When a child dies under the care of the city's Department of Human Services, a team of experts within the agency investigates, pinpointing failings in the system and suggesting improvements.
But more than half the time, those suggestions are ignored.
DHS failed to act on many of the staff recommendations its child-fatality-review teams made after examining 52 child deaths over the last six years, according to an internal DHS review released yesterday.
DHS examines all child deaths in which the agency was providing services to the child's family or had done so in the previous 16 months.
But of the 36 recommendations that resulted from the death investigations, the agency had not made any progress on 17, the report said. Many others were only discussed. A handful just recently resulted in policy changes.
And four of six high-priority reforms were never acted upon, the report said.
It concludes that DHS must overhaul the way it investigates child deaths.
"After six years of following the existing method, changes are needed in order to implement a higher level of systemic change," it says.
Acting DHS Commissioner Arthur C. Evans said those changes were now under way.
He recently introduced a child-risk-assessment tool, he said, that helps workers decide when a child is unsafe - as opposed to relying on personal judgments.
"The feeling was that there was a lot of variability," he said, "and one way to make sure we are covering all the bases is to use a formal assessment tool."
Another example, he said, is a recent alert he sent to social workers, telling them to pay close attention to high-risk cases where a child's parents had been abused or neglected themselves or where other children in the family had been abused.
"It's one thing that really popped out at me," Evans said. "These are related to increased risk around fatalities."
An Inquirer investigation last year found as many as 25 children had died in the last three years after they or their families had come to the attention of the agency.
In the aftermath of the investigation, Mayor Street ousted the agency's two highest officials, appointed Evans, and demanded reforms.
Evans asked a committee to review all past fatality-review recommendations and see if the agency ever acted on them. That committee met a dozen times in the last year.
Several of the failings addressed by prior DHS death investigations can be seen in one case The Inquirer highlighted.
Fourteen-year-old Danieal Kelly was found dead from heat exhaustion during an August heat wave. She was bedridden with cerebral palsy. She weighed just 46 pounds and had bedsores festering with maggots.
A city-paid social worker was supposed to have been checking on her each week.
Despite opening seven neglect investigations into Danieal's case, DHS never noticed that she was not enrolled in school and had missed recent medical checkups.
Federal and city officials are investigating the case.
The report released yesterday said that DHS at one time recommended a consistent and routine follow-up on the medical and educational status of children under its care, including contacting non-relatives who knew the child. It also said the agency recommended hiring workers with more expertise in behavioral health or physical health problems.
Evans said the agency had since hired two nurses to review cases for medical problems.
In some cases, The Inquirer found, the agency had contact with the family before its child was born.
The Inquirer reported numerous deaths in homes where DHS had previously investigated abuse or neglect allegations and had closed the case.
The child-fatality-review team noticed the same problem and had recommended that DHS check in with the families in those homes upon the birth of another child. No progress was made on the recommendation, but yesterday's report said it required immediate attention. Evans said that this had been done and that DHS social workers have been told.
In March, the newspaper wrote about 10-week-old Ciani Davis, who died in a squalid, freezing basement after her mother had refused to cooperate with DHS. Ciani was severely malnourished, having not gained a pound since her birth. Police charged the mother with endangering the baby.
Yesterday's report found that prior reviews had suggested that DHS figure out when avoidance was becoming a lack of cooperation and to assess how many visits should be attempted before taking a family to court. It's impossible to say whether the warning came before the Davis case, or because of it.
Evans released the report yesterday in response to an Inquirer request. He said future reports and the findings of death-review teams should be made public.
"We are going to be open and transparent," he said.
The newspaper has been fighting since November to obtain copies of the full child-fatality reviews, which detail how each child under the agency's care died. When that request was denied, the newspaper asked for the recommendations made in the death reviews, but the city declined to release them, citing state privacy laws.
Meanwhile, a panel convened by Mayor Street is conducting its own review of all 52 child deaths. That report is due out by the end of this month. Panel members have declined to discuss their findings, saying they will disclose the results to the mayor first.
Among the other findings in yesterday's report:
Services to children in the home, intensive services aimed at protecting children to teaching parents how to parent better, must be provided to all children in the home, not just the child identified as in need.
In high-risk cases, social workers and supervisors should meet more often, at least quarterly, to discuss a case.
Findings from death reviews should be used to develop new training around the issues of child safety and child fatalities.
Evans said the agency was now in the second phase of its reform action plan. The undertaking is enormous. The agency provides services for nearly 38,000 children. It saves many children from abuse and death, he said, but must go further.
"We just can't be focused on protecting a child," Evans said. "We have to intervene to break the cycle of abuse and neglect. We have to think about the next generation."
Since October, The Inquirer has been writing about children who have been harmed or killed after coming to the attention of the Department of Human Services. To read previous stories, visit http://go.philly.com/dhs