The fire that killed four of Shamaya Coleman’s children raced through their South Side building within minutes. But it was a tragedy years in the making.

It began before the fire started one floor below, in an apartment without working smoke detectors. It was already in motion before the flames spread through a broken door and up the stairs through darkened hallways.

In fact, the tragedy began long before the single mother moved her family into the modest one-bedroom home.

They were, like so many families, hoping for better days. They were also completely unaware the city had known for years the building was a firetrap.

City building inspectors had visited the 18-unit courtyard complex in Roseland more than two dozen times in the five years before the blaze, documenting more than 150 code violations. Just six months before the fire, inspectors once again found broken doors and missing smoke detectors — among other serious fire safety issues.

Had city officials fulfilled their central mission to keep people safe in their homes by enforcing basic fire standards, Coleman’s children might still be alive.

When firefighters made it into the apartment, they found the body of 7-year-old Eri’ana in a closet under a pile of clothes and her 11-year-old brother Shamarion slumped near an open window, according to police reports. The oldest — 15-year-old Carliysia — was found kneeling on the bed shielding the body of her 13-year-old brother, Carlvon. The back of Carliysia’s pink and red shirt had burned away.

“They were doomed,” said Rich Cooper, a since-retired Chicago Fire Department battalion chief in charge at the pre-dawn fire on Sept. 8, 2014. “A $5 smoke detector would have got them out of there 10 minutes earlier and they would have been fine.”

Coleman’s children are among at least 61 people — including 23 under the age of 17 — who died since 2014 in Chicago buildings where city officials knew of fire safety problems, sometimes for years, yet failed to crack down on property owners in time, an investigation by the Better Government Association and the Chicago Tribune has found.

They died in apartments the city knew lacked smoke detectors, in abandoned buildings the city was supposed to tear down, in homes where tenants had sought the city’s help because there was no heat.

City inspectors closed hundreds of complaints with little to no follow-up. City lawyers and hearing officers often took landlords at their word, never checking to verify promised repairs were completed. Tenants spent years living in unsafe conditions while City Hall lawsuits against their landlords stalled in court.

Together, these findings reveal a failed system that endangers residents in a city repeatedly scarred by historic fires. Tenants cannot rely on the city to act promptly on their complaints or effectively enforce safety codes designed to protect them from fire. Instead, the Tribune/BGA investigation found, city officials routinely put the interests of landlords above the safety of residents.

From 2014 through 2019, Chicago suffered 140 fatal residential fires. The BGA and the Tribune examined every one.

In 42 of the fires, officials had prior knowledge of fire safety issues that remained unresolved at the time the flames broke out.

The 61 people who died in these fires represent about a third of the 170 deaths in all the fires combined. The majority were Black.

Responsibility for these failures lies with the city’s elected leaders, who cut back on inspections, eased regulations and failed to follow through on promises of reform after headline-making tragedies; with city lawyers and hearing officers who deferred to property owners; and with front-line inspectors and their bosses at the Department of Buildings — an agency created after the Great Chicago Fire of 1871 specifically to prevent fire-related tragedies.

In the years since she lost her children, Coleman has learned about the long list of safety problems at her building that her landlord was never forced to address.

“The city knew he was a slumlord. The city knew he had citations,” Coleman said. “The city knew he had things he had to fix.

“These landlords should not be able to rent, buy, do anything unless everything is up to par. There should be no exceptions for anyone, not for the state and not for the landlord,” she said. “You are putting somebody else’s lives in danger, period.”

Mayor Lori Lightfoot declined to be interviewed for this report, instead referring all questions to her public relations staff and to city building officials. They acknowledged occasional mistakes but said ultimate responsibility for addressing life-threatening safety problems lies with the landlords.

“The first line of defense is the building owner,” said Buildings Commissioner Matthew Beaudet. “Any loss of life in the city of Chicago is tragic, whether it’s by fire or by auto accident. So we do take that very seriously; we work very hard every day to ensure the safety of the city.”

Building officials said there are no systemic problems with the code enforcement process and the department bears no responsibility for the 61 deaths.

