The Washington Post, by Sari Horwitz, Scott Higham and Sarah Cohen

Day 1: Decade of Deadly Mistakes

Critical Errors by City's Network Found in 40 Fatalities; Confidential Files Show Wide Pattern of Official Neglect

By Sari Horwitz, Scott Higham and Sarah Cohen

Washington Post Staff Writers

The decision sealed the fate of 2-month-old Wesley Lucas.

D.C. social workers were assigned to protect Wesley from his neglectful, cocaine-addicted mother. So they allowed the baby to stay with his mother's boyfriend. The 69-year-old man was dying from lung cancer, but the workers promised to provide a caretaker to help.

They decided not to send anyone over the long Presidents' Day weekend in 1998.

That Saturday, Wesley began to cry, a plaintive wail that echoed for hours down the narrow four-story stairwell of a pale yellow Northeast Washington apartment building. Finally, there was nothing but silence. When a maintenance worker opened Apartment 5's brown steel door on Tuesday, the man was found faceup in his bed, dead from his disease.

On his chest lay Wesley. The baby boy had died of severe dehydration. His death was officially ruled an accident, and his tiny body was cremated.

Social workers, who have an obligation under D.C. law and a federal court order to protect children like Wesley, later said they believed there was little risk in leaving the baby alone with Lucas over the three-day weekend.

"Who would have thought that the harm would come in the form of no food, water or other sustenance?" government officials wrote.

Wesley Lucas is among the 229 boys and girls who perished from 1993 through 2000 after their families had come to the attention of the District's child protection system, a network of social workers, police officers, judges and other city employees. The children include Rhonda Morris, Cecelia Rushing, Robert Williams, King Richardson, Diante Aikens and Brianna Blackmond, whose death last year outraged the city.

In a yearlong investigation, The Washington Post obtained records documenting the deaths of 180 of the 229 children. The circumstances of the deaths - and the District's culpability in many of them - have been hidden from the public for years. Some children died in accidents or shootings on the streets. Others succumbed to disease.

But one in five - 40 boys and girls, most of them infants and toddlers - lost their lives after government workers failed to take key preventive action or placed children in unsafe homes or institutions, The Post found. Although 15 of the 40 deaths were ruled to be due to natural causes, government officials reviewing those cases found numerous critical errors. Seventeen of the deaths were homicides, most of them in homes.

Thousands of once-secret documents provide an unprecedented look inside the city's child protection agency - the only one in the nation to operate under federal court control as part of a large-scale reform effort that began in 1991. The records illustrate how the decade-long effort failed some of the District's youngest wards. Interviews and additional investigation uncovered the reasons the children lost their lives, the government agencies involved, and the identities of the workers who committed critical mistakes and errors of judgment.

NickiColma Spriggs, 15, her spine curved sideways at a painful right angle, sat in a wheelchair waiting for an operation that never came and died in a nursing home hallway. Eddie Ward, 13, was put on a bus, alone, and ended up dead in a dilapidated house, his body pockmarked with insect bites. Sylvester Brown, 8, was left with a mentally ill mother who stabbed him so many times that the medical examiner couldn't count the wounds.

The Post could not determine the government's role in 49 of the 229 children's deaths, because key documents or files were never created or could not be located, or were part of pending homicide cases. What can be determined is that top government officials knew that D.C. children were dying for avoidable reasons and did little about it.

Police officers did not fully investigate abuse reports, leaving children with violent or drug-addicted parents or relatives. Social workers did not adequately monitor neglected children. Frail newborns were permitted to go home to drug-addicted and mentally ill parents without follow-up services. Judges sent children to unlicensed foster homes, or to institutions far from the District where their care went unsupervised.

For years, these persistent breakdowns have been cloaked in secrecy. Confidentiality laws drafted to protect children and their families have had the effect of shielding government officials from scrutiny and allowing them to escape accountability. The secrecy has prevented some of the worst details about the child deaths from becoming public.

Those details have surfaced only at closed-door internal government meetings, where witnesses are summoned to discuss how and why children die. The D.C. Child Fatality Review Committee - whose three dozen members include child protection agency supervisors, police officers, doctors, government lawyers and others - was created a decade ago to review children's deaths and recommend ways to prevent future deaths.

After protracted negotiations with city lawyers, The Post obtained the previously undisclosed records of the child death reviews: death certificates, police reports, autopsies, caseworker notes, hospital records and internal death summaries. The documents provide a rare look at a process that takes place in nearly every state but remains largely out of public view.

The records cover cases from 1993, when the fatality committee began to review child deaths, through 2000, the most recent period for which complete documents were available. An analysis of those records, along with hundreds of interviews with government officials and family members, found that:

Four severely disabled children died after they were placed in unsafe or inappropriate facilities.

Nine children died after social workers and police officers conducted flawed investigations into abuse or neglect complaints or failed to remove the children from unsafe homes.

Eleven medically fragile infants died after they were sent home to drug-addicted or mentally ill parents whose troubles were known to social workers or hospitals.

In eight years of confidential reports, fatality committee members issued more than 300 warnings about these and other problems in reviews of the 180 deaths, the analysis showed. They proposed specific solutions to the mayor, the D.C. Council, the police chief, the director of the Child and Family Services Agency and the chief judge of D.C. Superior Court. But over the years, even as some officials left and new ones took over, the great majority of the proposed solutions went unheeded.

"No one paid any attention to us," said Elizabeth Siegel, a lawyer and fatality committee member.

Mayor Anthony A. Williams (D), who was elected in 1998, is working to revamp the entire system. Last year, the mayor mounted a lobbying campaign to recover control of Child and Family Services from the federal court. That happened in June. Williams named a high-profile former Clinton administration official to head the agency and increased its budget and staff.

"If we're going to hold people accountable, we ought to at least hold them accountable for how we're treating kids," said Williams, himself a foster child.

Federal Takeover

When a child dies in the District, two reviews take place. First, the Child and Family Services Agency conducts an internal review focusing on its handling of the case. Second, the Child Fatality Review Committee examines the roles of all city institutions. In the 180 child death files The Post obtained, the agency issued 358 warnings, criticisms and recommendations; the committee issued 312 of its own.

The Post constructed a computer database that documented patterns in these 670 findings. The analysis found mistakes at each stage of the child protection process:

Doctors, educators, counselors and others who are required to report abuse and neglect frequently failed to call the emergency hot line set up by the District to summon police or social workers. David Wynn, a 2-month-old premature baby who had suffered from dehydration and pneumonia, died in a home where the mattresses were black with filth and hamburger meat rotted in the kitchen. A pediatrician had noted concerns in the boy's chart that he was being neglected, but he never called the hot line.

When people did call, social workers and police repeatedly did not conduct thorough investigations. Devonta Young, 23 months old, died after being beaten by his mother. Nine months earlier, a doctor had reported to the agency that Devonta had second-degree burns on his feet. A social worker closed the complaint as unsupported without interviewing relatives or neighbors, who were aware of the abuse.

Once the District opened a case to monitor a child, there were significant gaps. Social workers repeatedly failed to make required home visits every two weeks. Robert Charles Williams Jr., 11, died after his father punched him twice in the chest, angry that his developmentally delayed son could not read a clock. Social workers monitoring Robert in his grandmother's home were unaware that his father was staying in the house. A background check would have shown that the boy's father had 10 criminal convictions.

When police or social workers removed children from their homes, safe places were hard to find, and services often were not provided. Social workers placed Eddie Ward, 13, in a group home that had a contract with the city. He ran away, was picked up by police and was returned to the home. Workers there said they had no vacancies and told Eddie to take a bus back to the agency. They never ensured that he arrived safely. Three days later, Eddie was found dead inside a closet in a dilapidated Southeast house.

Washington was supposed to be a national model for child protection agencies. Ten years ago, U.S. District Judge Thomas F. Hogan delivered a landmark decision in LaShawn A. v. Barry, a case brought in the name of a D.C. foster girl, that held the city liable for failing to protect its children's constitutional rights.

"The District's dereliction of its responsibilities to the children in its custody is a travesty," the judge said when he ruled.

Hogan set new standards for safeguarding the "LaShawn children." He also ordered the city to examine every child death under its supervision. That mission fell to the fatality committee.

"Many deaths related to child abuse and neglect are preventable," the committee members wrote in their first public report in April 1994. But their detailed discoveries about government mistakes in those deaths would be kept confidential for years.

In February 1995, a horrific murder became front-page news. Rhonda Morris, 3, was beaten, strangled and burned with cigarettes by a cousin, Aaron L. Morris, 19, who was later convicted of involuntary manslaughter. Morris had earlier admitted to biting Rhonda's older sister and breaking her arm, fatality committee records show. But the D.C. corporation counsel's office, the city's lawyers, declined to pursue an abuse complaint against Morris.

After Rhonda died, Judith Meltzer, the court-appointed monitor hired by Judge Hogan, concluded that the corporation counsel and six other D.C. government agencies made mistakes contributing to Rhonda's "avoidable death."

Seeing little improvement, the American Civil Liberties Union lawyers who brought the LaShawn suit demanded a federal takeover. On May 22, 1995, Hogan complied, issuing another landmark decision applauded by child advocates. It was the first time in the nation that a federal judge had taken complete control of a local child protection agency.

'Thank God It Wasn't My Case'

Hogan began by trying to rebuild the agency's management structure. He turned Child and Family Services into a stand-alone department answerable to him. He appointed a receiver, Jerome G. Miller, to run the new agency.

Miller lasted less than two years. The second receiver, Ernestine F. Jones, resigned last year. Her tumultuous tenure culminated in her arrest in August 2000 by deputy U.S. marshals for disobeying a local judge's order to explain why a neglected toddler was not receiving services from her agency.

The upheavals at the top of the agency were matched by low morale and turmoil at the bottom. Social workers were besieged, supervising far more children than they could reasonably handle.

Judge Hogan tried to reduce caseloads, setting a maximum of 17 children for each worker. But Hogan's order was never followed, and as recently as last year, some social workers were in charge of as many as 60 children. Hogan said judicial ethics did not permit him to discuss the violations of his court orders or any other aspect of his takeover of the child protection system.

With so many children, social workers often cannot make the required biweekly visits, meet deadlines for status reports to judges or carefully investigate complaints. Several said they come to work every morning fearing news that one of their children had died the night before.

"I remember wiping my brow and saying, 'Thank God it wasn't my case,' " said Darryl Webster, a former D.C. social worker. "Everyone says that."

The fatality committee cited large caseloads as a problem in 15 child deaths.

One of those who died was King Richardson, who was born prematurely to a crack-addicted mother and released to a filthy house with no electricity. Three weeks after King was sent home, a social worker decided to stop monitoring him. The next week, the baby died of meningitis. The social worker was in charge of at least 37 children - more than double Judge Hogan's limit.

