Inquirer Investigation: 'Bury Your Mistakes'

Before they were killed - each by a parent, police say - all three children had come under the scrutiny of the city's child-protection agency, the Department of Human Services, which has the power to remove children from abusive homes. In each case, relatives or neighbors say they saw signs of danger. DHS either never saw those signs or discounted them.

Three years after a string of blunders by DHS were widely blamed for failing to prevent the torture-murder of toddler Porchia Bennett, an Inquirer investigation has found that young children are still regularly abused to death after coming to the attention of DHS. Although 3-year-old Porchia's death prompted the department to solicit expert advice on how to improve its investigative procedures, agency officials have failed to act on most of those recommendations.

From 2003 through 2005, at least 20 children died of abuse or neglect after coming to the attention of DHS, including 10 just last year, according to department records. Those numbers were coaxed out of the agency after four weeks of repeated requests.

In recent interviews, DHS Commissioner Cheryl Ransom-Garner acknowledged that the agency had made mistakes, but she declined to discuss them, citing confidentiality rules.

"I think DHS is doing a great job," she said. "Our staff do a heroic job every day, working to save Philadelphia's children. One child death is too many. And from every death we do a review to determine what can we do differently."

Those reviews, however, are secret.

"In Philadelphia, you can bury your mistakes," said Richard Gelles, dean of the University of Pennsylvania's School of Social Work.

Ransom-Garner declined to discuss details, but said DHS reviews had found that no policies or procedures were violated in six of the eight cases The Inquirer examined. In two of the cases, DHS could not answer the question by the time this article went to print.

There always will be deaths that child-protection authorities could not have foreseen or prevented. And the agency is in much better shape than two decades ago, when a class-action lawsuit forced it to improve.

But experts who consulted for DHS in recent years told The Inquirer that the agency's system for evaluating risk is inadequate. They said the agency still had not addressed key failings uncovered after Porchia Bennett's death.

"Their investigators are not being given a policy for how to make decisions or an understanding of what risks can be tolerated," said Gelles, a former DHS consultant who became so disillusioned that he now serves as an expert witness for lawyers suing the agency.

Mayor Street, walking into City Hall yesterday to attend a chess lecture, declined to answer questions about the performance of his human-services department.

"I don't have any comment," he said. "I don't have any comment on that at this time."

In the three cases with the most extensive public records about the department's actions, an Inquirer review of court documents and interviews with relatives and neighbors found that people had concerns about the children's welfare before they died - red flags that could have been apparent to inquiring caseworkers.

Five other cases, where there is less public information about DHS actions, raise questions about whether the agency could have done more to prevent the deaths. The Inquirer examined only cases in which the agency's involvement could be determined from other sources, because DHS would not disclose which of the dead children it had checked on.

The Inquirer found:

In the Bryanna Redmond punching death, the toddler was killed after the agency closed a case involving her mentally disabled mother, who had talked of abandoning the baby at birth. A grandmother testified in court that she had asked DHS for help, to no avail.

Marrieon Currie's mother, Lea, who had a history of mental and physical problems, told neighbors that she was hearing demons. DHS had been providing her services and left the infant in her custody. But neighbors, who tried to help with the baby, told The Inquirer that she was incapable of caring even for her dog.

When Alayiah Turman was beaten to death last month, DHS had been investigating an abuse allegation. The agency said it had not detected any injury; Alayiah's grandmother said she had seen bruises on the child, and the medical examiner found a healed arm fracture during the autopsy.

A video game unplugged

Police say Alayiah's father, Tyrone Spellman, confessed to killing his daughter after she pulled the plug while he was playing Tom Clancy's Ghost Recon, a violent combat video game.

Ransom-Garner told The Inquirer on Sept. 13 - before the newspaper launched its inquiry into child deaths - that the agency had been investigating the family.

A few weeks before Alayiah was killed, the commissioner said, an anonymous caller reported that an adult was yelling at a 2-year-old, and that there were holes in the floor of the home. The next day, she said, a caseworker interviewed Alayiah's mother, Mia Turman, and inspected the child. There were no bruises, Ransom-Garner said, and the toddler appeared happy and playful. She said there had been no other complaints.

