The tragic death of 6-year-old Khalil Wimes can inform efforts to improve Philadelphia's child-welfare system. The case showed that judges end up making life-and-death decisions about child placement without sufficient information; that parents with long histories with the city's Department of Human Services can regain custody of children as easily as one-time offenders; and, most obviously, that neighbors and others who should serve as the first line of protection often fail to report suspected abuse.

In Khalil's case, there were four critical junctures where the outcome might have been changed.

First, the courts should have gotten more information than they apparently did. Khalil had been placed in the care of a distant relative a week after he was born to a mother who had tested positive for drug use while she was pregnant with him. Although Khalil was thriving in that relative's care, when his birth mother petitioned for custody, a judge returned the then-1-year-old to his parents. Five days later, the child was hospitalized for severe neglect and asthma.

Custody courts make important choices about children and their care. Yet in Philadelphia, they make too many of those decisions with little or no objective information, not even obtaining families' DHS records.

The gold standard in these cases is a custody evaluation conducted by a clinician, including multiple interviews, a review of records, and psychological testing. But professional evaluations are costly, cases are already subject to long delays, and more than half the custody litigants in Philadelphia can't afford a lawyer.

Other jurisdictions require a comprehensive evaluation in every case and offer a sliding fee scale to accommodate poor families. Philadelphia needs mechanisms to ensure that judges get a thorough assessment of each child's needs and the prospective caregivers' capacity to meet them.

Low threshold

Second, the system should have asked more of parents who had failed seven other children before they could gain custody of another. When Khalil was placed in foster care as a 1-year-old, his parents' plan for reunification with him was minimal, requiring only that they get clean drug screens, counseling, housing, and employment — a low threshold more appropriate for a merely overwhelmed new parent. When parents appear to be in compliance with such minimal goals, a court has limited grounds to terminate their parental rights.

One or both of Khalil's parents — now facing murder charges in the child's death — suffered chronic addiction and perhaps serious mental illness, judging by the extent to which Khalil was tortured. Moreover, the court and DHS officials knew or should have known them well.

Given all that, it was too easy for Khalil's parents to regain custody. Parents with this kind of history should face greater hurdles, including thorough proof of sobriety, performance requirements, in-depth psychological evaluation, and intensive parenting education.

Moreover, adoption should happen faster in cases such as Khalil's, especially given that his parents had failed to care for so many other children. Children deserve diligent lawyering, thorough judges, expeditious litigation, and better communication between DHS and the courts.

Watchful eyes

Third, Khalil died as much from his isolation as from his injuries and neglect. Family members have reported that they witnessed his abuse but failed to act. Although families are entitled to their privacy once a court case is closed, children need continuing community connections and watchful eyes to keep them safe.

A respectful approach would be to insist that parents maintain supportive relationships in churches, schools, and neighborhoods that will be in place once the professionals are gone. Additionally, plans should include monitoring of a child's health care and well-being. Establishing a child's primary-care medical "home," where records are kept and treatment is coordinated, can provide additional surveillance of health and well-being. Health-care providers are required to alert authorities to signs of mistreatment.

Finally, child-welfare workers must be adequately trained to recognize signs of abuse and respond to them. In the months before Khalil died, the DHS worker assigned to supervise his visits with siblings noticed bruising, low weight, and other symptoms of child abuse, but was reportedly satisfied by his mother's explanations.

Recognizing the signs of abuse takes intensive training and consultation with supervisors. Communication between health-care and social workers about signs of injury or malnutrition can help. Most important, even though workers may be assigned to another primary task, such as supervising visits or helping siblings connect, a child's safety and well-being must be on the mind of every responsible adult, and it must remain a collective priority for everyone.

Frank P. Cervone is executive director of the Support Center for Child Advocates. Dr. Philip V. Scribano is medical director of Safe Place: The Center for Child Protection and Health at the Children's Hospital of Philadelphia. They can be reached at fcervone@advokid.org and scribanop@email.chop.edu.