you, Ms. Weinstein," he said, gesturing that the court session was over.

Tulman noticed that Weinstein's eyes welled up with tears as she pleaded with the judge. "Your Honor, may I add something?" she asked. "I really feel that it is important to do something immediately about the situation currently at Forest Haven. The court monitor and our own expert . . . have found that every day the residents are out there, they are in serious risk of harm. Now you have just given them another 120 days of danger, and I really feel that we have got to do something better than that, Your Honor."

But Pratt had already made up his mind: "I appreciate your concern. Thank you," he said and recessed the court.

Five more Forest Haven residents would die of complications related to aspiration pneumonia before Judge Pratt held his next hearing on Jan. 12, 1990.

On Oct. 11, 1989, Marcia Carter, 31, died of hypothermia and pneumonia, according to an autopsy report. Despite having been diagnosed with a disorder of the hypothalamus, which regulates body temperature, and previous hospitalizations for hypothermia, Carter did not receive appropriate medical care for either condition, a Justice Department review found.

One week later, 22-year-old Joseph Hardy Jr. died suddenly from complications associated with aspiration pneumonia. Joe Joe, as he was known to his friends and family, was placed in Forest Haven when he was 3. Joseph Hardy Sr., a former police officer who visited his son almost every weekend, recalls that he often complained about the way his son was treated, but he was ignored: "They never moved him too much out of the position that he was laying in. His bed sheets sometimes were filthy," and he constantly had bedsores. "They were feeding him baby food," Hardy says. "They wouldn't even give him time to swallow what he had in his mouth. They would be pouring it in him like they were pouring water down his throat and it would all just come back out of his mouth and nose."

"From the (medical) record," says Kugel's report for the Justice Department on Joseph Hardy's care, "it is clear that this man had repeated episodes of aspiration pneumonia and many episodes of vomiting. He was hospitalized on several occasions because of these problems. . . . Obviously, the staff was aware of the somewhat fragile nature of this patient and the likelihood of acute gastrointestinal disorders."

Kugel concluded that "one is astonished to see how little attention was given to this patient on the night prior to his transfer to the hospital and subsequent death. . . . There is no evidence that any of the physicians stopped by to see him or were asked to see him."

Kugel said his study of the death of Joseph Hardy was incomplete because he was hampered by "the lack of autopsy results." But the report concluded that his death was "due to acute bowel obstruction" or "volvulus." The report concludes: "Joseph Hardy died of inability to breathe because of twisting of the intestines."

After Joe Joe's death, the city paid for his funeral. "It was a very pretty casket he was in," recalls Hardy. "I'm not gonna lie to you. They dressed him up real nice."

Blue was Joe Joe's favorite color and Joe had asked the chaplain to find him a blue suit for the funeral. And there would be other funeral preparations as well: Because he had never received physical therapy, "his hands were like someone who had a stroke. Their fingers get real stiff and turn in," says Hardy. At the funeral home, they broke the bones of Joe Joe's hands, so they could be straightened, at his side, looking good and proper for viewing at the funeral.

On Nov. 9, 1989, the Justice Department told Pratt of the deaths of Carter and Hardy and asked him to more quickly consider their motion to have the city held in contempt. Pratt declined to move up the hearing date.

There were two more deaths in December. On the 8th, Mary Elizabeth Reeves, 35, died as the result of having suffered "volvulus of the intestine," according to an internal city report. Then, on the 17th, Willie Marie Gil, 21, died of complications related to aspiration pneumonia. At the time of death, she weighed only 28 pounds. And on Jan. 10, 1990, 20-year-old Walter Tolson died, also of complications related to aspiration pneumonia.

In a report for the Justice Department, Dr. Renee Wachtel, an expert in the care of the retarded, concluded that poor medical care was responsible for all three deaths: "There was no investigation of the role recurrent aspiration might be playing in her respiratory distress," she wrote regarding Willie Marie Gil. And despite the fact that Walter Tolson was regurgitating an average of 10 times a day just before his death and had "recurrent aspiration and GI bleeding" there was no medical intervention to save him.

On Jan. 29, 1990, Judge Pratt finally heard arguments about whether to impose sanctions. Dr. Wachtel's report, which had been presented to the judge, concluded: "Medical care and practice at Forest Haven is inadequate . . . (and) exposes (Forest Haven residents) to unreasonable risks of harm."

But Pratt praised the city, noting that it had reduced the number of residents from 1,300 in 1978 to a current level of 232.

"The most significant outplacement they've done is that they've buried five more people since the last meeting," Weinstein responded.

