Nov. 3, 2008, 2 a.m. - D.C. Mayor Adrian M. Fenty and Acting Attorney General Peter Nickles last week announced the findings of an internal investigation report into the February 2008 death of a District resident with multiple connections to government agencies and services. 

The report details the administration’s work to: (1) identify those connections and describe their individual and collective role in the resident's life and death; (2) pinpoint missed service opportunities and points of accountability; and (3) describe actions completed and underway to prevent similar situations from happening again.  

“Since we were not able to expedite the critical services needed to protect the health of this individual, we wanted to respond immediately with an investigation to ensure that something like this never happens again,” said Fenty. “The District will continue to work as hard as humanly possible to correct any missteps that might have happened in this case.”  

The report reflects research conducted by the Office of the City Administrator since Oct. 17 when the Mayor requested a formal investigation. The District assessed that the individual was primarily connected to three District agencies: the D.C. Office on Aging (DCOA), the Department on Disability Services (DDS), and the Department of Human Services (DHS).  

These connections existed as early as 2001, but increased dramatically in 2006. In early 2007, the individual showed signs he could no longer care for himself and needed residential placement in an Intermediate Care Facility for Mental Retardation (ICF/MR). Attempting to secure that service from DDS triggered a long struggle over his eligibility and placement, which unfortunately was not resolved before his untimely death.