It's not too few social workers.
It's not too little money.
It's not a lack of smart policies.
The harsh grand-jury report on Philadelphia's Department of Human Services said some caseworkers oversaw as few as 18 families. It said the agency, with its $600 million budget, was one of the best-funded in the nation. It said the agency had a perfectly adequate "risk assessment" process to figure out if a child was in danger.
The report said 14-year-old Danieal Kelly, who wasted away on DHS's watch, had died because the agency was steeped in a toxic culture in which workers failed to do their jobs and supervisors failed to hold them accountable.
In fact, the report said, it was a workplace where those who fell short were not punished but rewarded with promotions.
Most damning, the grand jury said, this culture remained entrenched despite past scandals, new leadership, and highly touted changes.
Two years ago, then-Mayor John F. Street fired the agency's top two officials and appointed a panel to overhaul DHS after The Inquirer published investigative articles highlighting the deaths of children under the agency's watch.
"We fear that change will be much harder and longer than many might believe," the grand jury said. "The dysfunction at DHS goes deep, down to the bone."
The grand jury charged nine people last week in connection with the homicide by neglect of Kelly, found dead in West Philadelphia in the summer of 2006, her bloody, emaciated body covered in festering bedsores.
One of nine children, she lived in a two-bedroom apartment in a dilapidated rowhouse in West Philadelphia. Requiring a wheelchair because of her cerebral palsy, Kelly lived a chaotic life, bouncing between the homes of her separated parents. She died of starvation and neglect, lying in a bed soiled with feces and urine, maggots in her bedsores.
She weighed just 42 pounds.
Those charged included her parents, two DHS caseworkers, and two employees of a private social-service agency.
Despite the changes launched after The Inquirer's investigation, the grand jury said they had barely penetrated the real workings of the long-troubled agency.
Its 258-page report portrayed DHS as rife with incompetence and indifference, up and down the ladder of command.
For example, Dana Poindexter and Laura Sommerer, the caseworkers criminally charged with child endangerment in Kelly's death, were suspended only after charges were filed Thursday.
DHS Commissioner Anne Marie Ambrose, who took over the department in June, said she was livid when she read the report and realized that the workers involved had gone undisciplined for so long.
Ambrose faulted herself for not realizing that swift discipline had not been imposed.
"No one told me, and I should have asked," she said. "I truly was blindsided."
According to the grand jury, Sommerer's failure to rescue Kelly couldn't be blamed on her heavy workload.
When assigned the Kelly case, she oversaw only 18 families. Moreover, the report noted, her main job was not to provide direct services but to supervise the work of private agencies that did.
Sommerer did visit the family, but did not raise any alarms, even though Kelly was not in school or receiving proper medical care.
The report held up Poindexter for particular scorn, citing his "slovenly, neglectful and dangerously reckless work habits." It said he had all but ignored the Kelly case; detectives found his file on the family at the bottom of a cardboard box, buried under food wrappers and unopened mail.
His suspension last week was the fourth of his DHS career. In 2003, he was suspended for 10 days for "poor work performance and placing children at risk" after a 3-week-old baby died in a home he was supposed to be supervising.
Poindexter, who surrendered to police Friday, declined to comment when reached at his job the day before. Tomika Stevens, a lawyer for Sommerer, declined to comment. Poindexter and Sommerer were the only DHS workers to be charged by the jury.
But the neglect and the apathy reached much higher, into the agency's supervisory ranks, the report said.
It criticized Janice Walker, Poindexter's direct supervisor, saying she failed to make sure he did his job - speedily evaluating neglect complaints to make sure children were safe, and turning in reports on time.
"This failure is appalling on many levels, not least because Ms. Walker's job was to supervise five employees to make sure that they completed their investigations," the report said. "If she did not do this, what on earth was she being paid for?"
Walker did not respond to messages left at her home and office.
Next up the command chain at DHS was Martha Poller, whose job was to oversee Walker and four other midlevel supervisors.
She, too, did not hold anyone accountable for repeated failure to investigate neglect complaints within the deadline of 60 days.
Rather than ensuring that workers were doing their jobs, the grand jury found, Poller simply went into the DHS computer and marked neglect complaints "unsubstantiated" - an action that meant no warning bells went off about Danieal Kelly.
Poller told the grand jury that closing out reports was common practice at DHS. It's done for "expediency," to cut through red tape and get families help faster, she said.
The grand jury found otherwise, saying the practice allowed "workers like Poindexter to continuously ignore reports of children being abused and neglected."
"Instead of supporting supervisors . . . who tried to hold Poindexter accountable, Ms. Poller covered up for him; for his lax supervisor, Janice Walker; and for herself," the report said.
If Poller had done her job, the report says, "Danieal might have been saved."
After Kelly's death, though, Poller got a promotion. As an angry District Attorney Lynne M. Abraham pointed out Thursday, Poller's new job was to lead a DHS team to review child deaths, to find out what went wrong.
Poller did not return calls and an e-mail seeking comment.
Public-interest lawyer Carol Tracy, a member of Street's oversight panel, said the grand jury's findings were no shock. She said her panel had heard from good DHS workers who begged the agency's brass to crack down on the lazy or indifferent ones.
"We heard from the DHS workforce: 'Find ways to get rid of the bad workers, because it brings us all down,' " Tracy said.
That panel recommended a number of changes, particularly in DHS procedures to assess risk to children.
In an interview last week, former DHS director Arthur C. Evans, who oversaw those changes, said he had made much progress overhauling the agency.
Evans, a psychologist, said that when he took charge in the wake of Kelly's death, he didn't see a need for an additional review of the death. At the time, he said, he expected any criminal charges would be leveled swiftly.
"We said whatever was done was done," Evans said, "and we'd wait until the grand jury finished its work."
Ambrose, Evans' successor, said the agency had improved since Kelly's death and would get better yet.
"Expectations need to be made clear to the workers, and I'm very very focused on accountability," she pledged.
She said she had spent much of Friday huddled with her staff to figure out what to do about DHS employees named in the grand-jury report who had not been disciplined. She will announce her decisions tomorrow, she said.
She promised that she would be a tougher leader.
"Some people are going to have to go as we move forward," she said. "I'm prepared to make those decisions, and it's clear from the report that other people who sat in my seat were not."
When she died at 14, Danieal Kelly looked "like a child victim of a concentration camp," the grand jury said. The report, with a startling photo on Page 23, is at http://go.philly.com/dhsgrandjury
Previous Inquirer coverage of DHS is at http://go.philly.com/dhs