"We don't know whether they would have died anyway," Pratt told Weinstein. "These people . . . are not in the best of health probably, any of them."

The next day, he issued an order concluding that although the district was in "consistent and continuing violation" of his court orders, he still would not make a final decision about sanctions until a March 1, 1990, hearing.

Judge Pratt declined to be interviewed for this story, saying he makes it a practice not to comment about cases over which he has presided and noting that his ruling and comments from the bench explain his actions.

The 83-year-old jurist, who won a Bronze Star and a Purple Heart in World War II, was appointed to the federal bench in 1968 by Lyndon B. Johnson. His judicial trademark has been to press litigants to settle their differences out of court, an often complex and time-consuming process.

At the March 1 hearing, Weinstein argued that Judge Pratt should fine the city each day it refused to properly feed Forest Haven residents and provide appropriate medical care. Again he ruled against her. And the dying continued. Just a week before, a patient named Michael Pipkin, a city report would later charge, had died after having received deficient medical care.

On April 9, Judge Pratt issued an order threatening the city with stiff fines if his schedule to close Forest Haven was not met, but he still refused to address the issue of medical care there.

Three months later, the Justice Department once more petitioned Pratt to impose sanctions, entering into the record a report by Victoria Therriault, a registered nurse, who warned: "Meal times remain a nightmare in terms of aspiration risk . . . . I continue to be horrified at the feeding techniques . . . used by staff. The sound of coughing and choking permeates the area at mealtime."

But again, Pratt rejected the Justice Department's motion.

On Nov. 14, 1990, a year and three months after its original motion charging the city of Washington with contempt, the Justice Department took the rare step of petitioning the United States Court of Appeals for a writ of mandamus. The little-used legal maneuver asks an appellate court to compel a federal district court judge to adjudicate a case or make a ruling when the judge refuses to do so on his own.

The petition related: "At least eight Forest Haven residents died between May 1989 and January 1990 . . . . Yet the court inexplicably has refused to decide whether sanctions are necessary to force defendants to comply with its orders."

The appeals court denied the writ three months later, saying that not enough time had passed yet for it to take action. But the three-judge panel also commented: "Although we understand that Forest Haven is to be closed by September of 1991, we are cognizant of the potential risk to residents in the interim. Thus, we are confident that the District Court will act with all due haste . . . ."

It took another two months for Pratt to hold a hearing to consider the contempt motion and request for sanctions. In listening to the arguments, Pratt was at a disadvantage because the city was withholding vital evidence it had obtained in its own investigation of Forest Haven.

The city had, in August, 1990, provided Pratt with sworn affidavits from two top city officials denying that there was anything wrong with medical care at the institution. One of the officials said in the affidavit that "current medical and nursing services" were better than they ever had been before. Mary Tierney, a physician and an official with the city's Commission of Public Health, informed Pratt that "overall medical care and practice at Forest Haven is adequate to meet the health care needs of its residents."

Neither official was telling the full story. Indeed, Tierney had overseen an investigation that concluded that a single city doctor working at Forest Haven had provided substandard care to five of the eight residents who had died in the previous year.

Among them was Arthur Harris. The investigation concluded that despite nurse's notes since June 28, 1989, showing "continued vomiting of blood, decreased blood pressure and rapid pulse, which suggests massive gastrointestinal bleed," the doctor never ordered the blood test that would have revealed the extent of the internal bleeding that eventually killed Harris.

A month before Tierney entered her affidavit into evidence, the city had sent a letter of termination to the doctor, telling him they were firing him for "inexcusable neglect of duty."

Federal investigators say that the city never alerted them to the investigation of the doctor, despite a request that the city keep them informed about medical care at the facility. And so when Weinstein and Tulman appeared in federal court, they had no knowledge of the findings.

Although kept in the dark, they still argued that the only way to force the city to provide appropriate medical care was to impose sanctions. But Pratt once more told the lawyers that he did not believe their charges that poor medical care was killing Forest Haven residents.

"You are assuming a nexus between being in Forest Haven and dying," Pratt admonished Tulman. "There is not necessarily that nexus. In some cases, there may be, but you've got a number of people who are elderly, a number of people who are suffering from serious disabilities, whose life expectancy is completely different from that of the average member of the population. These people are going to die quicker and die more often than other people . . . ."

Tulman indignantly challenged the judge:

"All I'm saying, your honor, is if they put me in that bed and didn't move me every two hours, or if they put you in that bed and didn't move you every two hours, we would end up with a high chance of dying of aspiration pneumonia. It has nothing to do with mental retardation." But Pratt remained unconvinced: "You will agree that the reason they are there in the first place is because of mental retardation?" he asked.

