Philly removes neglected children from homes to keep them safe. But they often face worse abuse in foster care placements.

A story like this could begin in dozens of places.

It could begin with Elliot, an infant shaken so badly that he suffered a traumatic brain injury; or Adeen, another boy, submerged in scalding water; or Samaya, held down and burned with an iron.

A story like this could also begin with a mom, like Tytianna Hawthorne, whose daughter Su’Layah Williams was removed from her care by the Philadelphia Department of Human Services and placed in a private home where the girl was allegedly murdered.

This story could begin with any of these tragic incidents because they all stem from the same problem: a child welfare system in need of reform.

For more than a decade, Philadelphia’s DHS has outsourced care for children involved in abuse and neglect investigations to small private nonprofits. Beginning in 2012, in the wake of a horrific case of child abuse, Philadelphia established community umbrella agencies, or CUAs, in 10 service districts across the city.

The stated intent was to streamline, to localize, and to better serve youth in need with smaller, neighborhood-centered welfare agencies.

But that goal has fallen far short, according to a first-of-its-kind investigation by Resolve Philly and The Inquirer. The news outlets found systemic breakdowns across the network of private companies contracted by the city’s DHS. Since their founding, the CUAs have engendered distrust among Philly families and been sued nearly 70 times for allegedly allowing kids in their care to be burned, beaten, sexually assaulted, and, in 14 cases, killed.

Court records and interviews indicate at least 50 of these lawsuits resulted in settlements or verdicts of $1 million or more.

In one case that settled for $6.5 million in July 2022, 3-year-old Hope Jones died of multiple blunt-force trauma injuries while in the care of a CUA, Northeast Treatment Centers.

These private nonprofits have incurred insurance and legal costs that now threaten to destabilize Philadelphia’s foster care system. DHS’s largest CUA (pronounced COO-uh), Turning Points for Children, decided in 2022 to close its four offices and its $40 million annual operation. Tabor Community Services told DHS in early 2024 that it would not renew its $7 million annual contract.

“I think the writing is on the wall that the CUA system is going to collapse,” said David Wilson, recent past president of AFSCME Local 2187, which represents 600 DHS workers. “If DHS leadership is aware of this or planning for it, I am aware of no plans.”

The Resolve Philly/Inquirer review of the scores of lawsuits, along with dozens of interviews with child welfare professionals, families, and young people placed in the CUA system, reveals core problems that trace back to DHS.

Among the findings:

“We’ve been talking about the same problems in the child welfare system for 30 years,” said Cathleen Palm, founder of the Center for Children’s Justice. “We just never fix them.”

DHS Commissioner Kimberly Ali, asked about the Turning Points and Tabor defections, said DHS provided money to pay for the CUAs’ rising insurance premiums. Turning Points wanted more.

“What the provider wanted the city to do was pay to indemnify them for their own negligence, and that is what the city was not going to do,” Ali told City Council members last spring.

Potential solutions to these problems, however, can be found just across the Delaware River in New Jersey, which emerged over the last 20 years from a kind of “dark ages.” New Jersey places children in foster care at far lower rates than Philadelphia without compromising safety. Whether Philadelphia leaders will view the current crisis as a reason to embrace reforms that have worked elsewhere remains to be seen.

Philadelphia DHS sought a new way to deliver care after the tragic 2006 starvation death of 14-year old Danieal Kelly. Covered in bruises and bedsores, weighing just 42 pounds, Kelly was neglected for months while receiving DHS services.

“There was a belief that the system had become too convoluted,” said Anne Marie Ambrose, who took over as DHS commissioner in the wake of the teen’s death. “The clarity around roles and responsibilities was often murky.”

Some local system professionals, however, rejected that idea at the time.

“Caseworkers understood their roles and responsibilities,” said Margaret Zukoski, a retired associate director of the Pennsylvania Council of Children, Youth and Family Services, who served on a committee that looked at potential DHS reforms back then. “If anything, adding the CUAs only complicated the system.”

A grand jury report on the Kelly case also rejected the “too convoluted” theory: “The Grand Jury has no doubt that, had DHS social workers simply followed the procedures prescribed in the agency manual, Danieal would be alive today.”

DHS went ahead with its CUA plan anyway — triggering an unforeseen consequence. State statutes limit potential civil damages against the city to $500,000. Private contractors, however, enjoy no such legal protection. As a result, city kids and families harmed by the child welfare system benefited from a new legal remedy.