The workload is exacerbated by an exodus of veteran social workers, who are extremely difficult to replace. When the jobs are filled, they usually go to recruits fresh out of college. In 1999, 90 social workers left - nearly one-third of the staff. "Children couldn't receive proper services," said Joan Mallory, a social worker who left after nine years. "Social workers were overwhelmed."

That year, a group of social workers sent a warning memo to Mayor Williams and several D.C. Council members. "The agency is in more disarray, services are more disjointed and chaotic" than a decade before, the workers wrote. "Employee morale is at an all-time low. . . . Staffing levels have been reduced to a point of crisis."

In 2000, 128 more social workers resigned.

The shortage affects the agency's ability to investigate neglect complaints. The U.S. General Accounting Office concluded last year that Child and Family Services failed to investigate more than 1,200 reports of neglected children within a mandated two-day deadline.

While social workers struggled with neglect complaints - dirty homes, no food, children left alone - police had the same difficulties with child abuse complaints, which cover physical violence.

In 1993, neighbors of 29-month-old Cecelia Rushing called the police to report screams coming from her aunt's Northeast apartment. But officers "failed to adequately pursue the matter," court records state. Two months later, Cecelia was beaten to death by her aunt.

Little had changed five years later.

In 1998, police were called to investigate a complaint that 35-month-old Diante Aikens was being abused. An emergency room doctor said he found markings on Diante's arms indicating he had been hit with a cord or "a linear object."

Officers did little besides warn Diante's mother to stop hitting him with a belt, a police report shows. They closed the case, saying there wasn't enough evidence to charge Diante's mother with abuse.

Nine months later, Diante was beaten to death.

A Highly Publicized Tragedy

If the social workers and police are the front-line troops of the system, the 59 judges of D.C. Superior Court are the officers, presiding over more than 5,100 neglect and abuse cases. The local judges were not answerable to Hogan, a federal judge whose authority was limited to the management of Child and Family Services.

The Post interviewed more than a dozen judges. They were unwilling to speak on the record, but they expressed strong misgivings about what they called a "dysfunctional" agency.

In separate interviews with GAO investigators last year, Superior Court Judges Zinora Mitchell-Rankin and Kaye K. Christian called the agency's performance "as poor now as it was a decade ago," blaming "lack of staff knowledge," limited resources and high turnover of social workers.

Several of the local judges were so frustrated with the agency that they wanted to go to the man in charge: Hogan. But one judge told The Post that Hogan refused to meet with them. Social workers have their own complaints about the judges, saying court hearings take up hours that could be spent in the field. With their cases spread among so many judges, social workers bounce from courtroom to courtroom.

"Being stuck in court all day is a waste of time," said Charly Mathew, a former D.C. social worker who resigned last year. "We would just sit outside in the hall for hours."

In December 1999, the system's many flaws combined to produce a highly publicized tragedy in the case of Brianna Blackmond, a 23-month-old foster child.

A social worker who thought Brianna should not go home missed a court deadline to tell the judge. The court-appointed attorney assigned to protect Brianna did not visit her for a year and failed to ensure that her mother's home was safe. The judge, who knew the mother had psychological problems, did not hold a hearing and sent Brianna home based on the word of her mother's attorney. The city lawyers supervising the case did not appeal the judge's decision, even though the District's child protection agency opposed the move.

Two weeks later, on Jan. 6, 2000, Brianna died from severe blows to the head. The mother's roommate is charged with murder, and Brianna's mother is charged as an accessory. Both have pleaded not guilty.

Brianna's death should not have come as a surprise to the fatality committee. The mistakes in her case were similar to the mistakes the committee had documented in scores of earlier deaths.

'Very Frustrating'

The fatality committee began reviewing the deaths of children in 1993 and issued its first round of confidential warnings to city officials the next year.

By 1996, committee members said that city officials were not paying attention to their warnings and that the committee had "fallen short" of its goal of preventing the deaths. "We have been unable to move the issues confronting families, children and systems to the forefront," they wrote.

The committee is made up of representatives from government agencies and a few volunteers from the community who are appointed by the mayor and serve three-year terms. For most of its existence, the committee operated with no staff and no budget. Earlier this year, it received its first appropriation: $296,000. Its members have long complained that their work and warnings were not taken seriously by city officials.

"It's very frustrating," said committee member Siegel. "You see these deaths come in and see that if we implemented the recommendations, maybe this death could have been prevented. It's like hitting your head against the wall."

But critics of the panel say the committee has created some problems for itself.

The committee began by announcing a clear mission: "ensuring that all public and private systems responsible for protecting the District of Columbia's children are accountable." But some former government officials say the committee does not follow up on its recommendations and places little pressure on government agencies in its annual reports to the public.

The reports include descriptions of anonymous child deaths two years after the fact, with the government's role largely omitted. And some of the most egregious cases of government failures uncovered by The Post were never described in the public reports.

Those omissions, along with the committee's unwillingness to publicly blame agencies, result in bland reports that attract little attention, said Barry Holman, a former Child and Family Services supervisor who attended fatality committee meetings.

"They weren't helpful at all," Holman said. "They didn't really tell us much about what had gone on in the kids' lives, what our agency had done or what the other agencies had done."

Committee members said they do not want to be openly critical because that might discourage city officials from participating in the voluntary child death review process.

The members also point out that they do note government mistakes by issuing recommendations at the end of their public reports. But the recommendations are general and laden with jargon. For example, the committee stated in its 1998 report that police "should reexamine their policies and practice related to unsupporting abuse cases."

Critics say that such prescriptions accomplish little because they are not tied to specific deaths.

"They're meant to mislead, because they're meant to protect the agency and those associated with it, who might be tarred by this information," said Miller, the former chief of Child and Family Services. "At all costs, they want to avoid conflict, and the reports are generated with that in mind."

The committee's most recent report, issued in May, contains more specific findings about government mistakes and culpability. This version was prepared at the insistence of D.C. Council member Kathy Patterson (D-Ward 3), who has been pushing for more public disclosure of child death information. The report also was prepared as The Post was gaining access to the committee's confidential files.

Sharan James, a government employee who coordinates the fatality committee, said things are beginning to improve under Mayor Williams.

"We are seeing a significant difference," James said Friday. "People are taking the committee seriously and moving in the right direction."

Silence in the Stairwell

Wesley Lucas needed help from the time he was born in December 1997. Interviews with neighbors and records from Child and Family Services and the fatality committee document his final days:

His mother, her mind clouded by cocaine, had been accused of neglecting three of her seven children. The District didn't want to take a chance with Wesley.

At 69, Charles Lucas was dying of lung cancer. He was the boyfriend of Wesley's mother, who had taken his last name. He was protective of the infant and didn't want him to be taken away like some of the others.

Lucas struck a deal with the District. He would keep the baby temporarily. To help watch Wesley, the child protection agency relied partly on the Edgewood-Brookland Family Support Collaborative, a neighborhood group that is paid by the city to provide social services to families. The agency also paid a caretaker to help Lucas and Wesley until a relative could be found to take the baby.

Wesley's mother was in and out of the apartment, spending most of her days and nights on the streets. Social workers sent the caretaker three days a week, leaving the weekends uncovered.

Lucas did his best, but he was dying.

"He was a small, fragile man who looked ailing," recalled Ethel Parker, a social worker from the Israel Baptist Church across the street. Mary Dews, a neighbor who lived across the hall from Lucas, said he was a "very wonderful man, very loving and caring." But he was also "very, very sick. It seemed like he was going to the hospital just about every other day."

In February 1998, social workers considered extending the caretaker's hours to include the long Presidents' Day weekend, but ultimately did not. Several social workers and their supervisors involved in the case did not return repeated calls from The Post.

Louvenia Williams, the collaborative's executive director, checked on the baby on the Wednesday before the weekend. She would later describe him as "happy, healthy and fat."

"We knew Mr. Lucas was going to die," Williams recently told The Post. "You can never predict when someone will pass. We assumed he had a little more time to go because he was doing so well."

On Saturday, Wesley began to cry. By Monday, there was silence in the stairwell outside the apartment on Saratoga Avenue NE.

On Tuesday morning, Wesley's mother came to see Lucas and her baby. She banged on the metal apartment door. There was no answer. She summoned a social worker and a maintenance man. They walked past the green chain-link fence, through the unlocked front door and up the 35 steps to the apartment.

At 7:45 a.m., they opened the door. Inside were the two bodies, the elderly man and the baby. Police said Lucas died first. With no one to care for him, Wesley became severely dehydrated, and his heart eventually stopped. He had been dead for three days. He was 10 weeks old.

Staff researcher Bobbye Pratt contributed to this report.

© 2001, The Washington Post Company

Day 1: Decade of Deadly Mistakes

New Child Services Chief Tackles Job With No Guarantees of Success

By Scott Higham

Washington Post Staff Writer

Olivia A. Golden continues to confront the question: Why did she agree to become the director of the D.C. Child and Family Services Agency, long considered to be one of the most dysfunctional child protection departments in the nation?

"It feels like a chance to make a difference," said Golden, 46, a no-nonsense administrator fresh from the Clinton administration, who started her new job June 16.

Child and Family Services is emerging from a court-ordered takeover that has been criticized as ineffectual. Golden is the first District official with unfettered power over the agency since 1995, when a federal judge and a succession of receivers assumed control of day-to-day operations.

Golden, a former assistant secretary for the Department of Health and Human Services, said the D.C. agency is ready to change the way it protects and helps the nearly 3,000 children under its care. She said there are no guarantees that she will succeed in the $132,000-a-year post in which so many have failed. But she called her hiring and the backing she has received from Mayor Anthony A. Williams (D) "a moment of opportunity."

In many ways, the January 2000 death of Brianna Blackmond, a 23-month-old foster child, was a catalyst for that opportunity. Brianna was slain after several D.C. agencies assigned to protect her failed to do their jobs, adding fuel to Williams's call for an end to the federal control of Child and Family Services. The circumstances surrounding her death, documented by The Washington Post in a series of articles last year, prompted numerous changes to the system.

Federal oversight is expected to end later this year if the city passes a probationary period imposed by U.S. District Judge Thomas F. Hogan. The agency's budget has been boosted to $184 million from $124 million two years ago. Golden will hold a position in the mayor's Cabinet with direct access to Williams.

Change is promised. The city is hiring more lawyers to assist social workers. It is ending a decades-long practice of dividing investigations between social workers who handle neglect complaints and police officers who take calls about abuse. Lawmakers have introduced a bill in Congress that would force D.C. Superior Court judges to create a separate family court to supervise abuse and neglect cases. And the city is establishing regulations for foster and group homes.

The mayor said that the city has turned a corner with the reforms he is now making and the hiring of Golden.

"I think it's just amazing that she is willing to come into a very, very difficult, complicated and unforgiving environment here in the District," Williams said. "It speaks volumes for her commitment. She's got the kind of policy, but also practical, experience that's going to make a difference for these kids."