Instead, they said many of the failures identified by the Tribune and BGA investigation can be traced to an unreliable record-keeping system that fails to show the extent of their efforts to enforce safety laws. Delays in legal proceedings are a hindrance to code enforcement, they said, but cases are out of their control once building officials refer violations to city lawyers.

“When we go out there and we find something, then we document it,” said Beaudet, a Lightfoot appointee. “We aren’t an enforcing department.”

The 61 deaths in buildings with known safety problems are “tragic,” Beaudet said, “but a lot of these fires are caused by the activities of the folks there.”

Following the BGA/Tribune inquiries, Lightfoot in recent weeks backed two initiatives she says will improve conditions for Chicago’s tenants. One renews an effort to publish a list of problem landlords, targeting dangerous buildings for increased enforcement. The other directs landlords to install long-lasting, tamper-proof smoke detectors over the next decade, a measure the City Council and city fire officials long opposed as too pricey for property owners.

“I am confident the new Building Code Scofflaw List will allow the city to more closely monitor these buildings, hold building owners accountable, and, most important, enhance the safety of building occupants,” Lightfoot said in a news release last month.

Lightfoot said the change came after a “comprehensive multi-department review.” But in response to a Tribune and BGA request for any records of the city’s review, her office said there were “no responsive records.”

A ‘death trap’

In Englewood, 56-year-old Evoughn Ware died in 2016 after faulty wiring in her small apartment sparked a wall of flames, thwarting her son’s attempts to reach her.

In the weeks before the fire, tenants in Ware’s building twice reported fire safety issues, including serious electrical problems and no smoke detectors, to city officials. There was no documented response to either complaint before the fire. The BGA and the Tribune found seven other fatal fires where records show no evidence city officials investigated complaints of fire safety issues that later played a role in the deaths.

In Little Village, 63-year-old Luis Bruno died in 2018 in a two-story building partitioned into 16 rooms in violation of city codes. The city received at least 10 complaints about the building from 2010 through 2015 alleging unsafe conditions, including overcrowding and missing fire alarms. In 2011, a city administrative hearings officer fined the landlord $500 and closed the case. Within months, more complaints began coming in — including one alleging “very unsafe” conditions. Records show inspectors never got inside to investigate those complaints.

After the fire, investigators found no smoke detectors and the building’s front stairs blocked by the rooming house partitions. They labeled the building a “death trap.” Besides Bruno, the BGA and Tribune found 10 other people who died in buildings city officials had been warned contained unauthorized apartments.

In Humboldt Park, 30-year-old Sarah Amann died in 2014 while occupying a building the city had slated to be torn down as unsafe.

The city received 16 complaints over several years about the vacant property, a hub for squatters and illegal activity, including one from Ald. Walter Burnett, 27th. A court order was issued to tear down the unsafe building, but it was still standing when the fire started nearly two years later. The city demolished the building two days after Amann died, records show. The Tribune and BGA identified eight other deaths inside abandoned buildings the city failed to secure or tear down. Three of those buildings were also under demolition orders at least a year old.

Beaudet said his inspectors are required to follow up on all serious complaints but sometimes don’t fully document all their interactions at the properties. After violations are issued, he said, the outcome is out of their hands.

Beaudet also said the city should not be blamed for deaths in vacant buildings, where people endanger themselves by ignoring signs and boarded-up doors.

“If you break in, you’re high as a kite and you fall asleep smoking on a mattress, it’s gonna be what it’s gonna be,” he said.

A spokeswoman for the city’s Law Department said the city seeks authority to demolish buildings but is not required to do so and “weighs many factors to prioritize” demolition orders.

To identify the 42 deadly fires where fire safety problems known to the city still existed at the time flames broke out, the BGA and the Tribune examined tens of thousands of pages of public records and interviewed more than 100 safety experts, firefighters, city officials and family members of fire victims.

In nine of the blazes, unaddressed fire safety issues identified by the Tribune and the BGA were listed in fire investigation reports as potential causes. In some cases, deadly fires started after tenants used stoves or space heaters to keep warm in buildings the city was repeatedly told had no heat. In others, faulty wiring and other electrical issues previously reported to the city started fires after going unfixed for years.

