A succession of child-welfare professionals, including Department of Human Services social workers, a Family Court judge, city lawyers, and a doctor, all missed chances to rescue 6-year-old Khalil Wimes from the abusive parents who were charged with his murder in March, according to a state-mandated review of his death.

Khalil was dead from head trauma, his emaciated corpse covered in scars, when his parents - Floyd Wimes, 48, and Tina Cuffie, 44 - took him to Children's Hospital of Philadelphia on the night of March 19.

An Inquirer review showed Khalil spent the final months of his life beaten, undernourished, desperately ill, and out of school, all while DHS failed to recognize a child in danger.

Known as an Act 33 review - required in all child fatalities - the new report, released to The Inquirer on Monday in response to a Right to Know request, revealed further details of how professionals failed Khalil.

One of his DHS social workers, for instance, did not record concerns over Khalil's condition until after his death. And city lawyers advocated, over the objections of a different DHS social worker, that Khalil be returned to parents who at that point had had five other children permanently removed from their care.

The Act 33 review team, with members including DHS Commissioner Anne Marie Ambrose, doctors and medical officials, child-welfare experts, and representatives from the District Attorney's Office and Philadelphia police, stated its intention to file a negligence complaint with the state Board of Medicine over the actions of Khalil's primary care physician.

That doctor, Carl N. Liedman, last saw Khalil 13 months before his death and did not recognize signs of the boy's "failure to thrive," according to the report. Liedman was not named in the report but was identified in court and DHS records obtained by The Inquirer. Liedman did not return calls seeking comment Monday.

(According to medical records, Khalil weighed 36 pounds at age 3 and 34 pounds at age 4.)

The report recommended a series of policy changes, which Mayor Nutter endorsed Monday.

"On multiple levels, the system did not function well, and in light of the recently completed investigation, we are taking all appropriate actions," Nutter said.

"When these deaths occur, we look hard at what we did and didn't do," Ambrose said. "And we're doing that with Khalil's death. We look to the Act 33 team to give us clear recommendations on how to improve practice and make sure this doesn't happen again."

Courtnei Nance, the DHS social worker who visited Khalil eight times in the last eight months of his life, including two weeks before his death, has resigned, Ambrose said.

Ambrose would not say if Nance was forced to leave.

Nance supervised eight visits between Khalil and his siblings at the family's South Philadelphia apartment and a DHS facility.

During these visits, Nance "observed a bruise on his face as well as other marks which the mother stated were from eczema," the report says. Nance also inquired about Khalil's weight, but always thought Cuffie had a "plausible explanation for Khalil's condition."

Nance violated DHS policy by not reporting her concerns to the DHS abuse hotline, which would have resulted in further investigation of Khalil's injuries, the report states.

She also failed to document any of her interactions with Khalil in the agency's electronic case-management system - another violation of DHS policy, according to the report.

Efforts to reach Nance have been unsuccessful.

Six other DHS staff members were also involved with Khalil's sibling visits, according to report. None of those staffers or any other current DHS employees were disciplined, Ambrose said, but she added that the investigation was ongoing.

DHS had received nine previous complaints against Wimes and Cuffie dating to 1995, according to the report.

In 2001, one of Khalil's older teenage sisters was found walking late at night in a West Philadelphia park, having "a foul odor coming from her body, her hair was uncombed and she was very thin," the report states.

When Khalil was born in 2006, Wimes and Cuffie were abusing drugs and living in an "uninhabitable" West Philadelphia rowhouse with no heat, no water, and no gas, according to the report.

"The mother had six of her children removed by DHS for residing in the same residence," the report says.

Khalil was placed in the care of a paternal cousin, Alicia Nixon, and thrived, but when Khalil reached his first birthday, Wimes and Cuffie went to Domestic Relations Court and regained custody of Khalil despite their deplorable parenting record.

"The judge in the Domestic Relations Court returned Khalil to his parents without reviewing the parent's DHS history," the report states, adding that Domestic Relations Court and Family Court have computer systems that are unable to communicate with each other.

A few days later after being returned to his parents, Khalil was rushed to the hospital, dirty and hungry and experiencing an asthma attack.

Judge Robert J. Matthews, who handled the case, declined to comment Monday.

Two years later, after completing a parenting program and substance-abuse treatment, Wimes and Cuffie again went to court trying to retain Khalil from his foster parents.

The report faults DHS for supporting the reunification of Khalil with his parents in the face of objections from the assigned social worker, Jessica Campbell.

The independent child advocate, Monique Sherman, also objected in court to Khalil's being returned to his parents, but then "did not appeal the reunification or file for their own petition."

The report recommended that the city law department implement policies to ensure more thorough "case conferencing" and information sharing between the city lawyers and DHS staff - essentially that city lawyers should be better prepared and be familiar with the histories of the parents they're dealing with.

The report also recommended that DHS "review and reinforce" its safety and documentation policies to ensure the safety of children who live in a home serviced by DHS, but do not have an assigned DHS social worker.

Ambrose said DHS has already begun to implement the Act 33 recommendations in recent months. In May, the agency reinforced directives regarding how social workers document their child safety visits, she said. And in June, the agency took steps to ensure that city lawyers are better prepared for court.

Richard Gelles, a dean of the University of Pennsylvania's School of Social Policy and Practice, said the case is an example of a troubling number of cases where city lawyers do not fight for terminating unsuitable parents' rights to their children, even in cases, like Khalil's, where there clearly are "aggravated circumstances regarding how the parents treated their children."

"They didn't try this case, and I believe they should have," Gelles said, adding that Pennsylvania legal precedent would have allowed DHS and the city lawyers to make a "compelling case" for Khalil's not being returned to his parents and staying with his foster parents, where he was safe.

"But they opted not to go into court to contest it," Gelles said. "It's not the first time, and it won't be the last."