Golden understands the obstacles. She said she wants to restore the "frayed trust" between top agency officials and social workers, while strengthening ties to neighborhoods and tracking children so that none are lost in what has been a haphazard, dangerous system.

"There are worse things than trying your best and not getting all the way," she said. "I fully intend to go all the way."

Golden is mapping a strategy to rebuild Child and Family Services. She said it's too early to tell what the agency might look like in a year or two.

Her former boss from the Clinton administration thinks she can make a difference.

"Almost anyone you meet in the business will tell you this job is not doable," said Donna E. Shalala, former secretary of Health and Human Services. "But if anyone can do it, Olivia can. She is a first-rate manager with a caring heart."

© 2001, The Washington Post Company

Day 1: Decade of Deadly Mistakes

By Sari Horwitz

Washington Post Staff Writer

Just before he resigned from the D.C. Child and Family Services Agency in July 2000, social worker Charly Mathew attended a hearing before D.C. Superior Court Judge Zinora Mitchell-Rankin, the former head of the court's family division.

The judge stepped down from the bench, hugged Mathew and said she wished he would stay. A lawyer in the courtroom had a suggestion.

"Issue a court order," the lawyer said. "Prevent him from leaving."

But it was too late. Mathew and scores like him have left, complaining that they cannot properly care for all the children under their watch. Many took jobs at other social service agencies in the District and surrounding jurisdictions. Mathew is now a social worker in Maryland.

At 34, Mathew was considered a star at Child and Family Services. With a reputation as an industrious, highly organized worker who was passionate about helping children, he was a favorite among judges, child welfare lawyers and colleagues. When the agency had a tough case requiring close attention, agency supervisors and judges often turned to Mathew.

"Charly Mathew is such a gem," said Anne Schneiders, a child welfare lawyer who worked with him. "Everyone inside and outside the agency adored him."

During his four-year tenure, Mathew had rewarding moments -- helping parents get drug treatment, reuniting children with their families, "seeing the joy in the eyes of a child" after an adoption.

But Mathew, who at one point supervised 70 children, said he and his co-workers found themselves juggling crises, leaving little time for the children. Small things became big problems. Workers wasted time recovering files from the bureaucracy. Sometimes they couldn't get agency cars to visit families, he said. It was virtually impossible for social workers to make the required visits, Mathew said.

"Visits to children were put on the back burner," he said.

When a child died under the District's care, workers "reacted like a family losing a loved one," Mathew said. Workers dreaded learning the name, fearing it might be one of theirs.

To keep up, Mathew worked long hours, sometimes arriving home past midnight.

"I would wake up thinking, 'Have I seen all the children enough?' " he said. " 'Have I made the necessary appointments? Are there court orders I haven't complied with?' "

By early morning, he would have to be in court.

Last year, Mathew discovered something disturbing. While serving on an agency committee set up to examine foster-care contractors who were paid $100 a day per child, Mathew and his colleagues said they found that the private therapeutic foster homes were failing to properly care for children with emotional and behavioral problems. Mathew also said he discovered that the contractors were hiring unlicensed workers.

Mathew said he alerted top agency officials but received little response.

He left when the agency decided to expand the role of the contractors.

"I didn't want to be part of that," he said. "I wanted to have a clear conscience that I was doing everything in my power to see that the children were being protected."

Mathew said he still worries about the District's children and stays in touch with his former co-workers. He said they are hopeful about their new director, Olivia A. Golden, and want to form a task force to advise her.

"They know how to make the agency better for children," Mathew said. "I hope she listens to them."

© 2001, The Washington Post Company

Day 2: Disabled and Forgotten

Child Protection Agency Failed To Watch Her in Delaware Facility

By Scott Higham and Sari Horwitz

Washington Post Staff Writers

--Second of four articles

The nursing home closed its pediatric wing in July. The facility cited several reasons, including "the negative political and operating environment created by certain parties who oppose children being taken care of in nursing homes," according to a letter Harbor Healthcare mailed to caretakers of its patients.

Bent over in her wheelchair, her spine twisted by scoliosis, Nicki Colma Spriggs died at age 15 in the hallway of a Delaware nursing home on Thanksgiving Day 1998. Her body looked like an upside-down L.

A child of the District, Nicki had been sent to Delaware in 1992. During the next six years, child protection workers who were her guardians under D.C. law and a federal court order failed to monitor the curvature of her spine and promptly arrange corrective surgery. Her back pitched sideways, slowly and painfully, until it was set at a right angle, with her head tipped at the side of her body.

"We really didn't pay attention to the children who were sent to live outside the District, and that's sad for me to say, because I was involved," said Pablo Ruiz-Salomon, a former social worker at the D.C. Child and Family Services Agency who supervised Nicki's foster-care case during the last year of her life. "By the time we started to look at that facility and others, and scrutinize what was going on with Nicki, it was too late."

What happened to Nicki Spriggs, one of 229 D.C. children who died from 1993 through 2000 after they or their families came to the attention of the child protection system, exposes the many ways in which the system can fail to protect abused and neglected children. Nicki is among 40 children who lost their lives after government workers failed to take key preventive actions or placed the children in unsafe homes or institutions, a Washington Post investigation found.

Even though Nicki had a court-appointed attorney, three D.C. Superior Court judges, four agency supervisors and eight different District social workers assigned to her case, she was visited just twice during the six years she spent in Delaware. A surgeon there examined Nicki in 1992 and scheduled a follow-up appointment for six months later. But he did not see her then, and he did not see her again for six more years.

Finding safe places for severely disabled foster children like Nicki has been a decades-long problem in the District. Child protection officials are forced to look beyond the city to such states as Florida, Pennsylvania and Delaware, where institutions and nursing homes have built wings and added floors to capture the lucrative market in hard-to-place foster-care children.

"The kids were basically dumped," said Jerome G. Miller, who was chief of Child and Family Services from 1995 to 1997. "They were stashed and forgotten."

'Always Worrisome'

When Nicki came under the protection of the District in 1990 -- after her mother had neglected her -- a nursing home near the Delaware Bay with a new 36-room pediatric wing seemed the perfect place for the disabled girl from Northeast Washington.

Then-D.C. Superior Court Judge Gladys Kessler signed the transfer papers in 1991. Nicki would live at the Harbor Healthcare and Rehabilitation Center in Lewes, Del., a three-year-old private, for-profit facility with 180 beds. Such care usually costs at least $65,000 a year in Medicaid funds. D.C. agency social workers would be responsible for reporting to the judge on Nicki's condition and progress.

"It was always worrisome, sending these children out of the District," Kessler, now a U.S. District judge, said in a recent interview. "You have to rely on the agency to keep track of them, and they just wouldn't do it."

On Jan. 30, 1992, Nicki made the 101-mile trip to Lewes. She was 8 years old with the mind of an infant, unable to walk or talk or eat on her own. She had cerebral palsy, spastic quadriplegia, scoliosis and severe mental retardation.

She also had a savior: her grandmother, Willie Mackall, 53, who tried to make up for the absence of her daughter. Twice a month, Mackall made the two-hour journey to Lewes, her bus fare paid by Harbor Healthcare. She would take Nicki outside in her wheelchair, pushing her down hills and finding places where the two could watch flags snap against metal poles in the bay breeze.

Shortly after her arrival, Nicki was examined by Kirk W. Dabney, an orthopedic surgeon at the Alfred I. duPont Hospital for Children in Wilmington. Dabney wrote in a medical report that the curvature of Nicki's spine measured 33 degrees, a moderate arch. He scheduled follow-up exams to take more X-rays, monitor her spine and examine her wheelchair.

"She will continue to have reevaluation on a six-month basis with X-rays of her spine and pelvis," Dabney wrote in a Sept. 14, 1992, report.

But that did not happen.

A Succession of Social Workers

Soon after Nicki went to Lewes, her social worker left the case, notifying the next worker: "The case is stable and intensive services [are] no longer required."

Within two years, Judge Kessler was named to the federal bench and left Nicki's case. By the end of 1994, Nicki's next social worker had come and gone without visiting Nicki andhad failed to file a report updating Kessler's replacement, then-Superior Court Judge Colleen Kollar-Kotelly, court records show.

In 1995, Child and Family Services assigned a new social worker to the case, Laura Hoffman. That year, Hoffman traveled to Delaware to visit Nicki. It would be three more years before another D.C. social worker would visit her.

Hoffman, a year out of college, wrote to the judge that the facility was "clean and well managed." Her report did not mention the condition of Nicki's spine. Several months later, Nicki's case was transferred to yet another social worker.

By the mid-1990s, D.C. Child and Family Services had become known as one of the most chaotic child protection agencies in the nation. A federal judge assumed direct supervision of it in 1995. He named his own director, Miller, who discovered that nearly 120 severely disabled District children were living in institutions outside the city. He also learned that his social workers were not visiting the children.

"We had social workers recommending that they stay in these places without ever meeting the kids," Miller said in a recent interview.

'Very Damaging Evidence'

Willie Mackall said her granddaughter's care started to slip at Harbor Healthcare as the number of workers in the pediatric wing appeared to dwindle. Mackall said that Nicki had bedsores and that her hair was matted and falling out from the back of her head. Mackall put up a sign in the room: "Please Feel Free to Comb Nicki's Hair."

Mackall said the medical staff didn't realize that Nicki's hip was dislocated until she told them that one of her granddaughter's bones was pressing against her skin. Surgeons would later operate on her hip.

"They would leave her in bed all day and all night," Mackall said. "I asked, 'Where is everyone?' They said, 'They're gone. We were paying too much money to all of those people.' "

Mackall said she tried to notify Nicki's D.C. social workers, but "it was so hard getting in touch. They always told me they were out in the field."

Mackall didn't realize that Delaware nursing home licensing division officials shared her misgivings about Harbor Healthcare. On June 11, 1997, a team of nursing home regulators inspected the facility. The regulators issued a 59-page survey report detailing patient-care violations. Patients complained that they were forced to sit in their own urine and feces for hours and were permitted to take no more than two showers a week because of staff shortages. "You feel worse than scum," one resident told the regulators.

After the regulators issued their report, Delaware's director of public health deleted 22 pages of patient-care violations before allowing the report's release. The report and the director's deletions became front-page news in Delaware.

State Sen. Robert Marshall (D), concerned about "very damaging evidence of poor care being provided to residents of that nursing facility," held a public inquiry. Ellen Reap, the Delaware official who ran the licensing division, testified that "improper influence and backroom deals" between state public health supervisors and nursing home operators were compromising the quality of care.

Despite all the publicity, D.C. records do not reflect that city social workers or the judges who handled Nicki's case knew of the Delaware report or hearings.

A Six-Year Delay

About this time, D.C. Superior Court Judge Cheryl M. Long took over Nicki's case. After reading the file, the judge became furious. At a court hearing, she questioned why Nicki remained in a wheelchair that no longer fit the contours of her arching back. She asked why Nicki had not been considered for spinal surgery.