Since the outsourcing, a series of “nuclear verdicts” in Philadelphia have driven insurance carriers out of the market, according to a report by Lockton, the insurance brokerage giant. The remaining insurers charge “punitively high rates and deductibles.”

Talks are underway to reintroduce state legislation that caps damages at $500,000, according to Mustafa Rashed, a government relations strategist hired by the CUAs.

Nadeem Bezar, a crusading child advocate who has filed far more lawsuits against the CUAs than any other lawyer, said that a cap on damages only passes the costs of caring for children’s ongoing medical and mental health needs to taxpayers.

“The problem isn’t that we need to protect the child welfare system from the kids it has harmed,” he said. “The problem is that the system needs to stop harming children.”

When investigators turn up at a family’s house, they examine every aspect of a child’s life — from abuse to what food and how much is in the house.

“In the child welfare system, they visit homes where the family might face some kind of stress, usually economically, and take their children for ‘neglect,‘” said Jamele Greenwood, a facilitator for the Philadelphia System of Care who spent time in foster care himself.

The problem is that families can be separated unnecessarily, and children sent to a home where they might face real danger.

Because of overcrowding, as one example, children and teens were temporarily housed in what is called the “overnight room,” a setting DHS maintains in its offices to feed and house kids for the night if no foster or resource home is available.

But the children did not just stay overnight. To be sure, some of the kids suffered from mental or behavioral health problems, making them more challenging to place in foster homes. Even so, an August 2022 investigation by The Inquirer revealed that kids stayed there for days or weeks at a time on cots and air mattresses with little oversight. Teens arrived and departed at a whim, and DHS staff reported incidents of children showing up high and others attempting to recruit overnight room residents into sex trafficking.

For more than two years, the agency found no solution.

“It’s the same exact situation,” says one case manager who worked in the overnight room this summer. “Broken toys, dirty underwear — they just wash it and put it out for the next child — a dirty shower, kids just lining up to use it with no cleaning between them.”

The case manager, who asked for anonymity for fear of retaliation, noted the hypocrisy.

“We go into homes as case managers and tell moms they should be serving their kids fresh vegetables. And we have a good, working kitchen ourselves. But we’re feeding these kids frozen chicken fingers, frozen pizzas, everything frozen!”

In recent months, DHS moved the girls temporarily to a group home. Boys, however, still live at the DHS office. According to a DHS union rep, “it’s still chaos.”

Teens legally in DHS’s custody still exit into the streets, day or night. “If we had a birth parent or foster parent letting kids walk in and out like it’s a revolving door, we’d take those kids into foster care,” the case manager said. “But what are we doing? It’s shameful.”

Brianna Donahue never felt she needed to be in foster care. But at 15 years old, DHS took her from her mother over allegations of inadequate supervision and improper care.

Once Donahue was in foster care, her foster parent physically, verbally, and emotionally abused her, according to a 2021 lawsuit she filed. Donahue reported the abuse to her CUA social worker, who allegedly failed to investigate the report and told the foster parent of Donahue’s complaints.

The physical and emotional abuse increased. Other kids in the home, encouraged by the foster parent, kicked, punched, and beat Donahue, threw her on the ground, and ridiculed her.

The foster parent withheld food from Donahue, sometimes all day.

After two months, Donahue ran away. Then she was placed in the Carson Valley group home, where she said she again reported the abuse. “Defendants Turning Points and DHS did no investigation into the abuse suffered by plaintiff at the foster home,” the lawsuit asserts. “Neither interviewed the plaintiff … [and] permitted the foster parent to continue as a resource.”

Donahue, now 22, was eventually reunited with her mother and obtained a settlement that prevents her from being interviewed about her case. Court papers from her case, however, describe the leading role DHS continues to play in foster care with the CUAs.

» READ MORE: Inside Philly’s hidden foster care system, where parents ‘voluntarily’ give up their children

Philadelphia’s DHS determines if a call to ChildLine, the state DHS hotline, warrants investigation, conducts the initial inquiry, decides if the child can remain safely at home — or should be taken into foster care. If so, DHS is involved in choosing the child’s placement through a contracted foster home referral agency. Using that agency’s guidance, DHS then assigns the case to one of the city’s 10 regional CUA offices, which then provides ongoing services.

