The City of Philadelphia decided a trip south was best for Omega Leach, an angry teenager who got in trouble for stealing a car.
In May, the 17-year-old arrived at the Chad Youth Enhancement Center outside Nashville, a mental-health facility for troubled teenagers approved by the city's Department of Human Services.
His stay was brief.
Leach died after a physical confrontation with staff on June 3. He tried to choke one counselor, and another staffer pushed Leach facedown to the floor and pulled his arms behind his back, police said.
Investigators are checking whether the restraint was applied improperly, preventing Leach from breathing. He was pronounced dead the next day in a Nashville hospital, about 15 hours after the confrontation.
"There's no doubt that the kid had an attitude and probably needed to be locked up somewhere," said Sgt. Brian Prentice, of the Montgomery County, Tenn., Sheriff's Office. "It doesn't mean he has to be dead."
Leach's death was one more lost life on DHS's watch. As with other Philadelphia youths committed to such centers, his care was DHS's responsibility. The agency was paying Chad $285 a day for his treatment.
Questions have been raised about the center before. In 2005, a 14-year-old Long Island girl died there of heart failure as she was being escorted by a counselor.
Although Chad staff was not blamed in her death, Tennessee officials quit placing teenagers there. New York did, too.
But not Philadelphia.
On DHS's recommendation, judges and social workers continued to send children to Chad, even though the agency's own reports consistently criticized its performance, an Inquirer review shows.
After the newspaper began asking questions about Chad and the two deaths last week, officials in Philadelphia and Tennessee began to take action:
Tennessee's child-welfare agency banned new placements at Chad and said it would force the facility to improve restraint procedures.
Philadelphia's DHS also froze admissions to Chad. The department said it was putting into place "a contingency plan" for relocating 45 city children still at Chad, pending further investigation. Some of the children are delinquents. Others had been neglected or abused.
A Philadelphia judge criticized DHS harshly for failing to inform the courts of the 2005 death and said he would insist on better communication.
"It's disturbing to the point that it's unacceptable," said Kevin Dougherty, administrative judge of Philadelphia Family Court.
Chad and its corporate owner, Universal Health Services Inc. of King of Prussia, declined to respond to detailed questions. They did issue a statement defending the facility's record.
UHS owns more than two dozen hospitals and 110 behavioral-health facilities in 33 states. It bought Chad and 29 other facilities the month after the Long Island girl died. The deal was worth $210 million.
"We have a reputation and history of being a high-quality provider of behavioral health and substance-abuse services to troubled youth and their families," said Duwayne Glaser, Chad's chief executive officer.
He said Chad's training exceeded industry standards.
Chad helps "troubled kids to get better," the statement said. "We take the responsibility of their safety and care very seriously."
Philadelphia's child-welfare agency has been scrambling to remake itself since an Inquirer investigation last fall explored a string of deaths of children under DHS protection.
DHS has undertaken a host of reforms, including new procedures to evaluate the safety of children. Its workers visit the most vulnerable children more often and has hired more nurses to spot medical problems.
In a tough report released four days before Leach's death, an expert panel appointed by Mayor Street said "significant system failures" at DHS had let children die needlessly.
In particular, the report criticized DHS oversight of the private agencies that receive millions of dollars to work with the city's troubled children.
Although Philadelphia has sent scores of teenagers to Chad, paying it $6 million in the last three years, city and state social workers failed to closely monitor how it was treating those children.
For example, in 2006, Pennsylvania child-welfare officials sent out a directive strongly discouraging restraint techniques except as a last resort.
Through a bureaucratic oversight, that directive was never sent to Chad. On Friday, state officials said they would make sure Chad got the message.
In Philadelphia, DHS officials struggled last week to explain why Chad continued to earn their approval, even as DHS's own inspectors filed reports that found the center consistently failed to meet many standards.
For example, one 2005 report said teenagers at the center had complained that staff members had improperly used physical force to restrain them. They also complained that staff members had sex with residents and watched pornography with them.
Before releasing it, the city censored that section of the report, saying it was related to the ongoing investigation and needed to be kept secret. The contents were confirmed by sources familiar with the document.
Throughout last week, DHS released confusing, contradictory and, at times, incorrect information about its dealings with Chad, particularly what it knew about the earlier death.