"I don't want to see her just sit there like a bump on a log and have no life except to get pain meds all the time," the judge said during a Feb. 5, 1998, hearing. "I don't know what their problem is. I hear one weird story after another about what's going on there. It doesn't make any sense."

Long ordered Child and Family Services to investigate. The task fell to Clairessa D. Lattimore, an agency employee. On March 2, 1998, she called Dabney, the orthopedic surgeon who had last examined Nicki six years earlier.

The surgeon told Lattimore that Nicki was scheduled for an appointment the same afternoon of their phone conversation. He described the visit as a "regular" medical appointment. Lattimore wrote in a report to the judge that "Dr. Dabney was unaware of why there would be a six-year delay in keeping appointments."

Eleven days after Lattimore's call, Dabney wrote to the District that he was "uncertain" as to why there had been a delay. The surgeon, who did not respond to recent requests for an interview, told Lattimore at the time that he wanted to schedule Nicki "as soon as possible for her surgery."

Two weeks later, Lattimore went to Delaware. She interviewed administrators and doctors and collected records prepared by Wilson Choy, an orthopedic surgeon and Harbor Healthcare consultant. Choy had operated on Nicki's dislocated hip in 1997. The doctor wrote, "This is not a case of neglect, but a neurogenetic type that progressed rapidly," according to Lattimore's report.

Choy added that Nicki's severe curvature "occurred recently." But Lattimore pointed to radiology reports dating back to 1996, indicating "a severe scoliotic curve to the dorsal lumbar spine."

Judge Long had heard enough.

"She's in a desperate, delicate condition," the judge said during an April 17, 1998, court hearing, a month after she ordered the investigation. "Every time we get within an inch of somebody actually ordering a wheelchair for her, they say, 'Oh, can't do it. Gotta do a spine operation. Gotta do this. Gotta do that.' And they keep putting off. Putting it off. Putting it off. And I keep wondering, 'What in the world is going on?' "

'Extremely Concerned'

While Judge Long tried to help Nicki, a new supervisor at Child and Family Services was trying to make sense of her file. Pablo Ruiz-Salomon said in a recent interview that the agency's paperwork was woefully incomplete, lacking specific details about Nicki's medical care.

Ruiz-Salomon supervised the agency's kinship care unit, which he said was not set up to handle children with special needs like Nicki. The unit, created to oversee children placed with relatives, had become a "dumping ground" to relieve heavy caseloads, he said. Agency records show that the unit's six social workers were supervising 31 boys and girls apiece, nearly double the federal court-ordered limit of 17.

"What we were doing was putting a finger in the dike," Ruiz-Salomon said. "When you came in in the morning, you would just hope there wasn't a fatality."

After Judge Long ordered the investigation of Harbor Healthcare, Nicki's case had become a top priority at Child and Family Services. The agency began to believe that the curvature of Nicki's spine would eventually damage her heart and lungs, Ruiz-Salomon said.

Concern also was growing at Harbor Healthcare. When staffers there read Lattimore's report, they became worried that they were about to be blamed. They traveled to the District to see the judge.

Jennifer Kihn, the nurse in charge of Nicki's pediatric wing at the time, recently told The Post that she and her supervisor had notified the judge that nurses at the facility wanted to schedule surgery for Nicki but that they needed authorization from her legal guardian, Child and Family Services.

Kihn said D.C. social workers kept leaving the agency before consent forms could be signed to pay for the surgery.

"If she didn't have the surgery, her lungs could collapse and her heart could fail," Kihn said. "It was outrageous. I know social workers are overwhelmed. I would never want to be one, because it's so hard to keep on top of everything. But too many hands were in the pot, and it was too confusing."

Three orthopedic surgeons examined Nicki's spine, and two of them concluded that her "life would be prolonged with the surgery," according to a July 7, 1998, report prepared by agency social worker Judah Campbell, who was now in charge of Nicki's case. Campbell told the judge she had called Dabney, the surgeon who examined Nicki six years earlier. Dabney told Campbell he needed approval from Child and Family Services to operate.

Two months later, Dabney said he was still waiting for approval.

"I have had an extreme amount of difficulty communicating with your agency," he wrote in a Sept. 18, 1998, letter to Child and Family Services. "After not receiving any response and after leaving several messages, I was finally able to get to speak to Ms. Judith [sic] Campbell."

Dabney noted that he reexamined Nicki on Aug. 10, 1998, and measured the curve of her spine at 100 degrees, a 67-degree deterioration since he had first seen her six years earlier. "I have since left two messages with your agency in [an] attempt to speak once again with Ms. Campbell, but have not received any return phone calls."

Dabney concluded: "If NickiColma's surgery is delayed much longer, her curve may progress to an inoperable magnitude. One would then question as to whether or not your agency would be negligent in allowing this child to have proper care.

"I am extremely concerned about this patient and would appreciate a follow-up and a finalization."

The surgery was eventually set for Dec. 2, 1998, according to court records. On Thanksgiving Day, six days before the scheduled operation, Nicki was found dead in the hallway of the nursing home.

One Final Mistake

Someone at Harbor Healthcare called Child and Family Services, requesting permission to release Nicki's body to a funeral home. A social worker gave the go-ahead, and Nicki's body was embalmed before an autopsy could be performed, according to medical records.

Jonathan L. Arden, the District's chief medical examiner, said Nicki's body should not have been embalmed, which can make it difficult to determine the cause of death. In Nicki's case, he said, it did not change his conclusion: The dramatic curvature of her spine factored into her death.

"The severe scoliosis compromised her respiratory system," Arden said. "It raises some very important issues as to whether she was receiving adequate care."

In February 1999, three months after Nicki's death, Delaware regulators discovered that at least five other pediatric patients had died at Harbor Healthcare from April 1998 through February 1999. The regulators turned the information over to the state attorney general's office.

Today, few people responsible for Nicki's care are willing to speak publicly about what happened. An assistant attorney general in Delaware said his office is investigating the deaths of the six children, including Nicki. "The investigation is ongoing. That's all I have to say," he said.

Chris Evans, Harbor Healthcare's administrator, initially consented to an interview, then requested that questions about Nicki's medical care be put in writing. "Confidentiality obligations prevent the facility from responding," Adam Balick, an attorney for Harbor Healthcare, wrote back.

The nursing home closed its pediatric wing in July. The facility cited several reasons, including "the negative political and operating environment created by certain parties who oppose children being taken care of in nursing homes," according to a letter Harbor Healthcare mailed to caretakers of its patients.

Dabney, the orthopedic surgeon, did not respond to phone messages or a certified letter sent to his office requesting an interview.

Choy, who operated on Nicki's hip, told The Post that he noted a "mild to moderate" curve of her spine at the time of the 1997 hip surgery -- even though a radiology report had documented a "severe" curvature a year earlier. Choy responded that he and the radiologist who wrote the earlier report might have different opinions about what constituted a severe curvature.

Choy also said he does not know why Dabney didn't see Nicki for six years.

"Kids get lost in follow-ups," Choy said. "No one was watching out for her."

A pediatrician for patients at Harbor Healthcare, Santosh B. Reddy, said he had assumed that orthopedic surgeons were monitoring Nicki's spine during her six-year stay at the facility. "I guess someone else was following up. I just don't know," he said.

Sondra Jackson, the last receiver named by the federal court to run Child and Family Services, did not respond to requests for an interview.

Russell D. Torwelle, Nicki's court-appointed attorney, declined to discuss his client's care. "I'm not going to get into this," he said before hanging up.

Of the eight social workers assigned to Nicki's case during the six years she spent in Delaware, only two remain at the agency, including Judah Campbell. She did not respond to phone messages or a certified letter requesting an interview.

Of the six social workers who have left the agency, five could not be located or did not return calls seeking comment. Laura Hoffman, the worker who visited Nicki in 1995, said she could not recall details about Nicki's case. But she said children in general were put at risk because there was not enough time to devote to cases.

"We were inundated by cases," said Hoffman, who joined the agency in 1994 with a master's degree in social work from Temple University. "There was not enough time to do the things we needed to do. And nothing ever came to fruition to get kids the things that they needed. Everything took a year and a day."

Hoffman left the agency after three years and no longer works in the field.

Judge Long remains on the Superior Court bench. Because she continues to supervise the case of Nicki's sister, she said she could not comment.

But the judge did try to make Child and Family Services pay a small price for its handling of Nicki's case.

A few days after Nicki died, Long convened a court hearing on Dec. 2, 1998, the day of the scheduled surgery. Paul Kratchman, an attorney for Child and Family Services, promised that his agency would reimburse Nicki's grandmother for the funeral expenses.

But Mackall never received a check. On April 14, 2000, Long issued a final court order, forcing the agency to pay Mackall $3,578 -- nearly 17 months after she laid Nicki to rest.

Database editor Sarah Cohen and Metro researcher Bobbye Pratt contributed to this report.

© 2001, The Washington Post Company

Day 2: Disabled and Forgotten

By Sari Horwitz and Scott Higham

Washington Post Staff Writers

In the District, there are few long-term alternatives for severely disabled children whom nobody wants: some group homes, expensive out-of-state institutions and foster homes like Betty Thompson's.

Thompson, 54, a retired postal worker, turned her two-story, four-bedroom Southeast town house into a place of last resort for six severely disabled children and two disabled adults. She received about $4,500 a month in foster-care and adoption payments from the District.

But once-confidential government records stated in 1999 that the D.C. Child and Family Services Agency violated its rules by placing children with Thompson because she had too many disabled children and her home was unlicensed by the city after 1996. Records compiled by the D.C. Child Fatality Review Committee also allege that Thompson and a companion were the subject of several child abuse complaints from 1977 to 1999 and that three children living in the home had died.

The panel said the Thompson case underscores the need for skilled medical facilities or foster homes for severely disabled D.C. children.

Thompson denied abusing children and said those who died had severe medical problems. She said her licensing was held up by agency paperwork, not problems in her home.

"My children love me, and I love them," said Thompson, who has adopted the children in her home. "I take excellent care of them. I work very hard with these kids to keep them clean and well-nourished. I give loving care to children who other people wouldn't spit on."

In 1986, six years after Thompson received a license to care for one severely disabled child, the agency notified her that her foster home would be closed "effective immediately" because of a child abuse complaint. But her home was never closed, and child protection agency officials could not explain why, fatality committee documents state. Thompson said she was allowed to keep her home open after an agency hearing.

"They gave me three or four kids after that," Thompson said. "If I had done anything to those children, I would be in jail."

A decade later, in March 1996, the city's Department of Consumer and Regulatory Affairs refused to renew Thompson's foster home license because there were too many disabled people in the home - a total of seven.

