Binders as fat as phone books are piled high atop Nadeem Bezar's desk. Amassed for a civil trial since 10-year-old Ethan Okula's death, thousands of pages worth of court documents are what it takes to detail how many people let this kid down.

It's all the paperwork and scrutiny and concern his case should have garnered while he was still alive.

Bezar is a lawyer for Kline & Specter, and he specializes in these types of cases. The children whom the system fails. The ones who need the most attention, and sometimes, heartbreakingly, get the least. Ethan died in July 2016 of a stomach ailment that went unrecognized by a school nurse and ignored by a foster mother who now faces criminal charges.

Ethan Okula’s donated headstone.
Ethan Okula’s donated headstone.

Bezar took the case in 2017, in the hope of winning civil damages against the child welfare agencies that placed Ethan with that foster mother and failed to make sure that his special needs — a serious stomach condition, hearing aids, asthma, and cognitive disabilities — were being cared for.

He represents children like Ethan, whose parents have lost their parental rights and who have been failed by so many. The cases can be brought to him by a family member who isn't estranged or an advocate. Before settlements, the children's estates sometimes consist only of the garbage bags of belongings they carry with them from house to house. Ethan's belongings didn't even fill one, Bezar says. At his last placement, he arrived with a few changes of clothes.

The attorney's vantage point is an unusual one. With so much turnover in the city's child system, he retains institutional memory of the worst cases of neglect and abuse — a through line of failures, of the children who slip through the cracks. And of the lessons that can be gleaned from the tragedies.

Lawyer Nadeem Bezar specializes in filing cases on behalf of children who have been abused or neglected.
Lawyer Nadeem Bezar specializes in filing cases on behalf of children who have been abused or neglected.

His first child welfare case was on behalf of the surviving siblings of Porschia Bennett, the 3-year-old South Philadelphia girl who was starved, whipped, and pummeled by her father even after the city Department of Human Services closed her case. That case became a touchstone in the city's struggle to right its child welfare system.

Fifteen years later, Bezar is still busy as ever. And Ethan’s case is a new touchstone — one that shows that even after so much needed reform, even after we’ve identified our shortfalls, systematic failures still take place.

He's seen the worst cases, the ones where he feels he's "looking into the eye of a monster." Repeated sexual and physical abuse. Cases where children were being sexually assaulted and were then returned to the home where it happened. "Imagine having to get out of that car, if you were that kid," he said.

Foster parents with years-long rap sheets. A father who shot a child and then tried to blame it on her sibling.

But in Ethan's case, there's no single monster. There's just neglect at every level.

On Friday, Bezar lifted the heavy binder at his Center City office and began to flip through the pages. It reads like a merry-go-round of missed opportunity: Northeast Treatment Centers, which placed Ethan with a foster mother whose licensing had lapsed and who was unequipped to meet his medical needs. (Employees later faked a home visit in his records.) Turning Points, the subcontractor charged with visiting him at home, which bungled his medical care. The foster mother herself, and the school officials who failed to get him the help he needed as he lay dying.

"I can't damn the whole system," Bezar, 53, a father of two, said. His work means that sometimes he gets to see the good the foster care system can do, and all the hard work that front-line workers shoulder. But cases like Ethan's, he says, point to the fact that even all that well-intended reform can still miss kids. And often, it's the ones who need help the most. Who can't speak for themselves.

"The kids that are developmentally delayed — if they have a roof, a little food, they deal with what they've got to deal with. They stay quiet," Bezar said. And those are the kids we need to work hardest to reach.

Too often, he represents the children who no one did.

Ethan's estate is now worth $5 million, thanks to a settlement announced this week with the agencies tasked with his care. The sole beneficiary is his little brother, who's still in foster care.

In his office, Bezar cleared the files off his desk. To make room for the next case.