This time, a judge sent him to Chad. He arrived May 2.

DHS had been placing children from neglectful or abusive homes there since 2001.

In 2006, Family Court judges began using the facility as a destination for a different class of children - those, like Leach, who had committed crimes.

Dougherty said his judges assumed that Chad was a good option because DHS had a long history of using it.

He said it was important that DHS and the courts "develop a protocol" to make sure judges know much more about the places where they are sending children.

Mediocre reviews

Even as the city accelerated its use of Chad, DHS continued to find problems.

Over the past four years, Chad's best evaluation found it met just 46 percent of DHS standards. Even so, DHS ranked the place "average" each year - and kept it on the approved list.

In 2005, Chad met only 34 percent of applicable standards. The reports found that Chad appeared clean, but faulted it for poorly documenting its service and for communicating inadequately with residents' families.

Estelle Richman, Pennsylvania public welfare secretary, said that performance was unacceptable.

"I would say 40 percent out of 100 percent is a problem," she said.

The DHS commissioner at the time of the death, Cheryl Ransom Garner, faulted Chad for not reporting critical incidents to DHS. "We were hearing about them from the kids," she said.

She said the agency checked out some of the reports but could not confirm them. On balance, she said, Chad appeared to be serving children well.

Nowhere in the thick stack of DHS reports on Chad is there a mention of the death of 14-year-old Linda Harris on Sept. 18, 2005.

At the time, Chad officials said she collapsed suddenly while being escorted to a "time-out room" after an emotional outburst.

Harris, who took antipsychotic medicines, had a history of going into rages.

The Nashville medical examiner later ruled she had died of natural causes brought on by a heart problem and asthma, aggravated by "morbid obesity." She was was 5 feet, 7 inches tall and weighed more than 300 pounds.

Michael G. Lindley, one of Chad's former owners, said the staff bore no blame for her death. He said Harris collapsed from a heart attack just moments after a counselor grabbed her arm.

While a Tennessee child-welfare investigation cleared the facility and its staff of any wrongdoing, the state nonetheless decided to stop placing its children there.