What led to Ciani's death is listed as "undetermined," though the case against her mother is expected to be heard this month.

"This baby did not starve to death," said Davis' attorney, Joseph Mitchell. "Something happened with that baby. The kid was 3 months old and small. Who knows? All kinds of things can happen to a baby like that, which, if not caught at that moment, could result in death. It could have been something that happened in her sleep."

In the end, the system designed to protect babies like Ciani couldn't save her.

The city's social-worker contractor, Northern Home for Children, said it had lost track of Davis, DHS court records show. Citing state confidentiality laws, Northern Home declined to discuss the case.

Records obtained by The Inquirer indicate that the private agency was having problems of its own.

In an annual review, the city noted that Northern Home had high turnover, recently hiring a new director, three supervisors and eight social workers.

"As a result, there was some unevenness of services," the evaluation said.

The review noted that face-to-face contacts, though at 82 percent, "can be further improved with an increase of timely formal alerts for missed contacts. At present, formal alerting is poor, at a level of 50 percent" of the accepted levels.

New director Mark Handelman said Northern Home had performed well and had corrected any shortcomings cited by the city's review.

A day too late

On Oct. 17, 2005, Hargrove said, she called DHS to inform it that Davis had given birth to a girl two weeks earlier.

In a court filing submitted after the death, DHS acknowledged the call, but does not say who made it. The agency said that it had learned about that time that Davis was living with Prather, but that the given address was incorrect.

DHS said it had conducted an electronic search the same day but couldn't find Davis. The agency said it used school records, LexisNexis, and other computerized data.

"One of the assumptions is that we had the ability to compel people to comply through the court, which is true, but it assumes we know where the person is," said Evans, the acting commissioner, who added that DHS had hired a private detective to track down Ciani.

Yet finding Ciani wasn't that hard. A reporter found the address in seconds.

On Oct. 26, 2005, a Northern Home supervisor reached Davis by phone at her basement home. Davis would not reveal her address, according to DHS's court filing, but agreed to meet at the McDonald's at Broad and Girard. The Northern Home supervisor said Davis had not appeared, court records show.

According to DHS policy, workers could have taken action to force Davis to let them check on Ciani. The policy, issued in November 2004, says that when workers are refused access to any child receiving services, they may seek immediate court intervention or police assistance.

The policy states that the worker should consider the latest safety assessment by DHS, which in this case indicated a high risk. Hiring a private detective is also an option.

DHS mentioned no such efforts in court filings submitted after Ciani's death to remove custody of Khiseer from Davis.