Said Spigner: "What we found was, the system does not know how to turn itself around."

One key issue, the panel found, was that the agency had become the angel of last resort for the city's most desperate residents, forcing social workers to try to solve an array of problems brought on by poverty.

The report said the agency long ago lost sight of its core mission: protecting children.

Again and again, the panel noted how random the decision-making had become within DHS.

To end that, the agency has already developed a new "safety-assessment tool" to guide all social workers in their contacts with clients.

The tool instructs DHS staff to focus on such issues as drug abuse, alcohol abuse and domestic violence - rather than, say, the cleanliness of a home.

Without guidelines, the panel found, social workers responded differently to the same set of problems in a family.

In particular, this "wide, wide variation in response" was noticeable in the case of children who died, said panel member Carol E. Tracy, executive director of the Women's Law Center in Philadelphia.

The panel said the agency had also been hamstrung by its allegiance to state recommendations about how to classify clients.

Following those state rules, the agency has been responding quickly to cases in which children were allegedly being abused or sexually assaulted. But it responded much more slowly to warnings about possible neglect.

"Children die from neglect. They didn't just die from physical abuse and sexual assault," said Spigner. "So it's a false dichotomy."

At the panel's urging, DHS had already begun responding with the same speed to all complaints involving younger children, regardless of their nature.

To underscore the new philosophy, Evans said, he has told his people, with a bit of hyperbole: "If we get a call saying, 'The hair isn't combed right,' we go out and see the kid."

The panel also called on DHS to do a better job of analyzing its performance and become more open with the public.

The department had piles of data in expensive computer systems, but made almost no effort to analyze it, the panel found.

"It's all there, but it never really comes together," said Evans.

He has been more transparent about the agency's inner workings since taking the post in October.

To turn around the agency, Evans will have to rely on the existing cadre of DHS managers, many of whom have been promoted over the years from social worker positions to management jobs without proper training, the panel said.

"Managing requires a different set of skills, and there has not been an investment to help people acquire them," said Spigner. "There are people in key positions who don't know how to manage."