Grand Jury Report - good wording -please read

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Marina
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Grand Jury Report - good wording -please read

Postby Marina » Tue Aug 12, 2008 4:05 am

This document is so good because it shows the wording to describe a lot of situations.

For example, it says that "It is the responsibility of ___ to do such and such." Or, the worker "failed to do her job"...



http://www.phila.gov/districtattorney/p ... HS_new.pdf

page 6

Introduction to the Grand Jury Report

We almost wish this had been a whodunit.
But we know who did it. The real question was: How could they?
How could parents have been so unloving? How could professionals have been so indifferent? And most of all, how could the Philadelphia Department of Human Services – the giant, expensive safety net we have set up to protect the children of uncaring or incompetent parents – have been so uncaring and incompetent?...

page 7

Employees of DHS and the private agency it hired were, when they bothered to show up at all, literally on the other side of the door. But they rarely if ever went inside. The biggest flurry of activity occurred only after Danieal died – when supervisors and staff scrambled to manufacture records in an effort to make it look like they had been doing something....

That is why DHS – and the private company hired by DHS, which called itself “MultiEthnic Behavioral Health” – exist. Yet these agencies, whose sole function is supposed to be protecting children from such parents, passed up almost every opportunity, over a period of years, to save Danieal.

As a result, we are recommending charges against not only the parents, but also several employees of DHS and its outside agency. These employees should be prosecuted for endangering Danieal by failing to fulfill their legal duties of care, and for attempting to cover up their inaction through record tampering and perjury. ..

page 8

The dysfunction at DHS goes deep, down to the bone.

page 11

Section IV - The Responsibility of DHS

Caseworker Poindexter

Danieal’s plight was first brought to the attention of DHS in August 2003, three years before her death. Unfortunately, for two of those years her case was stuck in the do-nothing hands of social worker Dana Poindexter. Poindexter was an “intake” worker. He was required to decide – within 60 days – whether a report of neglect was substantiated, and whether the child was in need of social work services. Yet even as reports mounted – four different complaints about danger to Danieal in less than two years – Poindexter refused to perform his duties. Only after a fifth complaint was (essentially by accident) assigned to a different intake worker, who actually did her job, did DHS determine that the Kelly family needed assistance. The evidence is maddening:

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For two full years, Poindexter failed to fill out a single document – not the required investigation reports, nor the progress notes, nor the risk assessments. When the case was finally reassigned, his backlog was disposed of by simply designating the complaints about Danieal as “unsubstantiated” or “unable to complete” – even though every single one was in fact true and easily verified.

A friend of the family who had been trying to get DHS involved ran into Poindexter and reiterated her concerns about Danieal’s welfare. Poindexter held his hand up in her face and told her it was none of her business.

During this investigation, we found a tall, filthy cardboard box in Poindexter’s cubicle, big enough to hold a file cabinet. The box was filled to the top with random case files, food wrappers, and unopened business envelopes (some with four-year-old postmarks). At the bottom of the pile was Danieal’s file.

Danieal Kelly was not even the first child to die under Poindexter’s inaction. In another neglect case assigned to Poindexter, he failed to conduct a home visit and check on the children. Three months later an infant in the house was dead.

Despite all of this, Poindexter received evaluations of “satisfactory” and even “superior.” He is still employed as a child protective social worker at DHS.

Caseworker Sommerer

Laura Sommerer was the DHS social worker assigned to this case when it finally slipped past the obstruction posed by Poindexter. All Sommerer had to do to save Danieal was to make sure the child was enrolled in school and seeing a doctor. And even that much did not primarily require Sommerer’s own hands. Her job was largely to monitor the outside contractor who was hired by DHS to provide day-to-day intervention with the family. She didn’t do it. After ten months of Sommerer’s “supervision,” there was still no school, no medical care; and Danieal was dead. In retrospect, we can see why:

Although she had only 18 families in her caseload, Sommerer never even read the DHS case file documenting the persistent problems and excuses that eventually killed Danieal.

Over the last five months of Danieal’s life, there’s no evidence Sommerer ever even discussed the case with the outside contractor she was supposedly monitoring.

page 13


Even when she personally visited the Kelly apartment, Sommerer failed to check on Danieal; on the last occasion, five weeks before the child’s death, when she had already lost 50% of her weight and was at times left sitting in her own urine and feces, Sommerer noticed nothing amiss at all.

