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.

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.

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.

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.

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."

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.