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.