Nor did Sommerer feel compelled to comply with her mandatory reporting duties. The records we received did include a review prepared by Sommerer, which she signed and dated “June 29" (when Danieal was still alive). But computer analysis revealed that in truth the document was created more than a month later – only after the girl had died and the heat was on.

While such conduct had dire consequences for Danieal, it did not for Sommerer: she was rated as “outstanding,” and is still employed as a DHS social worker.

The DHS hierarchy

Danieal Kelly did not die just because she was unlucky enough to draw bad social workers, twice. While these employees were surely ineffectual, they were not anomalous. They were the inevitable product of an institution that had the means to do better, but not the will.
When we started this investigation, we could almost understand how one child could have fallen through the cracks. After all, there is so much misery and, we assumed, so little assistance available. As the evidence came in, though, we found out many things about DHS that we didn’t know, and that we suspect most members of the public don’t know. It turns out that DHS is a surprisingly large agency, with significant resources and somewhat limited responsibilities. DHS itself doesn’t even do the job of providing ongoing services to individual families. Once a determination of need is made, the real work is contracted out to private agencies. Here are some of the details:

DHS has 1600 employees, 500 of them in the Children and Youth Division.

The role of social workers in this division is only to screen incoming neglect reports, and to monitor (in theory) the performance of the outside agencies contracted to provide actual services to families in need.


Even with these narrow functions, DHS social workers are restricted, by law, to a caseload of no more than 30; often the number is lower.

Caseworkers are backed up (in theory) by supervisors who oversee no more than 5 workers; these supervisors are themselves supported (in theory) by administrators who oversee no more than 5 supervisors.
There was plenty of manpower at DHS, therefore, to make sure that Danieal Kelly received the services that would have not only saved but improved her life. The failure to do so was a failure of inclination, at every level of the agency. Details like these illustrate the problem:

None of the supervisors of Danieal’s caseworkers ever asked them to fill out and file required reports – even though timely, accurate reports would have revealed both the danger to Danieal and the complete lack of progress on her case.

Indeed, at least one administrator herself back-dated reports about Danieal, some by more than a year, with false dates and determinations to make it look like they had been properly completed. She said this was a common practice at DHS.

Not only did supervisors never discipline Danieal’s caseworkers for their performance; two of the supervisors were themselves actually promoted. One, ironically, has been placed in charge of “fatality reviews” for all cases in which a child dies while under DHS protection.

The then-commissioner of DHS, Cheryl Ransom-Garner, the top person in the agency, summed it up: she testified before the Grand Jury that no one at DHS had any responsibility for Danieal Kelly’s death.

page 14

Section V - The Responsibility of the Private Outside Agency

After DHS finally recognized that Danieal and her siblings needed intensive assistance, the agency farmed out the task to a private corporation called MultiEthnic Behavioral Health. What could have been a lifesaver was a death sentence. Remarkably, MultiEthnic proved even worse than DHS. That should have come as no surprise, because before this case was assigned to MultiEthnic, the company already had a well-established history of fraudulent behavior – submitting falsified records to DHS

page 15

documenting home visits by MultiEthnic social workers that in fact had not been made. But the business kept flowing to the company anyway, and the same pattern repeated itself in Danieal’s case, with fatal results. Two MultiEthnic employees in particular were culpable.

Julius Murray

He had some tough competition, but Julius Murray may be the person in this case (other than the parents) who did the least of what he was supposed to do. For the five months leading to Danieal’s death, Murray was assigned to be the point person for the Kelly family. He was expected to visit and examine the children twice a week, making sure that they were well fed, in school, and healthy. Instead he was a complete no-show, except insofar as necessary to set up fraudulent billing for services never rendered.

Murray managed never even to meet, let alone work with, Laura Sommerer, the DHS social worker designated to monitor him.

Under his contractual obligations, Murray should have been at the Kelly home, interacting with the family, literally dozens of times. Yet none of the children interviewed after Danieal’s death knew who he was. We believe he never talked with any of them.