On Tuesday, Arthur C. Evans Jr., the acting DHS commissioner, said in a statement:
"We were not informed of the previous death. It was the Chad facility's obligation to inform DHS of the 2005 death, but they did not do so."
By Thursday, DHS admitted that was not true.
The agency reversed course after learning that a former Chad executive disputed its account. The executive said in an interview that he had flown to Philadelphia to brief DHS officials about the girl's death.
A source at DHS said on Friday that Evans was initially misinformed by a senior staff member.
Last week, Evans acknowledged failures in DHS's oversight but said a new system would provide "a much more accurate picture" of the quality of outside contractors such as Chad.
Steven Oakman heads the contracting office at DHS. "I'll have to refer you to the commissioner's office," Oakman said on Thursday. "All of the statements are coming out of there."
After Leach died, investigators descended on Tennessee, including teams from from DHS, Family Court, and the Philadelphia public defender's office.
They joined local detectives, child-welfare advocates, and officials from two Tennessee state child-welfare agencies in touring the Chad grounds. The center is a 20-acre complex in Ashland City in rural Montgomery County, northwest of Nashville, with a main classroom building, a gym, and several dorms.
Prentice, who is supervising the criminal investigation, said the Sheriff's Office had fielded a number of allegations over the years that Chad residents had been assaulted, either by staff or by one another.
"There are reports all the time," he said. "There's a lot of runaways, stories [from children] that 'We're being abused out there.' We've had some broken arms, some separated shoulders."
Prentice said victims would stop cooperating with investigators, apparently because they feared retaliation from staff or other youths. No charges have been lodged in any incident, he said.
"They're mostly street kids," he said. "They think they're better off to keep their mouth shut."
Investigators from Philadelphia recently spoke with about 20 city children at Chad and heard allegations that raised "serious concerns," said Robert Listenbee, chief of the juvenile unit at the public defender's office.
"The general feeling is that there are a lot of restraints, daily, weekly and monthly," he said.
Before Leach died, Listenbee said, a child from Philadelphia sustained a broken arm; since the death, another Philadelphia youth has suffered facial injuries during a restraint, he said.
"We're concerned about how frequently they use restraints, the types they use, and the quality of training they have received," he said.
A troubled young man
Outside the Leach family rowhouse in a battered part of Southwest Philadelphia, the walls are adorned with posters with his photo and words of farewell for "Manny," as he was known to friends and relatives.
His mother, Paulette Dolby, cried when asked about her son. She referred reporters to a lawyer, Edith Pearce, who is investigating the death for a possible lawsuit.
Pearce described Leach as an ordinary teenager who loved basketball and video games and doted on his younger sister. He carried a grade point average of 2.7 at Daniel Boone disciplinary school.
"My career goal is to be a lawyer," he wrote recently, in words quoted in his funeral program. "I like helping people, so I plan to be an affordable lawyer, and in that case I will have to go to college."
His father, Omega Leach Jr., 50, has been arrested nine times in two decades and has served time for burglary and drug dealing.
The younger Leach also had a long history of problems. One psychological report called Leach a "deeply troubled and difficult young man."
According to official records, police arrested Leach at age 14 after he allegedly cursed and threatened students and teachers at his school, Tilden Middle. He told one teacher he would "shoot him full of shells," police said.
"His mother is very afraid of him and his behavior," police wrote. The teenager "is out of control."
The city tried to straighten him out. In January 2005, just before Leach turned 15, he was sent to a private facility in Virginia.
By the time he was 16, Leach was back in Southwest Philadelphia. In December, police arrested him for racing through his neighborhood in a stolen Nissan.
Family Court found that Leach was a delinquent, as social workers labeled him with this diagnosis: "conduct disorder."
This time, a judge sent him to Chad. He arrived May 2.
DHS had been placing children from neglectful or abusive homes there since 2001.
In 2006, Family Court judges began using the facility as a destination for a different class of children - those, like Leach, who had committed crimes.
Dougherty said his judges assumed that Chad was a good option because DHS had a long history of using it.
He said it was important that DHS and the courts "develop a protocol" to make sure judges know much more about the places where they are sending children.
Even as the city accelerated its use of Chad, DHS continued to find problems.
Over the past four years, Chad's best evaluation found it met just 46 percent of DHS standards. Even so, DHS ranked the place "average" each year - and kept it on the approved list.
In 2005, Chad met only 34 percent of applicable standards. The reports found that Chad appeared clean, but faulted it for poorly documenting its service and for communicating inadequately with residents' families.