These CUA agency workers are trained by the state and city DHS. After the CUA takes over, DHS collects paperwork and remains involved in any future placement decisions. DHS has a small unit that fields complaints about the CUAs, but community members describe it as understaffed and ineffective.

DHS attorneys argue every dependency case in court with CUA case managers as their chief witnesses. DHS typically is not a named defendant in the CUA lawsuits, but the agency functions as designer and hub of the entire system, and court records and interviews show the department plays at least some role in the harm.

Five of the lawsuits — four of them death cases — involve kids with serious medical needs who were placed in regular foster homes that lacked the required, medically trained caregivers. This can happen because staff at the CUA did not inform DHS’s referral unit about the child’s medical condition, for instance, or because DHS workers did not check the child’s files, which typically include medical records, before making the placement.

Child advocates say DHS’s shortage of medical foster homes predated the CUA system.

A 2020 case exemplifies how a DHS decision can go horribly wrong.

That January, a Turning Points official said she had reservations about placing a deeply troubled foster youth, Xavier Johnson, in a foster home, according to emails obtained for this article. Johnson had acted violently in the past, which made him an appropriate candidate for a secure state facility. Instead, DHS assigned him to a longtime foster parent, 64-year old Renee Gilyard of Germantown, the mother of two sons, one of them a Philadelphia police officer. Later that month, Johnson was charged with murder after stabbing Gilyard to death in her bathtub.

A lawsuit, later settled, alleged that Turning Points was negligent for not informing Gilyard about Johnson’s violent past.

But DHS faced no consequence in civil court for rejecting the CUA’s reservations.

After a particularly horrifying death of a child in DHS custody, members of the media, the public, and the political class question how a child under the care of our government could suffer such obvious abuse.

Such cases, however, are outliers in Philadelphia’s foster care system. Nonfatal forms of abuse are far more frequent, leading to years of potential medical and mental health needs.

Records show that between 2017 and 2022, Philadelphia investigated almost 900 reports of abuse or neglect to children in government care and confirmed 186. These numbers are likely an undercount. In a national survey of adults who spent time in the foster care system, 30% report being abused or neglected at some point.

“Physical abuse, spankings, slapped faces, verbal abuse — like ‘you ain’t no good, nobody wants you, that’s why you’re here’ — and not feeding you or feeding you different from the other kids that’s there,” said Marcus Jarvis, a former foster youth. “Abuse of foster kids happens all of the time.”

Data published by the federal Administration for Children and Families appear to undercount the abuse of kids in foster care: Each year 0.3% of the children in foster care — one in 333 — face abuse while in government custody, which, if true, would mean children in foster care are almost three times safer from abuse than the typical American child.

Youth advocates who spent time in foster care explain why incidents may go uncounted.

“Some kids don’t report it out of trauma or a feeling that this treatment is what they deserve because that’s what their foster parent told them,” Constance Iannetta, founder of Foster Strong, an advocacy organization for current and former foster youth, said.

It also takes time to build trust with a case manager, an unlikely result when workers keep leaving. Sometimes, however, kids report maltreatment only to find their overworked case manager discourages them from speaking out.

“Sometimes your worker might say, ‘Are you sure you really want to do this?’ ” Greenwood said, “and it just kind of sends the message: ‘The next place could be worse.’ ”

In February 2020, a 3-year-old boy was brought into St. Christopher’s Hospital for Children with fresh bruises on his arms, hands, and face. Upon examination, doctors diagnosed him with bradycardia, a slow heartbeat caused by dehydration or extreme dieting and malnourishment. A mark encircled one leg, as if he had been tied.

The boy, later identified in court records as T.E., lived in a foster home overseen by Turning Points for Children, a CUA under contract with Philadelphia DHS.

Plaintiff attorney Bezar took the case and sued Turning Points for Children for failing to provide T.E. with a safe home. At trial, the case manager said she had at least 18 cases, a workload almost twice the size of DHS’s goal and one that she told her supervisors made it difficult for her to perform her duties effectively.

Child welfare agencies have had a hard time holding on to staff since long before the CUA system came online. Today, Philadelphia funds the CUAs sufficiently to hire one worker for every 10 cases, with each “case” comprising a family that can include multiple children. Leaders in the child welfare field, however, reject this method of measuring caseloads.