In another 24 of the fatal fires, the examination found, the city was warned about fire safety issues that — if fixed — could have saved lives. One example: the missing smoke detectors in Coleman’s building. In a few cases, the victims also had suffered injuries or overdosed on drugs, but records show the fires contributed to their deaths.

And in the nine other fires — including the one that killed Amann — city officials failed to make sure people stayed out of vacant buildings city officials said were too dangerous to occupy.

The BGA/Tribune review of these 42 fires also found that people of color, especially Black people, were disproportionately affected.

The fires were concentrated on Chicago’s historically underserved South and West sides, highly segregated by race and income. Of the 61 people who died, 39 were Black, 15 were Latino and one was South Asian. Only six were white.

In addition to the analysis of fatal fires, the Tribune and the BGA examined the outcomes of thousands of safety violations city officials documented as “serious,” which range from roach infestations and broken windows to such life-threatening conditions as lack of heat, blocked exits and deteriorating porches.

That analysis revealed how failures of safety enforcement contribute to long-standing inequities.

A review of 121,000 serious safety violations documented across the city from 2014 through 2019 found the majority were in predominantly non-white communities. Those areas of the city had 59 serious violations per 1,000 people, while mostly white neighborhoods had 13 per 1,000.

Violations in mostly non-white areas also were recorded as fixed at a lower rate. City inspectors marked 32% of serious violations in these areas as repaired, compared with 37% in predominantly white communities. Because so many of the violations were found in non-white areas, records show more than 69,000 serious problems went unfixed there, more than ten times the number in white communities.

Beaudet said those outcomes don’t tell the whole story, in part because of the department’s outdated technology. Inspectors also sometimes don’t enter updated records, he said.

“There is a lot of follow-up that, again, you’re not going to see in a computer system,” he said.

Flawed from the start

By the time a stove fire killed 2-year-old Samari Grace and her 7-month-old sister, Ziya, in their family’s West Woodlawn apartment, the city had received at least five complaints in four years that the building had no heat.

Despite making four separate trips to investigate, inspectors never got inside to check out the complaints, records show. The most recent inspection attempt came about seven weeks before the fire.

On the night of Feb. 25, 2017, the family was boiling water in the basement to keep warm when the pot melted and ignited nearby items.

“We just did what we had to do with the space heaters and the gas stove,” said Janice Franklin, the girls’ aunt who lived in the apartment. Her son, then 6, was severely burned but survived.

She said she never complained about the apartment to the city and she had no idea inspectors tried and failed to inspect the building.

“The whole situation was just really devastating,” Franklin said.

In 2017, the City Council eliminated a long-standing requirement that all residential buildings with more than three floors be inspected annually, shifting the city’s process for identifying unsafe conditions to rely almost completely on residents calling the 311 hotline to complain.

The following year, a 2018 report from the city’s inspector general found a backlog of thousands of resident complaints. Though the building department was supposed to conduct an inspection within 21 days of receiving any serious complaint, the IG found the department met that deadline only about a third of the time.

The result: The City Council threw out the 21-day requirement as well.

The BGA/Tribune investigation examined 599 complaints of serious violations tied to the 42 fatal fires where fire hazards went unaddressed. Records provided by the city showed no evidence of an inspection following 296 of those complaints, nearly half.

Building officials said there are several reasons those complaints were not fully investigated. In many cases inspectors are unable to get inside to conduct an inspection. Some complaints are mistakenly labeled by 311 operators.

In other cases, officials said, complaints are diverted to “active” enforcement cases involving previous problems at the property. In those cases, the new complaints are supposed to be inspected as part of the ongoing court or administrative hearing proceedings. Records provided by the city show no evidence that happened.

City building officials said that even though every serious complaint requires an investigation, inspectors and supervisors are intentionally given discretion to decide which complaints to prioritize. There are no written protocols, according to a 2019 inspector general report.

Asked why city records reflect no follow-up on so many complaints of dangerous conditions, Beaudet again cited his department’s “outdated” record-keeping system.