Tulman was now beside himself: "There was a case of a twisted intestine in one of the deaths. . . . If you go out and look at these folks, Your Honor, many of them have teeth that are gone. Why do they have teeth that are gone? . . . The reason these people's teeth are rotting out is that they're regurgitating their food constantly."

Weinstein warned Pratt that in the meantime, others would die: "People are getting sicker and sicker out there. . . . They've got somebody out there now who is bleeding internally. The best they can do about it is say, 'Golly, gee. She's bleeding internally.' . . . This court now has the power to do the things that need to be done. You have the power to keep people from choking; you have the power to make sure people get their medical care."

But Pratt closed the hearing by saying he would render a decision about sanctions against the city at some later, unspecified date.

On April 21, 1991, two weeks after the court hearing, Charisse Marcella Gantt, a 28-year-old resident of Forest Haven, died suddenly; the cause of death was once more aspiration pneumonia.

ASKED HOW SHE HAD COME up with such a beautiful name for her second child, Charisse Marcella, Sheila Gantt answers without hesitation:

"Romantic heart. I was always wanting to go to Paris. I don't know if I will ever go. So my oldest child's name is Paris Deseree." She gave her two youngest girls French-sounding names, too: Charisse Marcella and April Rochelle.

While Charisse was home, Gantt worked from 10:30 p.m. until 7 in the morning at the neighborhood post office: "That way I was home during the day to tend to her. I could still get some sleep during the day and still do for her. You know, feed her and dress her.

"She was a strong child. She tore up her crib. She would shake it. I was beginning to wonder how in the world I was going to contain her."

Charisse was sent to Forest Haven in 1967, when she was 5. "I could no longer lift her every day," Gantt recalls. "I knew she needed special attention. I thought that's what she would get."

Gantt had trouble visiting at first. "I was crying all the time. So for a while, I just got myself together and accepted the fact that that's where she was going to be. That she would be there and be OK there."

Charisse's roommate was another severely retarded girl, Christine. Even though they could barely speak, they still could communicate with each other "making little sounds sometimes," touching, playing. Charisse, always the mischievous one, came up with her own version of institutional bumper cars: "Charisse would fly her wheelchair into Christine's. Sometimes she'd run right into her and she'd laugh." Christine could barely talk, but Gantt could see the love between the girls--"her eyes would be smiling."

When Christine attended Charisse's funeral, someone rolled her up to the open casket to view the body, but she refused to look. Gantt looked for some expression on Christine's face, but all she could see was emptiness.

Shortly after Charisse Gantt died, the Justice Department filed yet another motion seeking a ruling from Pratt, asserting: "On April 21, 1991, a 28-year-old resident of Forest Haven, who was otherwise in good health, died . . . due to aspiration (pneumonia and) the recent death indicates that medical care deficiencies at Forest Haven continue."

On May 15, 1991, Judge Pratt finally responded to the request made almost two years earlier by the Justice Department. He refused to impose sanctions.

ON OCT. 14, 1991, FOREST HAVEN closed its doors forever, but the abuses continue for mentally retarded citizens in the nation's capital.

To meet Judge Pratt's schedule to close Forest Haven in 1991, at a time when there were still not enough beds in the community homes for all the residents leaving, the city relocated 21 former Forest Haven residents into a city-run nursing home called D.C. Village, where conditions are little better than at Forest Haven.

Joe Tulman went into federal court and expressed fears that the abuses that went on at Forest Haven would now continue at other facilities, including D.C. Village. The transfer of residents to the nursing home, he asserted, was a means by which the city could evade the court order to deinstitutionalize, and in not abiding that order, the city was continuing to place the lives of mentally retarded wards at risk.

On Sept. 5, 1991, John Dunne, then the Justice Department's civil rights chief, wrote to Washington Mayor Sharon Pratt Kelly, charging that mentally retarded individuals had been improperly placed at D.C. Village and that their constitutional rights were being violated because they were forced to live in life-threatening conditions.

Mentally retarded residents of D.C. Village, Dunne wrote, were inappropriately drugged, physically restrained and were not receiving proper medical care. Dunne also charged: "Our consultants observed physical restraints . . . routinely fastened backwards, which places residents at the risk of strangulation."

The Justice Department has since commenced a new investigation to determine whether neglect and substandard medical care might have contributed to some of the eight deaths of former Forest Haven residents at D.C. Village.

At least two deaths were the results of conditions associated with aspiration pneumonia, according to city records. Willie B. Reese, who had been institutionalized at Forest Haven at the age of 3, died on June 2, 1992, at age 26.

