Hargrove told the Department of Human Services that her adopted daughter abused drugs and neglected her children. Now the 22-year-old was living in a dirty, freezing basement on Marston Street in the Tioga section with the children's father.

In an interview, Hargrove said a DHS social worker had assured her that the agency would check on the newborn, Ciani, and her brother, Khiseer.

Weeks passed. No one came.

In December 2005, two months after DHS first heard of the newborn, paramedics were summoned to the squalid basement. Ciani was dead. The baby's body temperature was 83 degrees and showed signs of "severe starvation and dehydration," police said.

She had barely gained a pound since her birth 10 weeks earlier.

The mother, Cornelia Davis, faces two felony charges, including endangering the welfare of a child. She says that she is innocent, and that DHS failed her.

But the case of Ciani Davis raises questions not just about whether DHS did its job, but whether the agency can implement lasting reform to protect the city's abused and neglected children.

That's the task the city faces now.

In October, after an Inquirer investigation into child deaths, DHS revealed that 25 children had died of abuse or neglect in the previous three years after they or their families had come to the agency's attention. Ciani was one of them.

Mayor Street has since fired his DHS commissioner and a top deputy and created a panel of experts to make recommendations this year on how to improve the agency.

In Ciani's case, DHS workers did not follow their own policies to force the baby's drug-addicted mother to cooperate, according to the agency's court filings and interviews with the family.

The agency said it had been unable to find the family. But its records from 2004 included a working telephone number at the house where the family lived.

Using the same sources available to DHS, a reporter found the address in seconds.

Acting Commissioner Arthur C. Evans Jr. said DHS could not have prevented the death.

"We did all that we should have done," said Evans, who took over the agency after The Inquirer's investigative report. "The issue of child abuse is everyone's. You can't lay all these kids on the steps of DHS."

DHS deja vu

The city has been down this path before.

After a series of blunders was blamed for failing to prevent the torture-murder of toddler Porchia Bennett in 2003, DHS officials overhauled their procedures for finding families trying to evade the child-welfare system.

Under then-Commissioner Alba Martinez, DHS added research databases and hired a detective agency. It surveyed six states, four counties, and New York and Los Angeles in developing a step-by-step procedure for finding children. In heralding the overhaul three years ago, city officials said the new system would work.

"It's much less likely that a case like Porchia's will happen again," said John McGee, then-director of human-services operations.

Ciani's case says otherwise.

"The policy for finding children is just not adequate," said Richard Gelles, dean of the School of Social Policy and Practice at the University of Pennsylvania and a former consultant hired by the agency to rewrite its policy manuals. Gelles was also a paid expert who testified against the city in the Bennett case.

Gelles and others say the reform policy doesn't give specific direction on how to find people.

"The policy says you should never make a mistake, but how do you assure that they don't?" Gelles asked. "What tools do you give them?"

He said he hoped the agency's new search policy was not a harbinger.

"If you leave it as it is, which is with no oversight and no quality control with all decisions left to social workers and supervisors, then it can't be reformed," Gelles said.

Evans said the policy had little bearing on this specific case, but he accepted Gelles' criticism.

"This is the kind of thing we should look at," he said. "It seems we can strengthen this policy by being more precise."

Fears bring help

DHS learned of the Davis family on Aug. 17, 2004, when Hargrove called to say Davis - who was living with her - had waited a week to seek treatment for her 1-year-old son's broken leg, documents show.

Davis said Khiseer had fallen on a Monday while riding a tricycle. "He was playing out back," she said during a recent interview. "You know how boys are rough."

Five days later, during a birthday party, her family grew concerned.

"Every time you put him down on his leg, he would make a face," said Esse Davis, Hargrove's mother. "I told her to take him to the hospital."

A week after he injured his leg, Davis took the child to St. Christopher's Hospital for Children. Hargrove said the doctors had told her that it was unusual for a child so young to break a bone.

Hargrove called DHS and relayed her suspicions, saying Davis would often leave Khiseer alone while she got high, according to an interview with Hargrove and a DHS record of the call.

A few days later, a DHS investigator went to Hargrove's tidy rowhouse in the East Frankford section and questioned the family. It ruled the neglect allegation "unfounded."

Nonetheless, the worker determined that Davis' child was high-risk and on Aug. 24, 2004, scheduled "intensive services," meaning DHS would hire a social worker from a private agency, Northern Home for Children, to visit at least twice a week, records show.

