A Call Too Late: The Consequences of Ethical Failure

While my book focuses on COP work, the framework of my text extends beyond police operations.

"Ethics-Based Policing" could easily be titled "Ethics-Based Leadership" with only minor adjustments. Many of those who have read my book and follow my posts and newsletters have come to this realization, as have the many conversations we’ve had about applying my writings to both the private sector and other public-sector occupations.

During presentations, when my audience isn’t entirely composed of police officers, I often share stories about ethical failures in other professions—specifically, what happens when supervisors fail to take responsibility for holding subordinates accountable.

STORY

At the time, I was a captain with MPD, working in the Northeast section of the city. I was on the day shift during the week and had finished my paperwork that morning. As usual, I hit the road. It was a miserable day—cold, with a mix of snow and rain. I wasn’t the type to lead, guide, support, or assist those under my charge from inside the station while they were out answering calls for service, protecting, and patrolling. Like I said, I was out there with them, as usual.

At approximately 10:30 hours, a call went out for a unit to check on the welfare of an elderly woman. I responded. As I arrived, a two-man unit was walking up to a single-family home. I joined them at the door.

Heavy knocking and loud shouts received no response. We looked through the windows from the porch that faced the street. The house was in disarray, with water leaking from the ceiling—clearly, the pipes had frozen and burst. There was no heat.

I contacted the police dispatcher to ask where the call had originated. I was informed that it had come from D.C. Health and Human Services—Adults in Need of Supervision.

I directed the officers to break down the door. We entered. The temperature inside was the same as it was outside. We began searching the house.

One of the officers called out, “Captain, you better get in here.”

I went to the kitchen. There, sitting in a chair in front of a gas stove with the door down, was an elderly woman. She was deceased—and had been for some time, over a week. We checked the telephone, which was not working, and got her name from some mail. It was tragic in the extreme.

My wheels started turning. If Adults in Need of Supervision had called this in, they knew about this woman—so how could this have happened?

I called Crime Scene Search—my district’s crime scene technicians—and asked them to meet me. I inquired whether they had a Polaroid camera, which they did. I requested a roll of photos documenting the house and the woman.

Homicide was contacted, as this was an unattended death—standard operating procedure—and the coroner’s office was notified.

I took the photographs and headed to the D.C. Office of Health and Human Services. I was directed to the individual in charge of the unit from which the call had originated.

I told him I had just come from that address and provided the name of the deceased woman. He informed me that she was checked on daily, but due to the weather, they were short-staffed that day.

I asked, “When was she last checked?”

He replied, “The records reflect yesterday.”

Then he asked, “Is something wrong?”

I told him, “She has been dead for at least a week. Here are the pictures.” I handed them to him.

It was clear to me that there had been a severe ethical failure. A supervisor had failed to take responsibility for holding a subordinate accountable for doing their job—the right thing.

I told him I was confident their investigation into this event would result in appropriate action against those responsible. I also informed him that I would return in a week for a progress report—and that I would prefer not to have to go to the United States Attorney’s Office to discuss criminal neglect charges.

They did the right thing.

I could not bring the woman back, but there were consequences for this ethical failure in another public-sector agency.

Ethical leadership transcends policing. Whether in the public or private sector, serious harm can occur when there are ethical breakdown