But an internal Child and Family Services Agency document defended Thompson, with a supervisor describing her as "caring and capable" with a "cheerful, pleasant personality." Government records show that agency supervisors knew Thompson operated her home without a license. Instead of removing the children, the agency gave her one more.

In March 1997, a D.C. social worker brought 9-month-old Ricky Anthony to Thompson's unlicensed home. Ricky had been severely beaten when he was 3 months old by Charles Jones, a family friend. Jones pleaded guilty to aggravated assault. Ricky's brain was damaged, leaving him blind, deaf, retarded and subject to seizures.

Nearly two and a half years later, Ricky was found dead in a corner of his crib, with a diaper draped over his face. D.C. Medical Examiner Jonathan L. Arden ruled the death a homicide, blaming the previous beating by Jones. Arden said there was no evidence of fresh injuries. Jones, who is serving 40 months to 10 years for beating Ricky, now faces second-degree murder charges. He has pleaded not guilty.

In its confidential review, the fatality committee called Thompson's home "a safety hazard" because seven individuals in wheelchairs were living on the second floor with no means of escape in a fire. Thompson said only five were in wheelchairs and that she had installed a sprinkler system and smoke detectors.

On Dec. 9, 1999, the fatality committee wrote to Ernestine F. Jones, then the federally appointed chief of Child and Family Services, that the case demonstrated "very serious and chronic" problems that "could have been contributing factors to several children's deaths that occurred in this caregiver's home."

Jones responded that her agency had found no neglect and had "no basis to further scrutinize this home." She also said the agency was working on drafting foster-home licensing regulations, which go into effect this fall.

While reviewing Ricky's case, the committee noted something unusual.

Although the D.C. Consumer and Regulatory Affairs Agency refused to give Thompson a license, Jones had issued Thompson a temporary or "provisional" foster-home license covering just three months in 1999. The committee questioned the timing, noting that the temporary license "happened to coincide" with the date of Ricky's death.

Thompson, who showed The Post all of her licenses since 1987, said she never received the temporary license.

"They're just lying to cover their butts," she said.

Jones did not return repeated phone calls seeking comment.

After Ricky's death, the agency decided not to give Thompson any more children. But the city still pays her about $3,000 a month in adoption subsidies, she said.

"They made a mistake closing my home," she said. "I'll go to my grave saying that."

© 2001, The Washington Post Company

Day 2: Disabled and Forgotten

In addition to Nicki Colma Spriggs, The Washington Post documented the cases of three other severely disabled children who died from 1993 through 2000 after their families came to the attention of the District's child protection system. These accounts are based on interviews and records from the D.C. Child and Family Services Agency, the D.C. Child Fatality Review Committee, D.C. Superior Court, the medical examiner's office and the police department:

Latisha Bias

Nov. 1, 1974 - April 17, 1993
Seizure and microcephaly

Profoundly retarded with Down syndrome, Latisha Bias came under the District's care at age 2 after her mother died in a car accident.

Afterward, Latisha lived in D.C. shelters and hospitals. She eventually became deaf and blind. In 1985, the agency found her a foster family in Maryland. The next year, the family moved to Kentucky on the "pretense of a vacation," a fatality committee document says.

In August 1986, the family returned toMaryland. This move came after child protection authorities in Kentucky began to investigate a report of child abuse and neglect. Among the concerns cited: children were sleeping in a van, missing school, going without breakfast, living in a dirty home and being emotionally abused. The home consisted of a foster parent, an assistant, one biological child, seven adopted children and two foster children, including Latisha. All the children were disabled. The investigation found that "neglect was substantiated on all 10 children in the home," a fatality committee report states.

The results of the investigation were forwarded to a D.C. child protection agency social worker, but nothing happened. Two years later, the agency was notified by Maryland officials of another investigation into neglect allegations in the same foster home -- but again nothing happened and the family moved to another part of the state.

Latisha died in Maryland on April 17, 1993. A family physician determined that the child died of natural causes, a fatality committee report states. But an autopsy was never performed, because Latisha was cremated the same day. A D.C. child protection official wrote in a confidential letter: "It is highly unusual and inappropriate for a ward of the District of Columbia to die and then be cremated the same day without prior notice or approval from her legal guardians."

Another D.C. government worker wrote in a memo in her file: "I don't like the way the foster parent handled the death of this child. We were not notified by the foster mother of the death, nor did we give permission for the cremation. Police were not contacted. These are very suspicious circumstances."

© 2001, The Washington Post Company

Day 2: Disabled and Forgotten

Xermia Waytes

Nov. 25, 1974 - March 29, 1995
Seizure disorder

Everyone called her Mia. She was removed from her home at age 3 after her mother allegedly physically abused her, and she received a diagnosis of cerebral palsy and retardation. But her prognosis was good. As a teenager, she was described as "charismatic and engaging."

After 17 foster care placements in 17 years, Mia died in her sleep at age 20 in a ward for the hearing impaired at St. Elizabeths Hospital, even though she had no hearing problems.

Xermia's "tragic life and death suggest the most callous form of systematic institutional neglect," wrote Judith Meltzer, the federal monitor of the D.C. Child and Family Services Agency, in a 1998 study of child deaths.

From 1978 to 1986, Xermia lived in four foster homes. By her 13th birthday, she had been moved 11 times. She lived in psychiatric hospitals and treatment centers in New Jersey, Maryland and Texas. But Mia's records contained no explanation for the moves and no sign that social workers were monitoring her.

In 1990, Mia was sent temporarily to St. Elizabeths. Then she was moved to a treatment center in Florida. By 1992, she was having psychiatric problems. Still, she had "no active advocate or case manager," Meltzer found.

Two years later, she returned to St. Elizabeths. A social worker requested that she be examined for sleep apnea, a condition that causes people to stop breathing while asleep, according to Meltzer's report. St. Elizabeths agreed to do the exam but never did.

In the end, Xermia was placed in a St. Elizabeths ward for the deaf, even though she had no hearing problems. A doctor said the ward had a skilled staff, but Mia's social worker objected, arguing that Mia needed verbal communication. A judge ruled in February 1995 that Mia should be transferred. Meltzer said she never was. A month later, Mia died of "questionable natural causes in a placement that was acknowledged to be inappropriate to her needs," Meltzer wrote.

A spokeswoman for St. Elizabeths declined to comment, citing confidentiality.

"The lack of overall management of this child's life and the apparent disregard for her future is heartbreaking," Meltzer concluded.

Donnell Howard

Dec. 10, 1975 - June 13, 1995
Cardiopulmonary arrest

Donnell was found unconscious in his bed in a city-run nursing home one month after the U.S. Justice Department filed a lawsuit, charging that "dangerous" and "grossly deficient" medical practices at the facility led to the deaths of 37 residents in less than three years.

A death certificate lists Donnell's cause of death as cardiopulmonary arrest, but no autopsy was conducted on the retarded teenager.

He was born in 1975 to a 17-year-old mother. At 2, Donnell stopped breathing while playing. He was taken to the hospital and received a diagnosis of spinal meningitis. He was in a coma for four months, resulting in extensive brain damage.

In 1983, when Donnell was 7, he was taken away from his mother after a doctor at Howard University Hospital reported her suspicions that Donnell was intentionally overmedicated with phenobarbital. He was placed in D.C. Village, a nursing home of last resort for poor children, the elderly and the retarded. Donnell spent the next 12 years at the home near the Blue Plains sewage treatment plant in Southwest.

Donnell, still a ward of the District, was not visited by city social workers for seven years.

After his death, an agency report noted "very little involvement" by social workers and "large gaps in the documentation."

In its 1995 lawsuit, the Justice Department contended that poor medical practices at D.C. Village were placing residents in "imminent danger of infection, potential loss of limb... and even death." The lawsuit alleged that poorly trained staff ignored the needs of residents, who were living in squalid conditions, kept in restraints and given inappropriate medication.

"Within its walls, 269 of the District's most vulnerable and defenseless residents... lived in such conditions of filth and abuse that even basic needs were often neglected," a court-appointed monitor of D.C. Village wrote in 1997.

A year after Donnell died, then-Mayor Marion Barry closed D.C. Village.

© 2001, The Washington Post Company

By Sari Horwitz and Scott Higham

Washington Post Staff Writers

Day 3: Babies at Risk

--Third of four articles

The pattern was painstakingly documented. Fragile, sick babies were born to mothers in the District who had been abusing drugs or mistreating their children. Doctors and nurses noted their fears for the newborns' safety.

Still, the babies left the hospital with their mothers. And little was done to protect the infants -- even though a government panel repeatedly warned that they could die unless the city took action.

Eleven drug-exposed or medically frail newborns died from 1993 through 2000 after they were released to parents whose troubles were well documented by hospitals and social workers, according to previously confidential records obtained by The Washington Post.

The babies got lost in a system where no one assumes direct responsibility for them. Vague legal definitions and poor communication among caregivers hamstring those who would like to help, according to a review of case files and dozens of interviews conducted by The Post.

In the District's neonatal wards, few rules govern whether and when hospitals should release fragile, drug-exposed babies to troubled mothers. Hospital workers can call the D.C. Child and Family Services Agency when they are worried about sending an infant home, but each hospital makes those decisions differently.

In some instances when a sickly baby died, the hospitals did not notify the agency about the birth. In most cases, though, the agency failed to respond to the hospitals' calls, leaving babies in the hands of parents who were ill-equipped to care for them, according to government records.

"We do not have time to take care of everyone," agency social workers sometimes told hospital employees, according to a confidential survey of hospital staff members obtained by The Post.

"Child and Family Services says, 'We just can't handle all these cases,' " said Elizabeth Siegel, a lawyer who is a member of the D.C. Child Fatality Review Committee, a panel that examines the deaths of District children. "I say, 'We can't handle all these deaths.' "

Saying a Prayer

In her four years at the George Washington University Hospital's neonatal unit, hospital social worker Mary Kardauskas had seen her share of premature, drug-exposed babies. In October 1998, a baby girl named Tyrika Michelle Perry caught her eye.

Tyrika, a twin, was born six weeks early and weighed 4 pounds, 3 ounces. Her twin had serious respiratory and intestinal problems and was sent to another hospital.

Tyrika also had respiratory problems, though not as serious as her sister's. But Tyrika cried inconsolably as she suffered withdrawal from the cocaine her mother had used. Kardauskas was concerned.

She called Child and Family Services, the District's child protection agency. Kardauskas worried that the mother's drug use would affect her ability to care for the drug-exposed baby. The agency, which at the time was entering its third year of operation under a federal court order, is supposed to assess such calls and decide whether to monitor the family.

But a city worker told Kardauskas that the agency's "quota" of children was full and that it was unable to accept any new cases, fatality committee records show.

Agency officials now say that should never have happened. "Our quota is never full," said Karen Morgan Fletcher, an agency supervisor.