“We do answer the complaints,” said Beaudet. “We’re out there in a matter of days or hours. … We’re out there right away.”

The Tribune and the BGA found 75 serious complaints submitted prior to the fatal fires where inspectors reported they were unable to get inside the building, listing the outcome as “no entry.”

Inspections are not scheduled ahead of time, and records show there are often delays of weeks or months before the first visit. Building officials said inspectors call a couple of hours before they arrive, but the Tribune/BGA investigation found no evidence inspectors routinely call before showing up.

Building officials said they have no legal authority to demand entry to investigate complaints, and tenants often don’t make themselves available to let in the inspectors.

“They obviously are not serious about it if they’re not making themselves available to be at the property when the inspector tells them they are en route,” said Marlene Hopkins, the first deputy buildings commissioner.

The 311 complaint system is also “abused by many tenants,” Hopkins said.

“When tenants are in a disagreement with the landlord, perhaps they’re going through the eviction process, they will call repeatedly,” she said. “And again, not because there are valid conditions … but out of hope that we’re going to find something.”

Records show no evidence that inspectors who are unable to get inside on the first attempt routinely return to investigate those complaints again.

Lenient enforcement, persistent issues

When inspectors do find serious violations, enforcement is vastly inconsistent — even for the same issues.

Inspectors who find safety issues can recommend three paths of action. The most lenient is a warning letter to the landlord, with no further follow-up. The second is an order to appear at the city’s Department of Administrative Hearings, which is similar to traffic court. The most severe action is a city lawsuit against the property owner in Cook County Circuit Court.

Building officials say inspectors and their supervisors are given discretion to determine which enforcement route to take. But, they said, inspectors are directed to send the most serious cases to Circuit Court.

“As required, life safety, dangerous and hazardous goes straight to Circuit Court,” said Hopkins, describing the department’s violation referrals as “our core mission.”

However, city officials provided no documents or formal rules on what violations qualify as life safety, dangerous and hazardous. And records show the same serious problems are often handled in different ways. While one landlord is taken to court, another is issued only a warning.

The BGA and Tribune found the city sued landlords in fewer than half the cases involving conditions the city routinely labeled among the most serious, including lack of sufficient heat, exposed wiring, missing smoke detectors and blocked exits.

A review of all the outcomes from 2014 through 2019 found that of the more than 25,000 violations identifying those conditions, the city sued landlords over more than 11,000 violations. Nearly 11,000 others went to city hearing officers, and 3,261, about 13%, resulted in a warning letter.

In 2012, the landlord of a three-story apartment building in Hollywood Park received such a warning after inspectors found smoke detectors were not working.

Nearly three years later, 10-year-old Ans Khan died on the building’s top floor as tenants scrambled to escape an out-of-control fire. Multiple tenants later said they heard no smoke detectors. At least nine people survived by jumping from windows to escape the flames, including Khan’s family.

Contacted by the Tribune and the BGA, landlord Mihai Horga said smoke detectors were working in most of the common areas the night of the fire. He said he was aware of only one smoke detector in a stairwell lacking a battery.

Building officials said department guidelines have changed in the years after the 2012 violations in the building and now prohibit inspectors from issuing warning letters in such cases.

But an analysis of city data shows the percentage of cases ending in a warning letter has remained consistent. For instance, 15% of all smoke detector violations in 2019, or 259, ended in a warning. In 2014, it was 18%.

The discretion given to inspectors allows their decisions to be influenced by shifts in political leadership and their own personal biases, some experts said in interviews with the BGA and the Tribune.

Mark Limanni, a former general counsel with the Department of Buildings who left the city after more than 30 years, said he witnessed how priorities often change after high-profile tragedies.

“There is always some discussion about where to draw the line, where to be more aggressive or where to be more lenient,” he said.

A Tulane University sociologist who shadowed Chicago building inspectors for eight months as part of a research project said she saw inspectors base enforcement decisions on their perceptions of a landlord’s economic situation.

For example, they sometimes avoided more serious actions if they thought the financial burden of hefty fines could prevent the property owner from making repairs, said Robin Bartram, who reported on her findings in 2019.

