When a child dies under the care of the city's Department of Human Services, a team of experts within the agency investigates, pinpointing failings in the system and suggesting improvements.

But more than half the time, those suggestions are ignored.

DHS failed to act on many of the staff recommendations its child-fatality-review teams made after examining 52 child deaths over the last six years, according to an internal DHS review released yesterday.

DHS examines all child deaths in which the agency was providing services to the child's family or had done so in the previous 16 months.

But of the 36 recommendations that resulted from the death investigations, the agency had not made any progress on 17, the report said. Many others were only discussed. A handful just recently resulted in policy changes.

And four of six high-priority reforms were never acted upon, the report said.

It concludes that DHS must overhaul the way it investigates child deaths.

"After six years of following the existing method, changes are needed in order to implement a higher level of systemic change," it says.

Acting DHS Commissioner Arthur C. Evans said those changes were now under way.

He recently introduced a child-risk-assessment tool, he said, that helps workers decide when a child is unsafe - as opposed to relying on personal judgments.

"The feeling was that there was a lot of variability," he said, "and one way to make sure we are covering all the bases is to use a formal assessment tool."

Another example, he said, is a recent alert he sent to social workers, telling them to pay close attention to high-risk cases where a child's parents had been abused or neglected themselves or where other children in the family had been abused.

"It's one thing that really popped out at me," Evans said. "These are related to increased risk around fatalities."

An Inquirer investigation last year found as many as 25 children had died in the last three years after they or their families had come to the attention of the agency.

In the aftermath of the investigation, Mayor Street ousted the agency's two highest officials, appointed Evans, and demanded reforms.

Evans asked a committee to review all past fatality-review recommendations and see if the agency ever acted on them. That committee met a dozen times in the last year.

Several of the failings addressed by prior DHS death investigations can be seen in one case The Inquirer highlighted.

Fourteen-year-old Danieal Kelly was found dead from heat exhaustion during an August heat wave. She was bedridden with cerebral palsy. She weighed just 46 pounds and had bedsores festering with maggots.

A city-paid social worker was supposed to have been checking on her each week.