Hospital workers across the city have long expressed frustration that there is no law in the District that required the city to take further action. "Hospitals are told that the agency cannot act on simply drug-exposed babies without any other concerns," a report from a fatality committee file said.

On Oct. 8, 1998, hospital workers sent 6-day-old Tyrika home to her mother, providing her with an apnea monitor that would sound an alarm if the baby stopped breathing. They told the mother when and how to place the device on Tyrika.

After Tyrika left the hospital, Kardauskas said a prayer. It was a ritual she repeated every time a frail baby went to a home that Kardauskas knew would not be monitored by city social workers.

"These babies can't call 911 if they get into trouble," Kardauskas said.

'It's Crazy'

Drug-exposed babies are often born to mothers already known to District social workers because they neglected or abused their other children. The babies frequently are premature, with drugs in their blood, low birth weight, respiratory distress or deformities.

Social workers, doctors and city lawyers disagree about how deeply the government should intervene in these cases. The debate pits those who believe that mothers and children should be separated only as a last resort against others who argue that the government needs to do more to protect children from unsafe homes.

At the core of the debate is the question of whether drug use by pregnant women should be considered neglect or abuse under District law. Right now, it isn't.

"You have to make the connection between drug abuse and neglect to take away a mother's baby," Morgan Fletcher said. "You have to prove that substance abuse precludes a mother from being a good parent. There are functioning drug-addicted parents. You can't take their babies."

Others say that puts babies at risk.

"It's crazy," said Anne Schneiders, an attorney for neglected and abused D.C. children. "You have to wait until the newborn is neglected or hurt."

For years, some District child welfare advocates have been trying to change the law to classify drug use by pregnant women as neglect or abuse, following the lead of several states. If the law were changed, social workers would be required to monitor the babies or prevent them from going home with their parents.

At least 18 states have passed laws requiring some degree of government intervention -- ranging from investigations to removal of the child -- when a mother gives birth to a drug-exposed infant.

Last year, the Ohio Supreme Court ruled that a baby born addicted to cocaine is an abused child. In May, a South Carolina woman became the first mother in the nation to be convicted of homicide by child abuse for giving birth to a stillborn, crack-exposed baby.

Although the debate in the District remains unresolved, the fatality committee's files illustrate how babies have continued to die for the same reasons. The fatality committee began to examine the deaths of D.C. children in 1993 -- five years before Tyrika Perry was born. Committee members noted that medically fragile babies were going to unsafe homes and dying shortly afterward.

In 1994, the committee published its first report.

Its first goal: "Institute a city-wide policy that would require follow-up services to be provided to families of premature infants once released from the hospital."

Over seven years, the committee would recommend 46 more times that hospitals and social workers take steps to protect frail infants. But the warnings, many of which were confidential at the time, largely were not followed.

The year the committee issued its first report, a baby named Iesha Ferrell was born prematurely and weighed 2 pounds. Iesha and her twin sister were sent home to their mother with apnea monitors.

Child and Family Services had opened a case on Iesha's siblings the year before because of allegations that their mother was using drugs and alcohol and neglecting her children. But the agency failed to track the family, a fatality committee report states.

Records show that an agency social worker assigned to the case provided some services but "didn't address the mother's substance abuse problem." The worker then did not visit the family for more than a year "due to her heavy caseload," according to a fatality committee report.

The social worker didn't know that the premature twins had been born -- or were sent to a crowded two-bedroom home where nine children were living with four adults. A police officer would call the living conditions "deplorable."

Two months later, Iesha died. The D.C. medical examiner classified the death as sudden infant death syndrome, or SIDS, which is usually the cause given in the unexplained death of an infant. When her body was found, Iesha was not attached to the apnea monitor. In an interview with The Post, Iesha's mother denied using drugs. She also said that a nurse told her she could stop using the monitor after it set off several false alarms. But she told the police that she did not know the purpose of the monitor and hadn't used it for several weeks, according to a police report.

In its 1994 report, the committee noted Iesha's case and urged city officials to consider changing the law: "Explore legal barriers to removing newborns at birth from mothers who are addicted to drugs during pregnancy or mothers who have children currently in the child welfare system."

One After Another

In December 1995, Keyona Debrew was born prematurely at D.C. General Hospital, weighing 4 pounds. Child and Family Services had previously removed several children from the mother after receiving neglect complaints.

Keyona's grandmother, Lucy Brown, told The Post that her daughter had a history of mental and behavioral problems. The daughter, herself a foster child, started having children at 15, Brown said. Keyona was her ninth. "She was living wildly because she was on drugs," Brown said.

On Feb. 11, 1996, about a month after D.C. General sent Keyona home, the infant was found dead in a roach-infested apartment. Keyona's mother told police she awoke to find Keyona sleeping on her chest, her male companion's leg draped over Keyona's head. The fatality committee said the police report did not indicate whether the man was interviewed. Keyona's cause of death was listed as undetermined at first, but it was later reclassified as a homicide.

When it reviewed the case later that year, the fatality committee noted the substance abuse and mental health problems of Keyona's mother and criticized the hospital and the agency. "No follow-up services were provided by the hospital or [Child and Family Services] after child's discharge," the committee wrote in a confidential report.

The panel also found that the social worker, Michael Wright, did not visit Keyona after she was born, even though he knew that the baby and her mother needed help. The committee concluded that social worker caseloads were too high and that the workers were not trained to help substance-abusing parents.

Wright said in a recent interview that he did all he could for the mother. He said she had denied being pregnant. He also said he could not visit the house after the baby's birth because of a blizzard early in 1996.

He said he was frustrated that the law did not allow him to do more.

"You cannot take the child just because the child is born addicted," Wright said. "You have to try and monitor the situation the best you can."

Lucy Brown blames her daughter. "It's not just Child and Family Services. Has anybody thought about these mothers who don't care a damn about themselves? I know what went on with my daughter, and I'm not proud of it."

Brown and her son said they did not know how to locate Keyona's mother, and The Post was unable to find her.

In 1997, Dennis Campbell was born prematurely at D.C. General. The baby suffered from respiratory problems and tested positive for cocaine and heroin, which his mother had used during the pregnancy, fatality committee documents show.

D.C. General staffers were worried that the mother couldn't care for Dennis, but no one called Child and Family Services, the records show. If the staffers had checked, they might have learned that Dennis's mother appeared in agency files because one of her other children had been born exposed to drugs.

About a week after Dennis went home, he died. The medical examiner ruled the cause as SIDS.

"The hospital should not have released [the] child without at least contacting Child and Family Services first," the fatality committee wrote in a confidential 1998 report. "Hospitals should always contact [the agency] when a mother delivers a substance exposed infant to determine whether the family was known to the child welfare system."

In 1998, the year after Dennis died, Thornell Price was born at D.C. General. He, too, had been exposed to cocaine. Hospital staff members were concerned about sending Thornell home because of how his mother acted at the hospital. "Her behavior was erratic, and she was stealing from the gift shop," an internal agency report says.

The hospital asked Child and Family Services to remove Thornell from his mother's care. But a social worker said there was not enough evidence to support a neglect complaint, and D.C. General sent Thornell home. At 6 weeks old, the baby died, showing signs of malnourishment, fatality committee records state. The apartment also lacked food and electricity. "The baby should not have been discharged to the mother," fatality committee members said. They termed the agency's investigation "inadequate."

Thornell's mother, who had three other children, had been reported several times to Child and Family Services on allegations of neglect. One time, a U.S. Marshals Service employee notified the agency that she had appeared intoxicated in the courthouse cafeteria and dropped an infant on the floor several times. But a social worker said she was not able to find enough evidence to support a finding of child neglect.

"My daughter was taking drugs," said her father, Willie Price. "That was a known fact. The hospital shouldn't have released the baby into her hands. It was like suicide. It was just a matter of time."

Thornell's cause of death was listed as "undetermined" by the medical examiner.

"There are no standards, policies, procedures or consistent practice for dealing with substance abusing mothers, especially of newborns addicted to drugs," the committee wrote.

Thornell's mother is now in a drug rehabilitation program and said recently she is trying to put her life back together.

"They could have stepped in and said, 'You should get yourself together and then you can have the baby,' " said her father, Willie Price. "But they should not have put that baby in her hands. If they had given my daughter a blood test, they would have found nothing but drugs in her blood. A common person on the street could have looked at her and that baby and not released him to her."

Case Closed

By the time Tyrika Perry was born in 1998 at George Washington University Hospital, the fatality committee had made 32 recommendations to city officials to protect high-risk, medically fragile newborns after the deaths of Iesha Ferrell, Keyona Debrew, Dennis Campbell and several other babies. None of the recommendations was followed.

After Tyrika's drug-exposed birth, hospital worker Mary Kardauskas alerted Child and Family Services, where an unnamed worker declined to take the case, saying the agency had reached its "quota," according to fatality committee records.

Another agency worker called Kardauskas back three days later, after Tyrika had been sent home. Kardauskas said she told the worker that the medical staff at George Washington was "very concerned" about Tyrika going home. This time, Child and Family Services opened a formal case to monitor Tyrika and sent social worker Nadesia Henry to check on her.

Henry wrote in a report that the apartment was tidy, organized and well-stocked with food. Although the baby's mother said she had used cocaine and marijuana while she was pregnant with Tyrika, she told the social worker she didn't need drug treatment because she wasn't addicted.

"She considers herself a social drug user," Henry wrote in the report.

On Oct. 27, 1998, Henry filed her report to agency supervisor Rula Swann, recommending that the case be closed "because there were no other issues of child neglect."

Five months later, on March 22, 1999, Tyrika's mother awoke to find the baby dead inside her blue playpen. A jacket covered her body.

"I started hollering," she recalled in a recent interview.

Tyrika's apnea monitor was not attached. Her mother said a doctor told her she didn't need to use the monitor if the baby was improving.

An internal Child and Family Services Agency review faulted the handling of the case: "The CFSA worker was not adequately prepared to provide services on this case and needed more guidance in understanding and assessing risk with substance abusing parents and the medically fragile child."

Henry, the social worker, declined requests for comment.

"I have decided that it is in my best interest that I do not attempt to communicate with you, as I have no new information to contribute," Henry wrote to The Post.

Swann declined to comment through an agency spokeswoman.

The fatality committee criticized the death scene investigation as "inadequate." This past spring, two years after the event, Medical Examiner Jonathan L. Arden classified the baby's cause of death as SIDS.

Today, Tyrika's mother, who says she no longer uses drugs, works as a medical clerk. Tyrika's twin survived, but her mother still grieves for the baby she lost. The walls of her home are covered with photos of Tyrika. She keeps the playpen under a bed and one of Tyrika's pacifiers on her key chain.

"It was rough for a long time," she said.

Kardauskas, who now works at another hospital, said she has always dreaded the day she would receive a call or read about the death of a newborn who she knew needed help. When she first heard about Tyrika, she couldn't initially recall details of the case. There had been so many Tyrikas over the years, and so many warnings she had called in to Child and Family Services.