The sessions would be voluntary, giving the family the chance to head off further intervention if it cooperated.

Davis would have to undergo drug treatment, promise not to leave her child unattended, and provide nutritious meals. She would also have to ensure Khiseer continued to live in suitable housing with heat and running water. DHS would periodically assess the risk and safety of the child.

Davis conceded she had done a poor job of complying.

"I never finished 'cause I was looking for a place to stay," she said. "I needed help. I didn't have the time."

'No place to go'

By early 2005, Hargrove had grown weary of her daughter's drug use and of her boyfriend, Larry Prather, Khiseer's father.

"I didn't want them around my house when I wasn't there," Hargrove said.

Davis and Khiseer moved into Acts II, a large Philadelphia shelter.

There, Davis made progress. A welfare-to-work program arranged a job at the city Department of Licenses and Inspection. Occasionally a DHS worker checked in on her, she said.

But in May, Davis got back together with Prather and left the shelter. She stayed at a couple of different addresses during the next two months. And she was pregnant again.

Eventually a city-paid social worker visited her at one of the homes. Davis said she had hid her pregnancy from the worker.

"Nobody wants DHS involved in your life," she said.

Hargrove struggled over what to do, she said. She wanted to support her daughter and worried over the fate of the unborn baby, but she couldn't trust Davis to be alone in her home. To make things worse, Hargrove and her husband said, Prather beat Davis, but she stayed with him anyway.

Prather did not respond to phone calls for this article or to a visit to his home.

"I ran out of options," Davis said. "My family didn't want him around, and I had no place to go," she said.

By August, she had moved with Prather into the basement of a rowhouse owned by his family. The basement had only a small heater and no running water.

Things were turning grim. Neither she nor Prather had a job, and Davis worried about finding enough food for Khiseer and herself.

She was due in October.

A call to 911

The paramedics who responded to the 911 call the night Ciani died tried their best to save her. Even though her body was cold, they intubated her and raced her to Temple University Hospital. The 10-week-old was given an IV and epinephrine to jump-start her heart while workers tried to warm her.

They worked on her for 35 minutes. She was pronounced dead at 9:05 p.m.

To this day, it's unclear what happened.

According to the autopsy report, Ciani died of "acute anoxic encephalopathy," a lack of oxygen to the brain. Inanition, the lack of food or water, was listed as a contributing cause.

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.

Two months after she was born to an uncooperative, drug-addicted mother with a past allegation of medical neglect, Ciani had not been seen by anyone at DHS or its contractor.

If she had, someone might have noticed what was clear from medical reports: She was severely jaundiced and malnourished.

Just a day or two before Ciani died, Hargrove said, she called DHS and urged the case supervisor to go out and check on her adopted daughter.

Hargrove would realize only later that her calls to the DHS worker were not treated the same way as if she had called the child-abuse hot line. Calls received there must be acted on within 48 hours. There is no time limit to respond to calls to a social worker.

Finally on Friday, Dec. 9, 2005, one year after DHS became involved and five months after the agency first noted that Davis was not cooperating, a DHS worker gave Davis an ultimatum during a phone conversation.

He needed to check on the safety of the children no later than Dec. 12, and if Davis did not cooperate, DHS would file a dependency petition to take her children away.

On Sunday night, police were called to the Marston Street address. A paramedic had called the child-abuse hot line because the child was cold and malnourished, records show.

In an interview, Davis said she had been living in the basement since Ciani was 2 weeks old.

Davis had not fed the baby for 16 hours, she told police, even though the baby was supposed to be fed every two to three hours. Ciani weighed 71/2 pounds at the time of death.

A normally developing baby her size would have been about three pounds heavier.

"It's a mystery how she died, a mystery to me," Davis said during an interview in December. She was sitting in the basement of her mother's home, holding an empty photo album, mulling the artifacts of an unlived life.

"These are her little booties," she said, holding up a pair of baby shoes still tethered to a cardboard tag.

She lifted a handprint kit sealed in plastic and examined the box. Inside it read:

"I'll be grown up someday and all those tiny handprints will surely fade away."

Read The Inquirer's report on the city's handling of child-abuse deaths and other recent articles at http://go.philly.com/dhs

at 215-854-2473 or johnsullivan@phillynews.com.