The agency made another surprise visit a few days later. The caseworker asked Turman whether anyone else lived in the house, in order to perform a background check on each adult. The caseworker took Turman's word that no men lived there, Ransom-Garner said.

Neighbors and relatives told The Inquirer, however, that Spellman had been born at the Brewerytown rowhouse where Alayiah was killed. He was living there with his brother and another relative, Keith Walker.

Turman had moved to Spellman's house only recently, said neighbors, many of whom say he is innocent.

Walker told The Inquirer that he had tried to revive the little girl when he arrived home that night. Detectives later told him that there were obvious signs of past abuse, he said. Alayiah's grandmother Marvine Turman told The Inquirer that she remembered seeing bruises.

Asked about that, Ransom-Garner said she could not discuss the case, even though she had talked about it previously.

Asked whether caseworkers were instructed to interview neighbors during their investigations, she said that they were not prohibited from doing so, but that there were no specific guidelines about it.

A shattering death

Alayiah died three years after a killing that was supposed to change the culture at the Department of Human Services.

In August 2003, 3-year-old Porchia Bennett died after enduring months of abuse at the hands of a couple her mother paid to care for her. DHS acknowledged it erred in the case.

First it lost track of the family before Porchia was born, even though the agency had not resolved a previous abuse investigation.

Then, three days before she died, a DHS worker failed to investigate an abuse report at her house.

In the aftermath, DHS did make some changes. It overhauled the way caseworkers search for families, authorizing the use of databases and private investigators.

So why are children in its system still dying?

One answer, experts say, is that while the agency fixed its tracking system, it failed to adopt proposals for significant changes in how it investigates abuse and weighs risk to children.

As a result, the agency still depends on the judgment of individual caseworkers - some of whom are incompetent, according to DHS critic Gelles.

After the Bennett case, then-Commissioner Alba Martinez hired several consultants to examine and overhaul the agency's risk-assessment procedures.

DHS officials said Friday that they might implement some of the recommendations.

"This is a work in progress," Deputy Commissioner John McGee said.

Ransom-Garner said the agency was working to improve its systems on its own timetable, consistent with state regulations. She also argued that the Bennett case did not point to profound problems in how DHS operated.

"What happened to Porchia Bennett, we looked at that case and said, 'Lessons learned, what do we need to do here?' " she said. "The system was not broke."

Losing sleep

Ransom-Garner's predecessor, Martinez, struck a different tone when she hired a Penn team led by Gelles, a nationally recognized child-welfare expert, and Carol Wilson Spigner, a child-welfare official in the Clinton administration.

"This was Alba's project, because she wanted to prevent another Porchia Bennett," Gelles said. "She lost a lot of sleep over it."

Gelles said the DHS policy manual "said you should do this you should do that, but it gave almost no guidance as to how."

That policy manual on investigations is still in place.

Gelles now believes the best way to change the agency is to fight it, he said.

"I said to Cheryl, 'You can do this the easy way or the hard way: You can change, or I'm going to sue you.' They've chosen to do it the hard way," Gelles said.

In May, the Penn team handed over two major recommendations: a new policy on investigating child fatalities, and a new policy on assessing the safety of a child in a home.

The city has not adopted them.

John Goad, former deputy director of the Division of Child Protection at the Illinois Department of Children and Family Services, had a similar experience.

He had helped engineer a turnaround in Chicago's system, where, he said, reports of repeat child abuse fell by half. Martinez hired him to evaluate her agency.

Goad said DHS workers had a difficult time deciding how to handle cases and sometimes made the wrong decisions.

"Their decision-making structure is wanting," he said. "They tended to lose focus on some things that pertain to child safety."

After visiting the city in 2003, Goad wrote 65 pages of guidelines and definitions. His report included 14 scientifically determined factors that contribute to a child being unsafe.

Ransom-Garner said the agency had improved its call-routing system, but had not implemented Goad's other recommendations.

One year after Porchia died, McGee, then the agency's operations director, said: "It's much less likely that a case like Porchia's will happen again."

Not again

People knew Bryanna was in danger from the day she was born.

Nurses at Frankford Hospital-Torresdale Campus became concerned when her mother, Viola Redmond, a 22-year-old with an IQ below 90, told them that she didn't want the child.