The concerns documented in the Tulane report about the impact of fines on landlords also have been voiced at the city’s Law Department.

In 2019, the city’s top lawyer at the time — whose staff is charged with holding negligent landlords to account — appeared at a public hearing with aldermen and argued that fining landlords of smaller properties can stand in the way of fixing problems.

“In some cases, it is counterproductive to fine building owners who are already struggling with the cost of an architect and/or contractors to correct building defects,” said former corporation counsel Mark Flessner, who was appointed by Lightfoot.

More than half the landlords involved in the 42 fatal fires hold title to at least three buildings, records show, and also had a history of multiple building code violations at their other properties.

Long delays, unsafe conditions

After inspectors refer violations to an administrative hearing or Circuit Court, the process often takes months or years while tenants continue to live in dangerous conditions, the Tribune/BGA investigation found.

The BGA and Tribune examined 50 administrative hearings cases related to the buildings where the 42 fatal fires occurred, some of which included more than one case. Records show city lawyers often raised no objections as property owners requested extension after extension.

By the end, city hearing officers closed 20 cases despite knowing some of the problems were not fixed. In 18 other cases, hearing officers accepted the landlords’ evidence — including grainy photos, store receipts or statements solicited from tenants — as proof of the required repairs.

One example is Merced Gutierrez, the owner of a Little Village apartment building that became the site of the most notorious fire in modern Chicago history.

The building, which had a coach house in back, was one of four properties Gutierrez owned that together racked up more than 70 violations over eight years, 60 of which were for serious issues. In 2016, an administrative hearings case over 11 of those issues — including a lack of smoke detectors — resulted in only a $200 fine.

The case started when inspectors went to the Little Village address in October 2015 after tenants complained of rats and bedbugs.

The following spring, a city hearing officer closed the case with no further action after accepting evidence presented by Gutierrez — including close-up photos of smoke detectors — as proof repairs had been made.

Over the next two years, inspectors repeatedly visited the property over new complaints. In July 2018, they cited the landlord for missing smoke detectors in the main building, in addition to other serious issues.

Two months later, a fire in the coach house killed 10 children — from an infant to teenagers. Police and firefighters found no smoke detectors in the building. One detector without batteries was found in the rubble three days later.

City lawyers filed a lawsuit over the violations three weeks before the fire, but the first hearing date was set for September— a month after the fire.

Asked why the lawsuit wasn’t filed sooner, a spokeswoman for the Law Department said no life-threatening issues were found at either inspection that would warrant an emergency filing.

Gutierrez, the landlord, did not return messages seeking comment. His lawyer, former County Commissioner Tony Peraica, blamed the lack of smoke alarms on the coach house tenants who, he said, were in the process of being evicted and “made his life a living hell.”

Even when the city did take landlords to court, the Tribune and the BGA found dangerous conditions often persisted. Of the 42 fatal fires where fire safety violations went unaddressed, the city had sued the landlords of 22 of the buildings. In one instance, the city had filed a case but the fire happened before the first hearing could take place.

A settlement or a court order in a Circuit Court case also is no guarantee a property is safe, records show.

By the time 31-year-old Mark England died in a small home illegally converted into a rooming house, a court case against the property owner had been closed for nearly five years.

Seven years before the 2015 fire, the city took the landlord to court over the illegal apartments. The case ended two years later with a $500 fine and finding of “full compliance.” There is no record city inspectors verified the issue was fixed, despite two complaints from police and fire officials who reported the home was still being used as a rooming house while the case was ongoing.

England’s mother, Laura Hale, sued the landlord and agreed to a $125,000 settlement the following year.

“Why was he there?” Hale said in a recent interview. “We will probably never know.

“I think finally last year I just let go and grieved.”

Owners of the building where Coleman’s children died had been sued by the city four separate times since 2006. Three of the suits were filed against the previous landlords, Manohar and Sunita Lal.

In 2009, city lawyers took the Lals to court after inspectors cited them for dozens of violations and settled the case two years later. The couple paid a $6,000 fine and promised to fix any outstanding problems within six months.