"I always heard from the agency, 'Give the mother a chance,'" Kardauskas said. "Indeed, people do deserve a chance. But who was advocating for this child? What about her chance?"

Database editor Sarah Cohen and Metro researcher Bobbye Pratt contributed to this report.

© 2001, The Washington Post Company

Day 3: Babies at Risk

The Washington Post documented the cases of 11 babies who died after they were born exposed to drugs and sent to live with troubled parents without city help from 1993 through 2000. The following accounts of four of those cases are based on interviews and records from the D.C. Child and Family Services Agency, the D.C. Child Fatality Review Committee, D.C. Superior Court, the medical examiner's office and the police department:

Kristen Cheeks

Oct. 16, 1997 - Dec. 8, 1997
Blunt force trauma

Although her mother denied using drugs, Kristen was born addicted to cocaine, with trouble breathing. Three complaints about Kristen's mother had been called in to the child protection agency that year. Social workers did not open a case until the third complaint was made, a month before Kristen was born. A caller said the woman was using food stamps to buy crack and neglecting her 4-year-old child.

A social worker closed the case shortly before Kristen was born. Howard University Hospital workers sent Kristen home with an apnea monitor -- but without alerting the agency that a new child was born to the single mother, fatality committee records show.

On Dec. 8, Kristen's mother left the baby with a friend who was the subject of a neglect complaint involving her own children. Kristen was later found dead inside the friend's Columbia Heights apartment. The infant had suffered severe blows to the head, scratches, bruises and a burn on her body.

The mother's friend later told police that Kristen had been crying and she threw her down on a sofa bed, where the baby hit her head on a metal bar, police records show. The friend was charged with murder, but the charges were later dismissed. Separately, she pleaded guilty to assaulting two of her own children.

"Policies, procedures and practices were not adequate in addressing the needs of this family," an internal agency review found.

© 2001, The Washington Post Company

Day 3: Babies at Risk

Robert Walker Jr.

May 10, 1998-Sept. 5, 1998
Undetermined

Robert was born and died without any intervention by the District's child protection agency -- even though the agency was aware that his mother had been having trouble caring for the five children in her family for several years.

In 1991, the agency received a call complaining that the woman was spending public assistance money on crack, not providing food or clothing for her children and leaving them with unwilling caretakers. The case was eventually closed because the social worker could not find the mother, who lived under five aliases. In 1993, after another complaint, the agency removed three of the children and placed them with a relative. Two other children were later placed in foster care.

Robert was born in May 1998 at D.C. General Hospital. The year before, his mother had been reported to Child and Family Services for giving birth to a cocaine-exposed baby who needed surgery. But the agency closed that case before Robert's birth.

Robert also was born exposed to cocaine, and his mother told nurses she used drugs and alcohol during her pregnancy. It is unclear whether anyone from the hospital contacted Child and Family Services. But the agency did not open a case to monitor Robert.

"They should have taken that baby away," said Robert's uncle, Aaron Pledger.

Four months later, Robert was found dead in his parents' bed in an unkempt home, where police found drug paraphernalia and spoiled milk but no formula or diapers. Committee documents state that Robert's mother drank large quantities of alcohol and smoked crack in the days before his death, and the committee wrote that Robert's death was "suspicious." The cause of his death remains undetermined.

© 2001, The Washington Post Company

By Sari Horwitz and Scott Higham
Washington Post Staff Writers

Day 3: Babies at Risk
Premature, Drug-Exposed Baby Died in a Filthy, Dark SE Apartment

Like so many babies before him, King Richardson was born prematurely to a mother who had smoked crack while she was pregnant. Nineteen days later, in September 1997, Washington Hospital Center workers released King with an apnea monitor to track his breathing.

But he went to a home without electricity.

King's parents were struggling to feed four children and overcome drug habits. Two years before King was born, an anonymous caller had alerted the D.C. Child and Family Services Agency that King's mother might be neglecting her children, agency records show. The caller was concerned that the apartment was without power and the children had no medical care.

King's hospital pediatrician wrote a letter to Potomac Electric Power Co. requesting help on behalf of the family, which couldn't pay the bills, according to a report by the D.C. Child Fatality Review Committee. A Pepco spokesman said the company had no record of such a letter.

Child and Family Services policy requires an emergency investigation by social workers whenever children are living without electricity. But three weeks after King went home to his Southeast neighborhood, a social worker, Agnes Johnson, closed the case and stopped monitoring the family, even though the electricity was still out, according to the fatality committee report. An agency report stated that "hostility of the birth father appears to have intimidated staff." The father was described as "verbally abusive and physically aggressive."

A week later, King stopped breathing. He was 6 weeks old.

On Oct. 21, 1997, D.C. police officers found King unconscious in a filthy bedroom with no heat. Burnt-down candles sat atop a dresser. "The refrigerator when opened was overrun with roaches and was not working due to the power being off," the police report stated.

In King's cluttered crib was the apnea monitor. It was zipped in its case. King's parents said the battery was being charged at a neighbor's home, fatality committee records show.

Several hours later, King died of Group B streptococcal sepsis with meningitis, autopsy records show.

The fatality committee wrote: "The case was inappropriately closed. Home assessment not conducted .... The worker appears to have lost focus on why the case was initially opened."

The committee also found that the social worker, Johnson, was juggling too many cases -- at least 37 children, a violation of a federal court order setting a 17-child limit. Johnson declined to comment through an agency spokeswoman.

King's parents say they are now off drugs and both employed. They declined to discuss what happened to their son.

© 2001, The Washington Post Company

By Sari Horwitz and Scott Higham
Washington Post Staff Writers

Day 4: A Failure to Investigate
Mentally Ill Mother Threatened Her Son, but D.C. Police and Child Protection Agency Failed to Act

--Last of four articles

Along Anacostia Avenue in the Mayfair Parkside section of the District, Regina Brown was known as the proud single mother of her only child, Sylvester, a third-grader with a slight lisp who loved to ride his bike with the big boys on the block. Brown spent her days copying microfilm for the U.S. Patent and Trademark Office, the rest of her time doting on her son.

She bought Sylvester a mountain bike. A computer. Nintendo. Bunk beds so his friends could sleep over. Hot Wheels and Power Rangers. And $4,000 in U.S. savings bonds.

"I spoiled him even before he left the hospital," Brown would later say. "We were like brother and sister."

But beneath this pleasant exterior, Brown was succumbing to insanity. She thought TV talk show hosts were reading her mind. She believed God was instructing her to slay her son.

Those close to the 8-year-old boy knew he was in danger. They warned District police officers. They alerted social workers at the D.C. Child and Family Services Agency, which has a legal obligation to protect abused and neglected children and was at the time under a federal court order to improve its services.

But a police officer dismissed a complaint against the mother after an incomplete investigation. Another officer failed to tell the agency that the mother was threatening her son. And city social workers turned away calls to a hot line, contending that the mother's mental state didn't constitute a case of neglect.

"There are two victims in this, the mother and my grandson," said Warren Hall, Sylvester's paternal grandfather. "The system failed them both."

A Vacuum

From 1993 through 2000, 229 children died after they or their families came to the attention of the District's child protection system because of neglect or abuse complaints. Indozens of cases, police officers and social workers responsible for the safety of children failed to take the most basic steps to shield them from harm, according to previously confidential government records obtained by The Washington Post.

The records show that at least nine D.C. children, including Sylvester, perished after police officers and social workers conducted incomplete investigations or left the children to fend for themselves with violent, neglectful or unstable parents or guardians.

The D.C. Child Fatality Review Committee, a panel created to examine child deaths and recommend improvements, urged 63 times in eight years that the police department and the child protection agency fix problems with investigations and monitoring. For years, the recommendations went unheeded.

"They went to the great burial place of recommendations," said Barry Holman, a former Child and Family Services employee who attended fatality committee meetings. "There's a vacuum out there, and there was no mechanism for delivering the recommendations to the agencies and making sure they were implemented."

The recommendations were intended to save children like Sylvester, whose story emerges from interviews, court records, police reports, psychiatric evaluations and documents from the child protection agency and the fatality committee.

A Call for Help

Sylvester and his mother were inseparable.

"She was beautiful with that child," said Francine Griffin, a neighbor who lived in the same apartment house on Anacostia Avenue.

But in the summer of 1996, the normally effervescent boy turned solemn. Without warning, Brown quit her microfilming job. Sylvester and neighbors told relatives she was "acting funny." She was leaving pots and pans on her kitchen stove until they caught fire. She was putting household belongings in the garbage, only to retrieve them minutes later.

Workers at a community social service group suspected that Brown was punching Sylvester and beating him with a belt.

They called police.

Vanessa M. Douglas was a youth services police officer with seven years on the force when she arrived at 721 Anacostia Ave. NE at 1:08 p.m. on July 8, 1996. She walked up a short flight of stairs to Apartment 14. Brown told the officer that she never beat Sylvester. She said she quit work because her son was having trouble in summer school. Douglas went to Thomas Elementary School to interview Sylvester. The boy told the officer his mother hit him during play fights. Nothing more.

Douglas closed the case, writing in her report: "There is no evidence to support any allegations of abuse."

There is also no evidence in fatality committee records or police reports that Douglas interviewed Brown's neighbors or relatives. Or that she brought Sylvester to a doctor for an examination. Or that she took photographs of his body. Or interviewed workers at Community Connections, the group that called in the complaint.

Police and child protection experts say that, at the very least, Douglas should have interviewed neighbors and relatives. More importantly, they say, the officer should have spoken to those who called in the original complaint.

Douglas said in a recent interview that she couldn't recall the case. But she said she was handling 30 to 40 cases simultaneously and had little time to devote to any one of them.

"We were limited to how long we could spend on investigations," said Douglas, who left the D.C. police department in 1999 and now works for the Library of Congress police force. "We really cared about kids. But the same kids were coming through the system over and over again, and the judges kept sending them back to the same homes.

"After a while, it got depressing."

Investigating child abuse complaints has long been a low priority, D.C. police officers and their supervisors say. When the District first divided the investigations between police and social workers 25 years ago, the plan seemed simple: Officers would handle physical abuse calls; city social workers would investigate neglect complaints.

In cases involving both abuse and neglect, officers and social workers would investigate jointly. This setup was unique. In most U.S. cities, social workers handle all complaints and call on police only when there is evidence that the abuse constitutes a possible crime.

Over the years, the District's method of investigating child abuse has caused deep dissent and widespread confusion within the police department and the child protection agency. Although many officers care passionately about conducting abuse investigations, others view the cases as menial tasks better handled by social workers, police supervisors say.

After Douglas filed her report, the case was closed as far as D.C. police were concerned. The decision, in effect, severed the first of several lifelines set up by the city's child protection system to keep children like Sylvester safe.

