Washington Post: "Lost Children" im Original

1) 'Protected' Children Died as Government Did Little
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
Sunday, September 9, 2001

First of four articles 

The decision sealed the fate of 2-month-old Wesley Lucas.
D.C. social workers were assigned to protect Wesley from his neglectful mother, a crack addict. So they allowed the baby to stay with his mother's boyfriend. The 69-year-old man was dying of 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 had 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 the dying man over the three-day weekend.
"Who would have thought that the harm would have 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 Charles Williams Jr., King Richardson, Diante Aikens and Brianna Blackmond, whose death last year outraged the city.

In a year-long 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 agency 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 former 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 who were supposed to be 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 told Eddie to take a bus back to the agency to find another group home. 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 has 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 protecting children. "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 many of 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 her other children.

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 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.

2) A Foster Girl Is Sent Away And Dies Alone
Child Protection Agency Failed To Watch Her in Delaware Facility

By Scott Higham and Sari Horwitz
Washington Post Staff Writers
Monday, September 10, 2001

Second of four articles

Bent over in her wheelchair, her spine twisted by scoliosis, NickiColma 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 and had 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.