“There are too many make shift doors with locks which would make it difficult to exit in an emergency,” Davis wrote in a report.

That warning could have been the beginning of a prompt response to life-threatening housing conditions. Instead, it set in motion a cascade of bureaucratic bungling, miscommunication and missed chances that culminated last month with two deaths when a fire tore through the house at 708 Kennedy Street NW.

A Washington Post examination of the city’s handling of the code violations at the property reveals a chain of events in which virtually every relevant regulatory mechanism of the city government appears to have failed.

Fire and housing inspectors never visited the home. A business license regulator went to the property but gave up when he could not get inside. Crucial pieces of Davis’s message were lost because a fire department employee omitted an attachment on an email forwarded from a mobile device.

Inadequacies plagued the District’s response even as flames began to consume the building. An emergency dispatcher took four minutes to dispatch firefighters to the home — far above the 30-to-90-second window deemed acceptable by national experts.

The Aug. 18 fire killed a 9-year-old boy, Yafet Solomon, and Fitsum Kebede, 40.

Yafet Solomon, 9, died after a fire an Aug. 18 in a rowhouse on Kennedy Street NW. (D.C. Public Schools)

The fatal fire has put a spotlight on the dire living conditions endured by some in the nation’s capital, where high rents and home prices have driven many to the suburbs or into substandard housing in the city. Newcomers to the city, such as the Ethio­pian immigrants who filled the house on Kennedy Street, may be especially at risk.

But the tragedy has also brought scrutiny to the multiple layers of bureaucracy that could have prevented the deaths, and did not. Rarely does such a clarion warning come from such an authoritative source. Yet the police officer’s complaint generated no meaningful action during the five months that passed before the “emergency” he feared came to pass.

“It’s unusual that this many agencies screw up on the same address,” said D.C. Council Chairman Phil Mendelson (D), who said he plans to hold a hearing to examine the District’s handling of the property. “But all that does highlight that it’s important that each agency does what it’s supposed to do.”

He added, “We have a housing code for a reason: To protect human health and safety.”

Investigators at the back of the illegal rooming house after the fire. (Salwan Georges/The Washington Post)

A search warrant affidavit filed as part of an ongoing criminal investigation into the fire states that the code violations “contributed to the deaths” of Yafet and Kebede.

The owner of the property, James G. Walker, has not responded to repeated requests from The Post for comment.

Mayor Muriel E. Bowser (D) has hired a law firm to review the city’s handling of 708 Kennedy Street NW. The fire and police departments are adopting policies to ensure that dangerous building conditions are immediately addressed.

Ernest Chrappah, director of the D.C. Department of Consumer and Regulatory Affairs (DCRA), said he is also studying his agency’s response and is examining dozens of additional cases to determine whether any were closed improperly.

Four city employees — two from the fire department and two from DCRA — have been placed on administrative leave as the District investigates the case.

In the aftermath of the fire, public attention and criticism focused largely on a DCRA investigator who did not seek a search warrant to enter the Kennedy Street property — a procedure that is used when residents of a building could be in immediate danger.

But The Post’s review of the case, drawing on previously undisclosed emails and other documents as well as interviews with current and former regulatory officials, reveals a broader, and more complicated, set of shortcomings.

A disaster foretold

Davis, a 23-year employee of the Metropolitan Police Department, is known for a meticulous style and special interest in derelict housing, police officials said. His report on 708 Kennedy Street NW stated that he was called to the property by another officer who suspected code violations and wanted to consult the veteran officer.

Licensed as a pharmacy, the property was divided into cramped bedrooms on the upper floor and in the basement. Kebede’s room measured 8 by 5½ feet, according to search warrant affidavits filed after the fire.

One top-floor tenant paid $550 in monthly rent, according to a lease covering 2018 and 2019 that was reviewed by The Post. Median rent for a one-bedroom apartment in the District is currently $1,367, according to ApartmentList.com.

The affidavits said rooms “had been constructed of 2 by 4 lumber and drywall and are not consistent with proper living quarters, safety guidelines or building codes.” A locked metal gate, perhaps related to the pharmacy office, also blocked access to the front door from the basement — which had a separate entrance — and the back of the ground floor. Bars that could not be opened from inside covered the windows.

“Strongly recommend both DCRA & DCFD Code Inspectors respond to the listed location,” Davis wrote in his report, italicizing the words for emphasis. On March 22, he emailed the document as an attachment to six people — two D.C. Fire and Emergency Medical Services workers and four DCRA employees.

A fire investigator walks out of the illegal rooming house. (Salwan Georges/The Washington Post)

The Post obtained a copy of the email, which has not previously been made public, as well as two later emails among the recipients. Its subject title, “Serious code violations,” clearly announces its purpose. But the email itself contained ambiguities that ultimately contributed to the city’s lackluster response.

