A second report on the death of a 10-year-old foster child has found that a caseworker falsified documents after the boy's death and Philadelphia school officials failed to follow district protocol that could have helped him.

The report on the death of Ethan Okula was released Tuesday by the Act 33 team charged with investigating child fatalities for the Department of Human Services. It's the first time a child's death has prompted a follow-up report since the review team was formed in 2009. The second report was triggered by a separate state review of Ethan's death, which raised additional questions.

Ethan, a student at Julia De Burgos Elementary School in Fairhill, died Feb. 10 of a bowel obstruction after complaining to the school nurse of a stomachache.

The report found that after Ethan's death, a foster-care worker with Northeast Treatment Services faked a document describing a December meeting with caseworkers that should have taken place but never occurred.

The meeting would have outlined goals for Ethan's care and served as a check-in on the boy's well-being.

The fraud was discovered when follow-up interviews were conducted with people alleged to have been at the meeting who said no such meeting occurred.

"It is absolutely, 100 percent, completely unacceptable to falsify documentation," said Jessica Shapiro, chief of staff to the new commissioner, Cynthia Figueroa, who started this week. "I'm of the philosophy, I'd rather someone tell me they didn't do the work, or didn't document the visit, then make up the visit, and I think in this particular case they got nervous."

The review team wrote that "in light of rising caseloads, there is an increased risk in the potential that staff will falsify documents."

That concern is paramount considering home visits and planning meetings ensure a children's safety, said Sam Gulino, chief medical examiner and chair of the Act 33 Team.

Since January, 11 child-welfare workers have been fired and two have resigned for forging case documents, including four people involved in Ethan's case, the department said.

The department does accountability checks to make sure visits recorded actually occurred. The computer system does not allow for backdating reports, but problems persist and caseloads have swelled to 13 families per worker as more children have entered into DHS care in recent years.

In response, DHS has released funding to the private providers to hire 100 more caseworkers.

The report released Tuesday also added new details to the narrative of Ethan's last day.

While under the nurse's supervision, Ethan's legs gave way and he fell while in the bathroom. His stomach hurt so badly he couldn't sit up and he was placed in a wheelchair, according to the report.

The Act 33 Team found the school nurse, who has since been suspended from the district, did not follow protocol.

The nurse said she checked the boy's stomach and everything appeared normal.

A pathology report showed Ethan had abdominal surgery as a baby, causing serious scar tissue, the Act 33 Team found.

The pathology review said the scar tissue caused the bowel obstruction leading to Ethan's death.

"If the nurse had checked Ethan's abdomen, she should have noticed the scarring from his prior surgery," the report says. "Instead, the nurse noted no abnormalities."

The nurse also failed to fill out and send home with Ethan a form explaining his condition and instructions for his care.

After vomiting throughout the day and defecating on himself, Ethan was picked up by a friend of his foster mother.

A school officer had previously told the Act 33 team that the woman verbally and physically abused Ethan as she pushed him into her car, but no one reported anything to police.

According to the report, the District Attorney's Office declined to pursue criminal charges against School District staff for failing to report Ethan's condition or the alleged abuse to authorities.

Cameron Kline, a spokesman for the District Attorney's Office, said the investigation into Ethan's death was ongoing but declined to comment further.

Ethan was found unresponsive around 7 p.m. that day and was pronounced dead when he arrived at the hospital.