Report shows how DHS failed

The remedy: A new dedication to children—and oversight.

Children have died needlessly because of "significant system failures" that plague the city Department of Human Services, a panel of experts said in a wrenching report made public today.

The agency has been adrift for years, confused about its mission and resistant to change. As a result, it "fails to protect some of Philadelphia's most vulnerable children," the panel said in a much-anticipated review of the $600 million-a-year department.

Carol Wilson Spigner, co-chair of the DHS review committee, said major reforms are "urgent and doable."

Appointed by Mayor Street after articles in The Inquirer raised question about DHS, the panel said the agency had to make sweeping changes or children would remain "at risk of continued abuse and neglect."

The panel scrutinized 52 children whose families were known to DHS who died from 2001 through 2006 - and found that 27 died of abuse or in suspicious circumstances. A dozen others died needlessly in unsafe "co-sleeping" episodes, panelists said.

"There were preventable deaths," said panelist Cindy W. Christian, a pediatrician who heads the child-abuse unit at Children's Hospital of Philadelphia.

To overhaul the agency, the panel recommended a series of reforms ranging from a rethinking of its core mission to the development of new investigative tools. Among other steps, it said the agency must:

Visit all children under 5 within two hours of receiving a warning that they might be abused or neglected. Currently, the agency takes up to five days to conduct many such visits.

Require social workers to use a common set of guidelines to evaluate whether children are in danger. Before the scandal broke, DHS had no such common standard, leading it to render important decisions about families randomly and capriciously.

Monitor more closely the outside contractors who handle most of the face-to-face contacts with children, parents and guardians. The agency should issue public report cards grading their performance, the panel said.

The panel said the mayor must appoint a permanent oversight commission to keep watch on DHS.

"This is urgent and doable," said panel co-chair Carol Wilson Spigner of the School of Social Policy and Practice at the University of Pennsylvania. Acting DHS Commissioner Arthur C. Evans Jr., who took over after Street forced out the previous commissioner, said the agency had already implemented some of the changes and would phase in the rest.

"DHS is embracing all of the recommended reforms," Evans said.

Street, through a spokesman, commended the work of the unpaid panel but said a detailed response would come later. "The report is a road map to lasting reform and we welcome it," spokesman Joe Grace said.

Michael Nutter, the Democratic nominee for mayor, said last night that, if elected, he would use the report as "a blueprint for change."

Nutter added: "DHS must be fixed on behalf of the children of Philadelphia."

Al Taubenberger, the Republican candidate, said he found the report powerful and convincing.

"It's unconscionable that children are dying on the watch of the city and this agency," Taubenberger said.

The panel suggested that DHS' problems lie in a lack of leadership, not a lack of money.

As the report noted, "DHS is better financed and resourced than most, if not all, [agencies in] other major cities."

Nor is the problem a lack of outside scrutiny. The agency's pervasive problems have been documented in more than 20 lawsuits and reviews over the last two decades.

"Throughout the reports, there were themes that persist and remain unresolved today," the panel wrote.

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."

Rita Urwitz, head of the DHS supervisors' union, said she did not quarrel with the need for more management training.

"There has been for many, many years a problem with the infrastructure and zero training for staff and no real plan to fix it," Urwitz said.

Estelle B. Richman, who once was the senior child-welfare official in Philadelphia and now heads the state's Department of Public Welfare, said the report was a powerful critique of DHS.

"Unfortunately, the report is also a reminder that we've gone though this before," she said. "The challenge for me and everyone else is to never have to go through another report like this again."



Video of panelists discussing their findings plus an online Q&A with the co-chair are posted at

Contact staff writer John Sullivan at 215-854-2473 or