Estelle Richman, Pennsylvania public welfare secretary, said that performance was unacceptable.
"I would say 40 percent out of 100 percent is a problem," she said.
The DHS commissioner at the time of the death, Cheryl Ransom Garner, faulted Chad for not reporting critical incidents to DHS. "We were hearing about them from the kids," she said.
She said the agency checked out some of the reports but could not confirm them. On balance, she said, Chad appeared to be serving children well.
Nowhere in the thick stack of DHS reports on Chad is there a mention of the death of 14-year-old Linda Harris on Sept. 18, 2005.
At the time, Chad officials said she collapsed suddenly while being escorted to a "time-out room" after an emotional outburst.
Harris, who took antipsychotic medicines, had a history of going into rages.
The Nashville medical examiner later ruled she had died of natural causes brought on by a heart problem and asthma, aggravated by "morbid obesity." She was was 5 feet, 7 inches tall and weighed more than 300 pounds.
Michael G. Lindley, one of Chad's former owners, said the staff bore no blame for her death. He said Harris collapsed from a heart attack just moments after a counselor grabbed her arm.
While a Tennessee child-welfare investigation cleared the facility and its staff of any wrongdoing, the state nonetheless decided to stop placing its children there.
"We made a determination it was not worth the risk," said Randall Lea, assistant to the commissioner of the Tennessee Department of Children's Services.
Last week, Lea likened the decision to that of a restaurant inspector who gives a restaurant a 72, when passing is 70 - but then chooses not to eat there with his family.
"There's a gap between minimum acceptable standards and optimum practices, and every agency has to decide what they will settle for within that line," Lea said.
After Linda Harris' death, New York authorities also stopped sending juveniles to Chad and other out-of-state facilities.
"We generally like to have an extremely high confidence level on where we place children," said John Desmond, director of probation in Suffolk County, which had sent Harris to Chad shortly before she died.
"If we have questions about safety, we will not use that facility."
As for Philadelphia, it stopped sending youths to Chad for several months in 2005, but eventually resumed. Ransom Garner, who said she met frequently with Chad officials, said she did not recall discussing Harris' death.
At last count, DHS had 1,554 children in residential centers such as Chad. Of these, 233 were placed outside Pennsylvania.
Under agency procedure, DHS first tries to place all youngsters inside the state. Officials say they send them outside Pennsylvania only as a last resort.
A videotaped scuffle
As sheriff's investigators in Tennessee set out to figure out why Leach died, they caught a break: Part of the death struggle was caught on video.
An account of the staff's confrontation came from Prentice, who is supervising the probe.
A counselor confronted Leach about 2 p.m June 2 and told him to leave his dormitory room. Residents are not permitted to stay in their rooms all day.
Leach responded by shoving and trying to choke the counselor. A camera focused on the dorm hallway caught what happened next: "You see them fly out in the hall, with the juvenile actually being the aggressor."
The pair then tumbled back into the same room, out of the camera's view. Another counselor and a nurse run into the room, and the first counselor walks back into the hallway, visibly exhausted.
Inside the room, according to statements from Chad staff, the new counselor applied a restraint technique as the nurse slipped a piece of plastic under Leach's chin so he could breathe.
According to the statements, it appeared that the counselor, though not sitting on Leach, was putting his weight across him, while bowing his arms back, Prentice said.
That may have crushed Leach's diaphragm, he said.
According to a digital timer on the video, the counselor and the nurse stayed in the room with Leach for 20 minutes. Finally, they emerged and frantically began seeking a defibrillator.
Prentice said he could not say how long Leach was under restraint.
According to a 2006 report on restraint techniques issued by Pennsylvania child-welfare officials, "research indicates that most deaths occur within the first six minutes of restraint."
As yet, the medical examiner has not determined the cause of death. Toxicological results are not back.
An autopsy did find that Leach, like Linda Harris, had an enlarged heart. His body bore no bruises or signs of having been choked, Prentice said.
Prentice said he was deeply troubled at the second death of a teenager in the facility. He said he expected a long investigation that would focus in part on the training given the two counselors, both new hires.
"We have a a lot more to do," he said. "We've got to stop this. One is too many. Two is ridiculous."
Read a panel's report on DHS's failures, and recent news coverage, at http://go.philly.com/dhs