Four months later, 24-year-old Donna Cook also died. A union grievance filed by a physician working at the nursing home charged that Cook's death was the result of negligence, alleging that "due to a lack of staff to monitor her feeding, she had repeated aspirations and died."

On Aug. 2, 1992, the families of Arthur Harris Jr., Joseph Hardy Jr., Charisse Gantt, Mary Elizabeth Reeves, Walter Tolson Jr. and, later, Marcia Carter filed suit against the city of Washington, D.C., for the wrongful deaths of their children.

Larry Brown, a spokesman for the city, said he could not discuss the pending lawsuit or other allegations of improper care of the mentally retarded. But, he said, "We are concerned about the welfare of all the citizens we serve. It is our practice to provide the best possible."

Joe Tulman had first come up with the idea of suing the city for wrongful death in 1990, after one of his many frustrating appearances before Judge Pratt. Tulman knew that juries often award plaintiffs in medical malpractice and wrongful death cases large monetary judgments. The prospect of the city being held liable for millions of dollars, he reasoned, might serve as an incentive to improve conditions at Forest Haven, and also provide some small measure of justice for the families of those who died.

But Tulman had a difficult time finding a law firm willing to take the case. What he had not previously known was that in Washington, D.C., unlike some other jurisdictions in the country, damages in wrongful death cases are largely limited to what would be the earning potential for the rest of the life of the person who had died. Since profoundly and severely retarded persons have little, if any, potential to earn money, Tulman was told that even if the city lost, there would very likely be no financial recovery. As one lawyer who had earlier been approached by the family of Marcia Carter to sue the city explained, "I could make as much money suing someone for the wrongful death of your cat as I could from suing the city for the wrongful death of Marcia Carter."

SINCE THE BEGINNING OF my investigation of the deaths at Forest Haven, I had been determined to understand how so many people could have died with nothing done to end the dying. I concluded that although individuals and institutions were responsible for what happened there, they, in turn, represented the city government, the legal profession, the medical profession and law enforcement. The ultimate, terrible truth is that these institutions reflect the values of the larger community.

Perhaps nobody understood this better than Betty Evans. Her daughter, Joy, who died of aspiration pneumonia, was the name plaintiff in Evans vs. Washington, the lawsuit that ultimately closed down Forest Haven.

When the Pratt decree had been signed in 1978, Betty Evans declared the court order a vindication of sorts. But the following year, after finding that little had changed at Forest Haven, she wrote an angry, despairing letter to the editor of the now-defunct Washington Star. Despite the death of her daughter, Betty Evans now said, she only felt "relief that Joy no longer had to endure" the "indifference of the human race that moves through the streets, parks, houses and churches of the District of Columbia." An entire community was to blame.

From the 18 years of the Evans vs. Washington litigation, in the tens of thousands of pages of records, is a sworn affidavit, prepared for Judge Pratt, by Miles Santamour, a former special assistant to the President's Committee on Mental Retardation, describing a visit he had made to Forest Haven.

"Late one evening I visited the residence of a group of older women, all of whom were gathered in a large 'day room,' idly watching television or working on some piece of embroidery or knitting. As I circled the group, asking questions and explaining who I was, and why I was there, I began to sense the dominance of a large, matronly woman who had positioned herself on a couch in the center of the room. She watched my every move and as I began to leave, she summoned me back.

"So that all could hear, she began a series of questions to which she answered 'yes' without waiting for me to respond. Are you from downtown? . . . Are you a big shot? . . . Are you here to see how bad we live? . . . Are you here to make this place better? . . . Are you going to get us out of here?--at which point she turned to her assembly and began to laugh uproariously, almost hysterically, along with many of the other residents. My usefulness had been fulfilled, and without responding I left. Their laughter continued as I made my way out of the room and did not subside for some time.

"These women had spent a lifetime observing the likes of me evaluating their situation and then disappearing with no meaningful aftereffects upon their lives. One wonders how many times the likes of me carried on similar investigations, how many 'big shots' from 'downtown' had been responsible for raising the hopes of these individuals, how many times they had waited for such visits to change their lives, and for how many people the changes had never come."

Miles Santamour's affidavit was filed with Judge Pratt's court in April, 1977. The following year, Joy Evans was to die. Twelve years later, Arthur Harris, Joseph Hardy and Charisse Gantt would die at Forest Haven. Fourteen years later, the institution finally closed, but the dying has not stopped.

Remembering my own first visit to Forest Haven, I realize how little has changed, including the quiet rage.

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