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?"