A Warning

For two months, Brown had been hearing voices. They were calling her a "troll," telling her "nobody wants you," chanting, "Beast, beast, beast."

By the time Douglas visited Brown's home in early July 1996, the voices were becoming more persistent. She believed television talk show hosts were reading her mind and demons were coming to take her away. The voices were telling her that her son had a power that God wanted back. If that didn't happen, God was going to kill her.

Toward the end of August, Brown began to "purify" her apartment. She and Sylvester dragged chairs and lamps, tables and beds to the street. Then she told her son they had to bring the belongings back inside.

"It was bizarre," said a neighbor, Mary Beasley.

With the voices consuming her life, Brown decided to tell someone. At Sylvester's eighth birthday party in August 1996, she confided in Jenny Peterson, Sylvester's paternal grandmother, who was taking care of Sylvester during summer vacation. Brown told Peterson that someone or something was instructing her to slay her son.

"She told me she was going to kill him, that he was living in sin," Peterson recalled. "I said: 'Regina, what are you saying? He's not living in sin. He's 8 years old.' "

The next day, Peterson said, Brown called to say she was coming over to pick up her son from his grandmother's. "She told me she was going to kill him," said Peterson, who called police.

For the second time, the police dispatched a patrol car. Brown was at the house when the officers arrived.

"She kept saying she was going to kill him," Peterson said.

The officers decided to leave Sylvester with his grandmother and his father, Warren Holmes, at their Northeast Washington home and bring Brown to a hospital for an emergency psychiatric evaluation.

Before driving off, the officers gave Sylvester's grandmother a warning.

"They told me that when she gets out, you have to give him back," Peterson said. "The police officer said, 'You don't have custody of him, and if you don't give him back, we'll lock you up.' "

For the second time, someone had summoned police for help. And for the second time, police would sever a lifeline for Sylvester.

There is no documentation in government records that the officers notified the Child and Family Services Agency that Sylvester's mother had been hospitalized and her son would be staying with relatives. The agency had no idea that Sylvester's mother was slipping into psychosis.

By not contacting the agency that day, police failed to follow procedures set up under District law to protect children from "imminent danger." If police had made the call, Sylvester could have been placed under protective supervision, his case monitored by the agency's family services division. His case also would have come before a D.C. Superior Court judge to ensure that Sylvester's mother was mentally fit before she could be reunited with her son.

'A Danger'

At Howard University Hospital's psychiatric ward, Brown was hallucinating. Doctors concluded that she had a psychotic disorder. She told them someone was controlling her mind.

"She was noted to be depressed, anxious and hopeless with suicidal thoughts," a court-appointed psychiatrist would later write in a report after reviewing Brown's records from Howard. "She had dreams her son would die."

Six days later, the hospital permitted Brown to check herself out against the advice of doctors. "Despite all these indications that she was psychotic and might be a danger to her son, she was allowed to discharge herself," the psychiatrist wrote.

There is no evidence in fatality committee files obtained by The Post that the hospital contacted the child protection agency. Hospital officials declined to discuss the case. "We have no comment, based on the laws governing patient confidentiality," said Donna L. Brock, a Howard University spokeswoman.

Child protection and legal experts say hospitals have an obligation under D.C. law to notify Child and Family Services, because the mother had been deemed a danger to her son. Doctors, nurses and other medical staffers are "mandatory reporters" under District law, and they must notify the agency if they suspect a child is in danger.

The failure to report when children are in danger has been a persistent problem in the child protection system. From 1993 through 2000, the Child Fatality Review Committee cited the failure to report children who needed help in the deaths of 16 children.

Another Call for Help

Soon the imaginary voices returned. Voices from relatives, taunting Brown, cursing at her. Her neighbors at the Parkside Addition apartment house on Anacostia Avenue were worried. For the first time, Brown told them about the voices. She didn't tell them what they were saying, but Tracey Wells was frightened for the family.

Wells lived one flight up from Brown. For five years, she took care of Sylvester while his mother was away at work. Wells told Brown she was going to call Child and Family Services.

For the first time in the sad odyssey of Sylvester Brown, the agency responsible for the well-being of the District's children was officially made aware of the boy's plight.

"I told them about the voices," Wells says. "I asked them what could they do, because she has a little boy. They said that wasn't something they could handle because it wasn't neglect."

Ten days later, Brown had gotten worse. Wells called the agency again.

"I told them Sylvester was in danger," she says. "The voices were coming more and more. The voices were telling her to do things that she didn't want to do."

She said an agency worker whose name she can't recall told her there was nothing Child and Family Services could do.

For years, the agency has been improperly turning away calls for help and conducting incomplete investigations into complaints of child neglect, fatality committee documents show. Many social workers were poorly trained, not enough were assigned to handle the calls, and their supervisors failed to check on the quality of their field work.

By refusing to follow up on the calls about Brown, the agency violated District law, veteran social workers say. Under it, an investigation is required if a parent is "unable to discharge his or her responsibilities" or to care for the child "because of incarceration, hospitalization, or other physical or mental incapacity."

The city had cut the last lifeline for Sylvester.

"She was sick," Wells would later say, "and they didn't help her."

'Mama, No'

Sylvester's mother had submitted to the voices.

Shortly before Christmas in 1996, Brown again began to empty her apartment, placing their belongings on the street: Sylvester's bunk bed, his bike, his savings bonds, his Christmas presents, still wrapped in colorful paper, and their tree, the lights dangling from its branches.

On Dec. 18, 1996, one week before Christmas, Brown made her son supper. She gave him a bath and put him to bed. A voice told her to get a knife, she would later say. Brown returned to her son's bedroom and stood in silence at the doorway until he fell asleep.

Neighbors had just finished putting up Christmas decorations when they heard Sylvester's screams in the apartment house hallway.

"Mama, no," the boy cried. "No more."

Police opened the door to Apartment 14. Inside, they found Sylvester on the floor next to his blood-soaked bed.

"God came to me and didn't give me words, but spoke to my subconscious," Brown would later try to explain to a psychiatrist. "He told me I could kill, but could never destroy, because only He has the power to destroy. That made me know Sylvester's safe in Heaven."

At the funeral, Sylvester's friends stepped up to the coffin. Someone had put a Power Ranger in his hand. One by one, they leaned over his body, and one by one, they placed Hot Wheels cars in his casket.

The Protectors

After examining Sylvester's case, the fatality committee said the police department should "examine its policies on abuse investigations and determine the need for change." Among the committee's suggestions: that officers photograph children, bring them to Children's Hospital for exams and interview witnesses outside the immediate family -- all the things officers failed to do in Sylvester's case.

Lt. Yvette Tate was a police representative on the fatality committee at the time of Sylvester's death. No longer a member of the panel, she said in a recent interview that she could not discuss committee business, citing confidentiality. When asked to discuss what happened to the recommendations intended to improve investigations, Tate said she didn't have time to talk and ended the interview.

Police supervisors say there are not enough officers assigned to investigate child abuse complaints. Until recently, when the department added 10 officers, the youth division was down by nearly a dozen. Instead of spending a week to examine serious complaints, officers were sometimes forced to close cases after a day or two.

Part of the problem is persuading officers to handle child abuse cases.

"We had to force people to the youth division," said Executive Assistant Police Chief Terrance W. Gainer. "They went kicking and screaming."

This fall, the District plans to end the practice of dividing investigations. The Child and Family Services Agency will conduct the initial investigation of abuse and neglect complaints and will call in police only in the most serious abuse cases.

Social workers say they fear that the additional cases will overwhelm an already chaotic agency.

Since 1995, the District has been proposing a better way: the Children's Advocacy Center, where social workers, police officers, lawyers and others would work together on child abuse and neglect cases. Although a small center already exists in the city, the District had promised a major expansion.

But in June, the executive director of the center submitted her resignation, citing frustration with top city officials. The director, Kimberly A. Shellman, said District officials were not willing to find a large enough space for the proposed expansion.

"It is with great regret and disappointment that on July 31, 2001, I will leave this project unfinished and in a state of no progress," Shellman wrote to Mayor Anthony A. Williams on June 15. She took a job in Atlanta to help child protection officials there create their own center.

Today, Regina Brown, 33, is confined to St. Elizabeths Hospital. She has been there since November 1997, after a judge found her not guilty by reason of insanity. From time to time, she calls Sylvester's paternal grandfather, Warren Hall.

"Mr. Hall, I'm sorry," she tells him. "They tell me I hurt Sylvester, but I would never hurt him."

Hall, 58, a driver for the city's income maintenance organization, tries to understand.

"That was the only child she had, and she doesn't even know what she did," he says. "I don't blame her."

But five years later, Hall remains haunted by what happened. He says he has a dream that he can't shake. In it, Sylvester is standing on the roof of his grandfather's Northeast town house. His arms outstretched, he asks his grandfather why no one helped him.

Hall feels himself pitching backward into darkness before he awakens, his fall broken by consciousness, his grandson's question unanswered.

"I don't know what to tell him," Hall says. "You could see it happening, and no one did anything to stop it."

Database editor Sarah Cohen and Metro researcher Bobbye Pratt contributed to this report.

© 2001, The Washington Post Company

Day 4: A Failure to Investigate

"Everybody kept saying that Cecelia got lost in the system," Kareem said recently. "That's not what happened. The system lost Cecelia."

In addition to the case of Sylvester Brown, The Washington Post documented the cases of eight children who died after police or social workers conducted incomplete investigations or ignored signs of danger from 1993 through 2000. The deaths occurred after the children's families came to the attention of the District's child protection system or were under the watch of social workers. These accounts are based on interviews and records from the D.C. Child and Family Services Agency, the D.C. Child Fatality Review Committee, D.C. Superior Court, the medical examiner's office and the police department:

Cecelia Maria Rushing

May 5, 1991-Nov. 3, 1993
Blunt force trauma

"She was a perfect little baby," recalled Cecelia's godmother, Bernice Kareem. Kareem and her boyfriend, Purcell Campbell Jr., cared for the toddler while her mother lived on the streets. The mother later sent Cecelia to an aunt, Darnella Adams, who had a history of violence and mental illness. Neighbors soon heard cries coming from Adams's apartment. They called 911 several times, but police "failed to adequately pursue the matter," according to a prosecution memorandum filed in court.

Two months later, on Nov. 3, 1993, Adams shook Cecelia when she wet her pants, then slammed her against a wall, killing her. An autopsy showed that her brain was swollen, her liver lacerated. Adams pleaded guilty to second-degree murder. Before the mother had sent Cecelia to live with Adams, Kareem notified authorities that the mother was using her welfare checks to buy drugs. Kareem feared for Cecelia's safety. But social workers never came to investigate, according to Kareem, and the mother eventually sent her daughter to Adams.

"Everybody kept saying that Cecelia got lost in the system," Kareem said recently. "That's not what happened. The system lost Cecelia."

© 2001, The Washington Post Company