The body of Davis’s email contained a single sentence: “I also need an inspection of a dwelling residence located at 5410 14th Street NW as an illegal rooming house and No Certificate of Occupancy.” That text referred to another, unrelated property with potential code violations, and was meant as a postscript to his attached incident report on 708 Kennedy Street.

But the lack of a specific reference to Kennedy Street in the body of the email would prove problematic. When one of the original recipients — John Barnes Jr., who works in the fire marshal’s office — forwarded it from his mobile device to a co-worker who could act on the complaint, the attachment was not included, according to a Bowser administration official with knowledge of the communications.

The fire marshal’s office did not visit the Kennedy Street property and scrutinized only 5410 14th Street NW. That address, it turned out, did not exist. The building Davis meant to flag was 5310 14th Street NW. Fire department workers closed the case when they learned the written address was bad.

“There was a failing of the systems in place at the fire marshal’s office,” said Kevin Donahue, the District’s deputy mayor for public safety and justice. Donahue said that “there was not an expectation or a standard operating procedure for verifying a handoff to close off any question about accountability” in the handling of a complaint like that submitted by Davis.

'Treat it like a crime scene'

The complaint would meet a similar fate at DCRA.

A sprawling agency whose wide-ranging functions include dispensing business licenses and construction permits, and enforcing lifesaving building regulations, DCRA has historically been one of the least-loved domains of District government, and to many in Washington, it remains a byword for bureaucratic inertia.

After Davis’s email arrived, one of its recipients — Inez Saki-Tay, who according to city personnel records is a DCRA community outreach specialist — responded to the group that the email “was sent to Ferdinand Gamboa,” whom she identified as the current “duty officer.”

The Post obtained a copy of the email sent by Saki-Tay, who declined to comment for this article.

Chrappah, the DCRA director, said a duty officer fields complaints and dispatches inspectors as necessary. He said it was not clear whether Gamboa actually opened the attached incident report from Davis. Gamboa did not respond to requests for comment.

Davis sent two follow-up emails to DCRA — on April 24 and May 21 — inquiring specifically about the Kennedy Street address, according to the Bowser administration official with knowledge of the case. An investigator was eventually dispatched — not to assess housing code violations but to determine whether the property needed a rental license. City officials have refused to disclose the investigator’s name.

Fitsum Kebede, 40, died in the Aug. 18 fire. Police say the blaze started in a small room he occupied in the back of the basement. No cause has been established. (Brook Kebede)

James Delgado, a former DCRA inspector who became a minor celebrity in District government during the 1990s for his efforts to crack down on negligent landlords, said it was a mistake to dispatch a licensing specialist to assess dangerous building code violations. A housing code inspector — who would have more experience with similar cases and with the process for seeking a search warrant to enter a dangerous property — would have been the appropriate choice, he said.

“If the cop comes in and says to you, ‘I walked inside, and I saw these horrible conditions under which people are living,’ and your focus is, well, let’s find out if he has a license — that’s a mishandling of the damn complaint,” Delgado said. “What difference does it make if you don’t have a license, if these people are living in overcrowded conditions? Who gives a s--- about the license?”

He added, “A major situation like this, this type of building, you treat it like a crime scene.”

The DCRA business license investigator visited 708 Kennedy Street three times, city officials said. Unable to find anyone to let him inside, he sent a letter at the end of May to Walker, the house’s owner, asking whether he was operating an unlicensed rental property. Then he closed the case.

Chrappah said his employees should have sought a search warrant to enter the property, rather than simply giving up after visiting. He also acknowledged that it would have been appropriate, judging by the contents of Davis’s report, to dispatch a code inspector as well as a license investigator.

“Based on what we know now,” Chrappah said, “they would have taken a very different action.”

A four-minute delay

If I stay in my room, I die.

That thought dominated the mind of Sara Mengiste on the morning of Sunday, Aug. 18. Mengiste, 46, had been too tired after a shift stacking boxes in a District warehouse to attend church with the three other Ethio­pian immigrants who shared the top floor of 708 Kennedy Street NW. So she had stayed in her room, which was just large enough for a queen-size mattress.

Then she smelled smoke seeping through the door.

Opening it, she was blinded. Mengiste stumbled into the hot hallway, then down the stairs, where she fell as she scrambled toward the front door. Shouting — she would later learn they were from a police officer at the front of the house — sounded somewhere below her.

She moved toward the sound and burst into the open air. Mengiste would be briefly hospitalized for smoke inhalation and had bruised her knee when she fell on the stairs, but she was otherwise unhurt.

Others were not so fortunate.

