NUMBERS CAN be numbing, but the total of children lost to death in the city shouldn't be: According to most recent city statistics, in 2004, about 400 children under the age of 19 died.

All of these are a tragedy, no matter what the cause - illness, accidents, or the more sinister reasons. But those who die each year while in the social-services system, under the care of the Department of Human Services, are the most devastating, and demand the most careful scrutiny.

From July 2001 through August 2006, 52 children who had been receiving DHS services died; half were due to abuse, or had signs suggesting abuse.

A just-released report provides that scrutiny into the operations of DHS, and the deaths of children - more than 10 a year - who were in the DHS system. The report provides a series of recommendations for fixing the system.

But whether it provides the moment of real change for the agency is still a question.

The Philadelphia Child Welfare Review Panel was appointed by Mayor Street last year to review the work of DHS and to recommend reforms; this followed a series in the Inquirer of child fatalities in families receiving DHS services. Comprising an impressive group of experts in the fields of law, health and social services, the panel delivered in its 200+ page report (available online at a disturbing snapshot of a dysfunctional agency and a road map for change.

It describes an operation whose M.O. is randomness, with inconsistent standards for performance among staff and outside contractors, and a rule-bound bureaucracy, focused on paperwork rather than results.

Too much of this sounds familiar; as the report points out, in the last 20 years, at least 22 reports, studies and litigation focused on DHS operations have been issued.

So the mystery is not so much how to fix the problem - some of the work is already under way - but, rather, this: How is it that a system of people with good intentions, fighting for such a noble and important cause - protecting children - rides off the rails as often and consistently as it does?

Surely, there are many exemplary DHS workers, but it's clear the system itself has been intractably flawed for decades. And this is not just a problem particular to Philadelphia.

It's also not a question of resources, at least not in the same way that money hobbles the school district; DHS has a budget of $600 million.

One suprising detail that emerges from the report, that its authors actually call "shocking": More than half of the parents in the DHS death cases reviewed in the report had themselves been children in the DHS system.

This is a tragic legacy, all the more horrifying considering that if even one of the earlier reports on DHS had led to the necessary reforms, this generation of fatalities might have been prevented.

We urge the current and future mayor, and state leaders, to commit to stopping this legacy of death. We can't afford to let another generation live in harm's way.

If we can't rely on DHS intervention to prevent children dying by abuse or neglect, then we must question not only the value of the organization, but our own intentions as a society. If we allow the circumstances that killed these children, aren't we admitting that some children are just doomed, no matter what? And once we do that, we're all doomed. *