Staff at St. Elizabeths Hospital — the District’s only public psychiatric hospital — should have been able to prevent the murder of a patient in his room in March, according to a new investigative report by Disability Rights DC, the District’s federally mandated protection and advocacy program.

The report, released Tuesday, says staff persons at the unit where the patient was murdered “grossly neglected their duties and failed to follow many hospital policies,” and gives a detailed rundown of five “missed opportunities” in which staff could have saved the patient’s life.

Andrea Procaccino, staff attorney at Disability Rights DC, told DCist/WAMU that staff are trained thoroughly to intervene in such incidents and that it was not an issue of staffing — the unit in fact was assigned extra staff.

“It is really inexplicable, how this happened. I cannot explain this much neglect,” Procaccino said. “It’s a locked unit, and it’s not the first there’s been aggression on that unit.”

In a statement, a spokesperson for the Department of Behavioral Health said that the hospital took “appropriate personnel actions” after the murder, including terminating staff who weren’t following policies on that night in March.

“Immediately following this tragic incident nine months ago, Saint Elizabeths Hospital strengthened its safety protocols that include doubling the number of nursing staff who conduct evening and night safety checks at 30-minute intervals, requiring routine review of videotapes to make sure safety protocols are being followed, and conducting random unit searches and random, unannounced visits on the units by the nurse supervisors,” the statement continues.

Disability Rights DC refers to the patient in the report as Donald Howard — a pseudonym — and the patient charged with murdering him as Patient #1. Procaccino told DCist/WAMU she cannot confirm who the patients were in accordance with HIPAA. However, the report refers to an article by the Washington Post covering the murder of a patient named David Dowdell. The article identifies the patient charged with killing him as Charles Lee.

The report says six clinical staff persons and a security officer assigned to the unit the night of the murder did nothing to stop Lee from entering Dowdell’s room. There, Lee went on to “aggressively assault” Dowdell for more than 35 minutes before staff arrived to find Dowdell bleeding on the floor with Lee’s foot on his neck. Dowdell was pronounced dead shortly afterwards.

“If the staff persons had been adhering to Hospital policies and fulfilling their required duties that night, they should have been able to prevent this horrible tragedy,” the report reads. “Instead they spent time … looking at their cell phones, reading or talking to each other, on a computer, or in some cases, not even on the unit where assigned.”

In a statement to DCist/WAMU, Disability Rights DC said that if even one staff person at the unit had been following policies, they may have been able to prevent the murder.

“It is difficult to understand how each and every staff person on duty that night neglected this important part of their duties,” the statement read. “More consistent oversight is needed to prevent another horrific tragedy and keep all of the patients safe at St. Elizabeths Hospital.”

Disability Rights DC analyzed videotaped footage of the unit — included in the report as tracings — from before to after the murder took place. Leading up to the incident, the report details, staff failed to observe the unit, taking no notice of Lee’s “agitation” — he was leaving and entering his room five times just before three in the morning.

Meanwhile, two staff members behind the nurses’ station, responsible for observing the unit, were looking at their cell phones or talking to other staff, according to the report. They appeared to still be looking at their cell phones when Lee entered Dowdell’s room. Other staff who were present, some who do not appear in the footage or only in some parts, Disability Rights DC continues, did not seem to take notice of Lee’s behavior.

Staff responsible for “one-to-one” observation for two individual patients were also not at their assigned posts, from which they would have been able to see Lee going in and out of his bedroom five times and entering Dowdell’s room. Had they been at their posts, the report says, they likely would have heard the assault taking place and could have quickly intervened.

A security guard assigned to the unit at the time was also not present, per the report — a violation of the hospital’s policy. Disability Rights DC says if the guard had been present “for even a few minutes,” he would have observed and intervened.

While the assault was taking place, a nurse responsible for conducting security checks passed Dowdell’s room, carrying a flashlight. As the report details, the nurse did appear to briefly shine the light through Lee’s room but appeared to not notice that Lee was missing. The nurse failed to inspect Dowdell’s room, and is described as passing Dowdell’s door “with his head down, shining his flashlight on the floor.” One of the nurses claimed that he saw Dowdell and Lee in their own beds — a report that Disability Rights DC calls “an obvious impossibility.”

When a nurse saw Lee was in Dowdell’s room and found Dowdell lying on the floor, he did not immediately assess Dowdell or try to resuscitate him, as required by hospital policy. In the St. Elizabeth’s Unusual Incident Report and nursing progress notes, Disability Rights DC claims, the nurse documented that he called a “Code Blue” and immediately went into the room. Instead, he went down the hallway to the nurses’ station. No one entered the room until three and a half minutes later. Staff did not try to remove Lee from his room for more than three minutes after Dowdell was discovered.

Crystal Davis, the daughter of Dowdell, remembers her father as a “very outgoing person” who had a joke for everything and loved the outdoors. When people needed him, he was always there — he’d “drop everything” to help.

“He was my best friend,” Davis told DCist/WAMU. “He’d give the shirt of his back if you needed him.”

Davis says her father recently got to meet her daughter and stepson and “worshipped the ground they walked on.” But some of her family will never meet him.

This time most years, she’d be making Christmas dinner, getting ready for her father to come home. She still has his phone number and says she can’t bring herself to erase it.

“I just want people to know, just because he was in a place like that. … didn’t mean that he deserved for this to happen,” she said.

Lee was charged with first-degree murder in March.

“It’s a tragedy for him too,” Procaccino said. “He’s a patient who was there for care and treatment.”

St. Elizabeths opened in 1855 and offers residential treatment to nearly 300 patients. In recent years, St. Elizabeths has faced scrutiny for ramping up its use of seclusion and restraint on patients — though D.C. law permits those tactics only in select situations. Meanwhile, in 2020, four patients sued the hospital, alleging that officials failed to manage a COVID-19 outbreak that killed four patients at the beginning of the pandemic. As of November 2022, the parties are in mediation.

Procaccino said that staff abuse and neglect of patients has become a pattern. She’s hoping to get someone familiar with trauma-informed care — care that recognizes trauma as pervasive, prioritizes healing, and avoids retraumatizing patients —  to get a cultural shift at the hospital.

Hospital leadership, she said, needs to be held accountable.

“These things keep happening under their watch,” Procaccino said.

The Department of Behavioral Health added in its statement that since the murder, St. Elizabeths has re-trained all employees on safety protocols and procedures.

“The Department of Behavioral Health conducted a thorough investigation as the Disability Rights report notes and these changes were made in collaboration with DC Health, the District’s hospital licensing agency,” the department’s statement continues. “The Department of Behavioral Health and Saint Elizabeths Hospital will continue to do periodic reviews of all safety protocols and procedures to ensure patients and staff remain safe.”

Procaccino said that there needs to be more regular oversight of psychiatric facilities in the city generally. This past summer, Disability Rights DC issued a report alleging a pattern of abuse and neglect at the Psychiatric Institute of Washington, the only for-profit psychiatric hospital in the District.