That deadline came and went, records show, and the Lals received extensions lasting almost two years. Court records show the case was closed in 2013 with many of the violations unrepaired — including defective light fixtures and a lack of emergency lighting.

Tahir Sheikh purchased the building from the Lals in September 2013. In the first six months of 2014, inspectors found 41 safety violations, many of which mirrored problems from the 2009 court case. Among them were missing smoke detectors and broken doors — dangerous fire hazards still unrepaired months later when Coleman’s four children died.

In June 2014, three months before the fire, the building department referred the issues to court, but the case was not filed until the day after the fire, following a flurry of internal city emails. Those emails, obtained under the Illinois Freedom of Information Act, were heavily redacted.

Reached by phone, both Sheikh and Sunita Lal declined to comment on the fire and the violations found at their building. Sheikh sold the building in 2017. The same year, the city dismissed Sheikh from the housing court case after he paid a $460 fine.

‘I’m still here, and they’re gone’

Coleman said she woke up when her daughter knocked on her bedroom door to report an odd smell. She didn’t know then that a fire had started in an empty unit one floor down. Neither apartment had working smoke alarms.

Opening her apartment’s front door, Coleman couldn’t see anything in the pitch-black hallway. But she could smell smoke. She woke the rest of her children. Hand-in-hand, Coleman, her kids and her boyfriend went to the apartment’s back door. They were turned back by smoke and the orange flash of flames.

The family retreated to their only bedroom, where Coleman pushed a window open. She clambered onto the windowsill, looking out from the top floor of the building.

“I’m screaming for help, and smoke went in my nose, and it just … I just lost it,” Coleman said.

She jumped. Lying on the ground with both arms and both legs broken, Coleman turned to see her boyfriend on the ground as well after he jumped from another window. She pleaded with arriving firefighters to save her kids, then lost consciousness.

She woke up in a hospital bed later that day in intense pain, with soot still on her face.

When family members asked her about the children’s clothing sizes and favorite colors, it finally hit her: They were planning a funeral. She would never see the kids again.

“They were my morning, my afternoon, my evening. They were my everything,” Coleman said in a recent interview. “And I’m still here, and they’re gone.”

From the time she moved in, Coleman knew the one-bedroom apartment on Vernon Street wasn’t perfect. But after years living with extended family, she and the four kids were eager for a place of their own.

Coleman described her children as smart and easygoing, excited about living alone as a family and filling out adult-sized personalities before her eyes.

Carliysia was doing well in high school and had her eyes set on Ivy League universities and a career as a lawyer, Coleman said. Her oldest son, Carlvon, was disciplined and hardworking, finding odd jobs to earn money. His mom said the growing teenager liked to wrestle with his younger brother, the jokester of the family. Shamarion — “Mari” to his family — loved to dance and was lean and tall after a summer growth spurt in the months before the fire.

The “baby” of the four, Eri’ana, developed an affinity for Keyshia Cole songs and declared that she’d be better than Beyoncé.

Coleman was taking classes in medical billing and working part time. She told herself and her four children to be patient while she aimed for a higher-paying job and a larger home

“It wasn’t supposed to be permanent,” Coleman said of the apartment, adding that nothing she saw in the building seemed life-threatening. “I didn’t know how bad it was.”

Coleman said she’s angry to learn the city failed so many more families in fires where safety problems were known in advance.

“People lost their kids or lost their family members or life changed forever because of a fire — because of their negligence,” she said.

“If you knew this was happening you could have prevented it from happening,” she said. “But them being responsible for it just made me think like it’s politics. It’s the government, and they just kind of get away with whatever.

“It’s no winning when we’re in the situations that we were in.”

Coleman said that when she sees images of another fatal fire on the news, she can’t watch because of the memories of her kids and the fire that took them.

“I’m still trying to figure it out,” she said. “When I had them I wasn’t alone, it was me and them. So I’m learning how to be alone.”

AnnMarie Hilton, Carolina Gonzalez, Nicole Stock, Sahi Padmanabhan and Deborah Wilber contributed to this report as interns for the Better Government Association.