The Perils of Industrial Mental Health: Documents were forged, and falsified,

From the Philidelphia Inquirer

The social workers who were supposed to watch over 14-year-old Danieal Kelly didn't do much of anything while she slowly died of starvation and neglect.

But they got very busy after she died, according to a grand-jury report.

The call came Aug. 4, 2006. She'd been found dead, looking like a victim of a concentration camp, with rotting bedsores and weighing 42 pounds.

That afternoon, workers for MultiEthnic Behavioral Health Inc. scrambled to forge documents to make it look as though they had been visiting the girl and her family, as they were being paid to do by the city's Department of Human Services.

In the months before the girl's horrific death, the workers for MultiEthnic were not the only ones who failed to do their jobs - or to try to cover their tracks afterward - according to the grand-jury report.

"The fate of a sweet and promising child depended on the willingness of a number of particular adults to do the bare minimum of what they were supposed to do," the report says.

". . . Had just one of them performed their duty or done their job, Danieal would be alive today."

The DHS caseworker assigned to the family, Dana Poindexter, ignored warnings that the girl was at grave risk, the report alleges, and later lied to the grand jury to make it appear he had been doing his job.

Months after her death, a homicide detective found the case file - at the bottom of a box filled with food wrappers and dusty unopened letters, some of which were four years old.

Poindexter testified he didn't know that Kelly was entitled to go to school, or that it was against the law for a parent not to provide necessary care. "He must have been asleep during his training," one expert told the grand jury.

Pressed to provide a summary of the case a year before her death, Poindexter wrote an account that the grand jury called "pathetic," "self-serving," and "almost certainly false."

Poindexter, who had been suspended three times for poor performance, testified that he prepared many documents and put them in the Kelly case file.

"The grand jury has no doubt that he never prepared these documents," the report said. He is charged with perjury, along with endangering the welfare of children.

Reached by phone, Poindexter, 51, declined to comment. He was suspended again by DHS yesterday.

Another DHS worker, who did not bother to enter the girl's room during her last visit, backdated her report, the grand-jury report said.

And a supervisor admitted she falsified case records to make it seem that DHS had investigated old neglect reports involving the Kelly family and found them "unsubstantiated." Called to testify, she told grand jurors that was common practice at DHS; she said it was a bureaucratic procedure that helped hasten services to families.

That supervisor, Martha Poller, is still with DHS and recently was given a new job: project manager for a team that will examine child-fatality cases. During a news conference yesterday, District Attorney Lynne M. Abraham said she was incredulous that Poller had been entrusted with that new duty.

Poller did not return phone calls yesterday seeking comment.She was not charged.

The 258-page report brims with outrage and fierce criticism of the people involved in Kelly's case - not just of the nine people who were charged, but also the people who ran DHS, the investigators who responded to the death, and even a Public Health Department official who tried to squelch her employees from talking about the case.

The findings in the report echoed, in part, the findings of a DHS review panel that found deep problems at DHS and suggested sweeping reforms.

"What I can tell you is: The internal accountability was weak, and the demand for external accountability from providers was equally weak," said Carol Spigner, the head of the panel.

"When that happens, there are a lot of risks in the system."

The grand-jury report found that the management failures began years ago, before Danieal Kelly even arrived in Philadelphia.

DHS workers complained that MultiEthnic was not visiting families as required and was falsifying records to cover it up.

An investigator for DHS found that the fraud charges were likely true. But the agency wasn't fired. Cheryl Ransom-Garner, who later became DHS director, summoned Mickal Kamuvaka and the other directors of the agency and "read them the riot act," the report said.

Later, a DHS evaluation lauded MultiEthnic for its "energetic" performance, calling it "remarkable." When called before the grand jury, Ransom-Garner said she didn't remember hearing any complaints about the agency - a response the grand jury called "incredible."

Ransom-Garner did not return calls seeking comment. Kamuvaka could not be reached for comment.

These missed chances to check up on MultiEthnic would be repeated again and again, the report found.

The agency's caseworker assigned to the Kelly family, Julius Murray, allegedly visited the home only a few times, and the investigation found no evidence he ever met the child.

In previous cases, Murray and other caseworkers allegedly would have families sign batches of blank forms, attesting to visits that never happened. Murray is charged with doing the same thing in the Kelly case.

The fraud was no aberration - "it was MultiEthnic's modus operandi," the report said.

After the girl's death, the grand jury found, the cover-up kicked into high gear.

A secretary, Vanessa Jackson, was told to come in on her day off on orders from Kamuvaka, "Dr. K." The problem: DHS was coming over for the Kelly family file at 4 p.m., and "Dr. K didn't have much of a file."

She was put to work fabricating notes for home visits that never happened, while another employee sat forging quarterly reports.

"I don't want them to test the notes for the ink to see if they had been written earlier," Jackson quoted Kamuvaka as saying.

They kept a courier from DHS waiting for 20 minutes while they assembled the file.

Like Poindexter, the next DHS worker to get the case, Laura Sommerer, didn't find anything wrong with MultiEthnic's performance. She visited the home June 29 and allegedly saw nothing amiss. She later said she didn't try to speak to the girl.

After the girl died, Sommerer's boss asked her for her report on the June visit; she gave it a day or two later.

But after investigators analyzed her computer, Sommerer admitted she didn't write the report until after the girl died. The grand jury called that "an obvious attempt to cover up her negligence."

During the investigation, the top official in the Health Department also tried to squelch information about the case, the grand jury said.

The doctor who performed the autopsy, Edwin Lieberman, said he was told to keep quiet about the case by Carmen Paris, then the department's acting commissioner.

Edward McCann, who heads the homicide unit for the District Attorney's Office, said that Paris told him it was a miscommunication.

Donald Schwarz, deputy mayor for health, said Paris was suspended pending a hearing today.

In October 2006, after The Inquirer published reports on deaths of other children under DHS supervision, Ransom-Garner at first prepared a counteroffensive - an opinion piece attacking the paper's findings.

She admitted that she didn't bother telling Mayor John F. Street much about the Kelly case "because it wasn't in the press."

But then someone showed Street the photographs of Danieal Kelly. The next morning, on Oct. 20, she was called into the office of Managing Director Pedro Ramos.

"This is the case that is going to take the mayor down," Ransom-Garner quoted him as saying.

There would be no opinion column. Instead, Street fired Ransom-Garner and her top deputy.