“The entire field, all of the professional organizations that collect data and issue industry standards, have for decades advised agencies to calculate caseload by the number of kids for which each worker is responsible,” said Zukoski, formerly of the Pennsylvania Council of Children, Youth, and Family Services. “When I talk to professionals in other jurisdictions about how Philadelphia calculates its caseload sizes, they’re stunned.”

Marcia Lowry, a lawyer who led a successful legal effort that led to major child welfare reforms in New Jersey more than 20 years ago, said that measuring caseloads by families “hides the true caseload that workers are facing. Because as we know, many families have more than one child. And without a manageable workload, they simply cannot do their jobs.”

The Child Welfare League of America has recommended 12 to 15 child clients per caseworker. By that measure, Philadelphia DHS is regularly expecting workers to handle 20 cases or more at any given time. Caseload sizes are so fundamental to any calculation of risk that the insurance broker Lockton’s recent market analysis identified adverse “staff to case ratios” as a key driver of lawsuits.

“This has been a concern of ours for a long time,” said David Wilson, who left his post as union president in January. “Using the number of families hides a case manager’s real workload” because a single family could mean one child and one address or five children and multiple homes to visit.

DHS’s most recently released data indicate five of its CUAs have a median caseload of between 11 and 21 families, meaning that half of those workers have caseloads that exceed its own goal and far exceed CWLA’s recommended standards.

Bezar said he asks about DHS caseloads in his civil suits. “The standard caseload is supposed to max out at 10. And I am regularly getting answers of 12, 14, 17. … It’s a persistent issue, and the correlation between high caseloads and kids facing abuse while in the foster care system doesn’t look like a coincidence.”

In September 2021, he discovered that Turning Points for Children offered $500 bonuses to staffers to take on more than 13 cases each, “offering them more opportunity to screw up … incentivizing staff they know needs the money to take on more cases than DHS’s own policies indicate.”

A possible solution for the problems of caseload size and the abuse of kids in foster care lies in seeing them the way experts have, through the lens of safety science, a method of looking at catastrophes first pioneered within the airline industry.

“The idea is to also look at the circumstances surrounding the incident that enabled or caused agency workers to make the decisions that they did,” safety science expert Scott Modell said. “You wind up solving for less dramatic but more common problems and make these catastrophic failures less likely, too.”

In the case of T.E., safety science would have led back to the fundamental issues of a foster care system with too many kids in it and an overburdened workforce.

Today, DHS leadership touts impressive data to suggest that the CUA system works. The number of kids in foster care has decreased by almost 60% over the last seven years. During this time, the number of children maltreated repeatedly declined as well.

“To reduce the number of kids in foster care by 53%, that’s astounding,” Ali said in an interview last year.

At times, Ali sounds like a reformer.

In February, at a kickoff conference at Temple University’s Beasley School of Law, Philly Voice For Change, an activist organization, laid out its case against the system. As keynote speaker Dorothy Roberts, a University of Pennsylvania law professor, decried the systemic racism of what she calls the “family policing system,” Ali sat in the back, taking notes and offering enthusiastic “mmm-hmmms.”

In interviews with The Inquirer, Ali declined to set any goals for how much further DHS might be able to reduce its foster care population. But some local system professionals suggest Philly would need to cut the number of kids in foster care a further 60% to match New York City’s rates.

Based on the dozens of CUA suits he has brought against the community umbrella agencies, Bezar is the city’s foremost authority on the failures of the child welfare system. He also has served on the board of directors for Juvenile Law Center, the nation’s oldest nonprofit law firm for children.

“We’re talking about a child welfare system that needs a complete overhaul,” he concludes. “It places too many children into foster care, claiming they’re safer, but it doesn’t actually have the capacity to take care of these kids. But this is a system that has always resisted big change.”

Such change would mean far fewer negligence cases for Bezar, a prospect he said he would welcome.

“Put me out of business,” he said. “Please. My goal is for the system to perform so well, there’s no need for me anymore.”

The following reporters contributed to this article: Luisa Suarez, Beatrice Forman, Lucia Geng, Raven Yamamoto, Aakruti Ganeshan, Katrina Janco, Lindsey Perlman, Rjaa Ahmed, Jeffrey Fishman, Amy Liu, Angelique Bacha, Lydia McFarlane, Maria Utz, Stella Vallon, Kiara Santos, Mariyum Rizwan, Amanda DeJesus, and Deesarine Ballayan.