It had taken two police officers, assisted by six bystanders, to break through the front door of the house, said Randy Griffin, commander of the 4th District police station. “It was almost impossible,” Griffin said. “They couldn’t see anything. There was nothing but thick, black smoke billowing from the dwelling. It was impossible to get in without being overtaken by the smoke. Visibility was zero.”

The officers would ordinarily have been aided in those crucial first moments by a team of firefighters. The first police call about the fire came in at 9:36 a.m., said Karima Holmes, director of the D.C. Office of Unified Communications. The reporting officer shouted “fire,” and provided the building’s address.

However, the dispatcher would not send a team until the officer responded to questions about what type of fire it was — answers the officer struggled to provide while trying to breach the front door of the house to save lives. The dispatcher put the shouting police officer aside to deal with an unrelated call about someone suffering chest pains, then dispatched the call at 9:40 a.m.

After a four-minute delay, “time is not with the victims,” said Brian Dale, associate director of medical and quality process for the National Academies for Emergency Dispatch. Dale said that though there is no uniform standard for dispatch deadlines, cities typically strive to dispatch emergency responders within 90 seconds of the first 911 call.

Dabney Hudson, president of the D.C. firefighters union Local 36, called the delay “completely unacceptable” and said a full alarm — five engines, two trucks, an ambulance, a rescue squad and two fire chiefs — should immediately have been deployed.

The delayed fire response was first reported by FOX-5.

Holmes said her agency had performed an internal review and determined that the call was handled well. She said the dispatcher’s questions were important to determine what type of equipment should be sent to the scene of the fire.

When firefighters finally arrived on scene, they pulled from the charred building Kebede and Yafet, both found unconscious inside. Investigators would later determine that the fire had started in Kebede’s basement room and spread to block the sole exit in the basement. The cause of the fire has not yet been determined.

Kebede died that day at the hospital. Yafet, who was preparing to begin a new school year at Barnard Elementary, died two days after the blaze.

'I want him to come back'

District officials said they continue to examine what went wrong in the handling of the complaint about 708 Kennedy Street NW and to craft policies that will prevent those mistakes from being repeated.

This month, the city’s fire and police chiefs, prompted by the mayor, announced new protocols for their responses to suspected code violations. The new rules require that a police officer report potential fire code violations to a supervisor, who will relay the complaint to the fire department through the District’s dispatch center. A fire battalion chief will immediately go to the site to perform an inspection.

The goal, said Fire Chief Gregory M. Dean and Police Chief Peter Newsham, is to establish clear routes for complaints to prevent the kind of confusion that ensued after Davis’s email about the Kennedy Street rowhouse.

Chrappah said his agency also expects to announce new procedures for addressing dangerous building conditions. He said his staff is investigating how Davis’s email was handled and is reviewing 67 cases — dating to December 2018 — that may have been closed without sufficient action.

District officials have declined to identify the four government workers who have been suspended as their conduct is examined.

Fanaye Getaneh reacts as other women speak about fire victim Yafet Solomon, 9. The women were having lunch at Selassie Ethiopian Market on Aug. 20. Getaneh had lived at the house for seven years. (Salwan Georges/The Washington Post)

On the night of Aug. 30, a small crowd — many conversing softly in Amharic, one of the two principal languages of Ethiopia — gathered in front of 708 Kennedy Street NW. It was a vigil for Yafet. Dozens of lit candles glowed on the sidewalk amid pink and white flowers.

Kebede, who had worked in information technology in Ethi­o­pia, would have a later burial service. He had fallen on hard times after immigrating to the United States more than a decade ago, relatives said. He had been doing odd jobs at his church to make ends meet.

Described by his teachers as “one of the brightest stars” at Barnard Elementary, Yafet wanted to be a lawyer and tried to help classmates make up when they had arguments. According to a GoFundMe site established to help his family, a teacher had recently run into Yafet “dragging his mom around to be sure he had all his supplies for school.”

Yafet’s mother, who has not spoken to reporters since the fire, sat in a folding metal chair at the vigil, a black shawl draped over her shoulders. She lived with Yafet at the house, but when the fire broke out she was at work. The boy was alone.

“He’s with God, okay? He’s in heaven,” Rahel Gizaw told her three young children as they stood in front of the house. She had met Yafet and his mother when her son attended school with him.

“I want him to come back,” said her 7-year-old daughter, Sharon.

Yafet’s mother stared past the candles at the facade of her former house, now empty, its windows boarded up.

City officials have repeatedly been asked, since the fire on Aug. 18, how many other places in the nation’s capital are like 708 Kennedy Street NW. Places where the vulnerable, such as recent immigrants or impoverished families, have accepted unsafe living conditions out of ignorance or as a trade-off for low rent.

The answer — from the head of DCRA, the council chairman and the deputy mayor, the police and fire chiefs — has been consistent. They say they have no idea.