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On Tuesday, Sept. 3, workers at St. Elizabeths hospital found Joanne Hicks, a 51-year-old District resident, dead at the bottom of a laundry chute. Four days earlier, Hicks had checked into the hospital’s acute-care ward, a four-story building that houses the city’s most deeply troubled psychiatric patients. Hicks fit the profile of an acute-care admission: She was reportedly strapped in four-point restraints when she was transferred from D.C. General’s emergency psychiatric unit. But despite Hicks’ condition, acute-care staff lost track of her the day after she checked in, leaving her free to roam hospital halls throughout Labor Day weekend. How Hicks ended up at the foot of a chute intended for dirty linens—whether she was pushed or jumped—may remain a mystery.

Rhonda Stewart, a spokesperson for St. Elizabeths, declined to comment on the incident, citing an ongoing hospital investigation, patient privacy, and the feelings of Hicks’ family. Mental-health advocates, however, argue that the hospital’s refusal to comment on Hicks’ death has more to do with damage control than patient rights. Over the past year, St. Elizabeths has come dangerously close to losing federal funding for failing to deliver basic services to its patients.

Although hospital rules make it difficult to verify Hicks’ death, let alone determine who was responsible for it, one conclusion pops through the shroud of secrecy: The death, cause notwithstanding, is another gruesome emblem of chronic management and oversight failures at St. Elizabeths.

Hicks apparently gave the staff of the acute-care ward the slip soon after her arrival: According to Linda M. Jones, an advocate for the mentally ill familiar with the case, Hicks finished lunch on her second day and disappeared. Hospital procedures described by the staff would seem to make her disappearance impossible: During meals, ward supervisors take head counts before the patients leave their ward for the dining hall, when they get to the dining hall, before they leave the dining hall, and before they go back to their ward.

“Somebody, somewhere, in one of those four possible counts they’re supposed to do, should have noticed that whoever she is wasn’t with them,” says a hospital staffer who asked not to be identified.

And although Hicks was admitted to acute-care Ward 7, according to Jones, her lifeless body was discovered at the foot of a laundry chute connected to Ward 5. Guidelines mandate that acute-care patients remain confined to one of the eight wards in the four-story building. If things are running right, all doors between the wards are locked.

“If I want to get onto a ward, I have to be ID’d as an employee,” says the staffer. “They just don’t let anybody and their brother onto a locked psychiatric ward.”

How Hicks managed to break through to another ward is anyone’s guess. “We don’t know how she got down the chute, quite frankly,” says a source with the D.C. Mental Health Commission. He says it has been theorized that Hicks may have broken into Ward 5.

Jones can’t say specifically what happened to Hicks either, but she lays the blame for her death at the feet of hospital staff. “The system failed. No matter what happened, whether she tried to kill herself or tried to escape, whether somebody shoved her…the staff failed,” Jones says.

Detectives at the Metropolitan Police Department (MPD)’s 7th District are investigating the death, according to MPD spokesman Ken Bryson, but MPD has declined to say whether it believes the death was accidental. However, the source at the mental health commission says there was no indication of a homicide. “Based on evidence on the scene, the most likely explanation is that she was trying to escape and jumped down the chute,” says the source. “To my knowledge, there hasn’t been any evidence that she was beaten up and assaulted.”

Dr. Linda Boyd, a spokeswoman for the District’s Department of Human Services, says Hicks died of head injuries “compounded by fractures of her extremities.”

“The manner of death is undetermined,” she says.

Jones questions whether Hicks should have been allowed to roam freely around the ward in the first place. She says that Hicks was held in four-point restraints after her family checked her into D.C. General’s Emergency Psychiatric Response Department (EPRD). EPRD performed a psychiatric evaluation and transferred her to St. Elizabeths.

“You have to give them some indication that this is the only way they can contain you,” says the St. Elizabeths staffer of the four-point procedure. “If I have a patient with a long history of violence, as soon as he walks in the door, they put him in four-points….It’s a good indication that upon admission [to EPRD] the patient was possibly very agitated, very delusional, very verbally aggressive, very possibly physically aggressive, and it took [four-point restraints] to contain her.”

But the acute-ward staff apparently concluded that Hicks was relatively stable because, according to Jones, she was allowed to dine with her fellow St. Elizabeths patients after being transferred from EPRD.

Hicks’ family may never discover how she wound up at the bottom of a laundry chute in an institution that was supposed to protect and treat her. And it’s doubtful, given the current level of oversight at the institution, that St. Elizabeths staff will be held responsible for losing track of Hicks.

Outside investigation of cases like Hicks’ falls to the city’s protection and advocacy (P&A) group for the mentally ill. P&A groups draw on federal funds to investigate complaints and safeguard mentally ill patients from abuse and neglect. All states and the District are required to select their own P&A groups.

But at the time of Hicks’ death, the District’s P&A group, the Information Protection and Advocacy Center for Handicapped Individuals (IPACHI), had been closed for over a year. IPACHI collapsed under the weight of bad debts, unpaid taxes, and a federal criminal probe. (Jones, who has been raising questions about Hicks’ death, worked for IPACHI back when it was still functioning.)

Controversy over IPACHI’s successor left a vacuum. Last February, Mayor Marion Barry nominated a group headed by longtime crony Anita Shelton to pick up where IPACHI left off. However, mental-health advocates attacked Shelton’s qualifications—she served a short and very controversial stint at the D.C. Office of Human Rights in the first Barry administration—as a defender of the city’s mentally ill. The control board caught wind of the matter and in late August ordered Barry to select a different P&A group. After a well-publicized spat, Barry relented and chose University Legal Services (ULS) to receive $750,000 in federal P&A funds.

ULS President Joseph Cooney says he’s aware of Hicks’ death and pledged to conduct an investigation. But before his group takes on recent cases, Cooney says it must first hire a staff of attorneys and sift through the 100 boxes of files IPACHI left behind.

Until ULS sorts through the mess left behind by IPACHI, the investigation of Hicks’ case will be the exclusive province of MPD. And if MPD detectives find that Hicks’ death was an accident, they will close the case and leave a probe of staff negligence to ULS and the federal Health Care Finance Administration (HCFA), a group that monitors hospitals receiving federal funds to care for the mentally ill. An HCFA source says that “HCFA [is] doing an investigation” into Hicks’ death but is “waiting to start until the criminal investigation is complete.”

St. Elizabeths, once a celebrated facility, is a mess by any objective standard. The feds last year threatened to cut off Medicaid funding for St. Elizabeths after staff and patients complained that the facility’s heating system didn’t work. And in 1995, IPACHI disclosed that juvenile patients at the hospital had not been served vegetables or fruit for a month. In a letter to the Washington Post last February, Robert Keisling, former medical director of the hospital, argued that St. Elizabeths should be closed down, citing heating, power, and hot water failures, floods, sewer backups, fires, and elevator malfunctions.

“The people at St. Elizabeths aren’t considered human beings,” Jones wrote. “If it happens at St. Elizabeths, it’s not a priority.”

Hicks’ case demonstrates that lapses in internal controls and oversight have left a vulnerable population even more vulnerable.

“There are 56 P&A programs in the United States, of which only 55 are functioning,” says Jones. “Somebody has got to watch that place.”—Brett Anderson