Murray did meet with the mother before she starved her daughter to death, but the only thing he accomplished was to have her sign blank forms with future dates, falsely attesting to visits that would never be made.

This was not the only case in which Murray falsified documents for nonexistent work. Evidence before the Grand Jury indicated his use of the same tactics in other cases as well.

Mickal Kamuvaka

Mickal Kamuvaka had a dual role in relation to this matter. Kamuvaka was one of four owner/directors of MultiEthnic. But she was also the direct supervisor of the Kelly case, responsible for assigning a caseworker, monitoring his delivery of service, and


page 16

billing DHS for it. That special role, and the manner in which she carried it out, revealed Kamuvaka as perhaps the most mercenary of the characters we encountered in this investigation. We considered especially the following facts:

Kamuvaka had been personally implicated in previous fraudulent billing to DHS.

For the first several months after getting the Kelly contract, Kamuvaka assigned no social worker to the case at all, instead giving it to an unpaid, untrained student intern. When the intern was unavailable, sometimes for weeks at a time, no one took his place – even though the Kelly family had been designated for the highest level of services, requiring constant, direct contact.

Eventually, although she was almost certainly familiar with his modus operandi, Kamuvaka assigned Julius Murray to the case. She had the temerity to claim that he was one of her best workers.

On the afternoon and evening of Danieal’s death, Kamuvaka convened what was in essence a forgery fest in her office. She summoned Murray and other employees, sat them at a table, and directed them to concoct almost a year’s worth of false progress reports, to substitute for all the work that had never actually been done. The only reservation she expressed was that FBI ink testing technology might later be able to expose the fraud.

Kamuvaka is now a professor of social work at a local university, teaching newcomers to the profession how it should be done.

Section VI – The Investigation of Danieal’s Death

Unfortunately, the missteps in this case did not end with Danieal’s death. The investigative response to the child’s death was itself flawed. ...

page 17

...As a result, the police department’s homicide unit did not become involved until much later, and the crime scene was never processed for physical evidence by police or ME’s office investigators. While there was still more than enough evidence to show what happened (given the testimony of family members and paramedics, photographs taken of the scene, and the body itself), compelling corroborative evidence was lost forever.
These acts were clearly negligent – but other steps taken were actually obstructive. Shortly after the death, the commissioner of the Health Department, which has jurisdiction over the Medical Examiner’s Office, ordered ME personnel to discuss the case with no one. Such an order, which fortunately was not followed, would have impeded the law enforcement investigation of this case, resulting in the loss of additional important evidence. The acting Health Commissioner, Carmen Paris, also questioned the redetermination of the death as a homicide, and called the police department to push for information about the case that was subject to grand jury secrecy. We believe that all these actions were done in the hope of limiting the public relations fallout from Danieal Kelly’s death while under the city’s protection.
The investigative response of DHS itself, at least initially, was better. A conscientious DHS employee (one of several who testified) promptly visited the scene, took photographs, conducted interviews, and came to appropriate conclusions. Thereafter, however, the agency returned to bureaucratic form. Its internal review of the case failed to account for all the years of inaction, failed to acknowledge the previous history of fraud by the outside contractor, and failed to name a single name. The report concluded that the department had no need for the external, multi-disciplinary review that was called for by state regulations. DHS could handle everything by itself.

page 18

Section VII – Criminal Charges
These are the charges the Grand Jury has voted to bring:
Andrea Kelly: Because the evidence indicates that Danieal’s mother acted with malice as to whether she lived or died, and may even have wanted her dead, we recommend charging Andrea Kelly with murder, as well as the lesser offenses of involuntary manslaughter and endangering the welfare of children.
Daniel Kelly: Danieal’s father was no longer on the scene by the time his daughter was starving to death. But his actions in getting her to that point warrant the charge of endangering the welfare of a child.
Dana Poindexter: The DHS intake worker knowingly and repeatedly failed to carry out his duty to investigate, and lied to us about his conduct. We recommend charging him with endangering the welfare of a child, recklessly endangering another person, and perjury.
Laura Sommerer: The DHS caseworker failed to provide any of the promised protection to Danieal and her siblings, and did nothing even with Danieal lying in the next room, skeletal and suffering. The charges are endangering the welfare of a child and recklessly endangering another person.
Julius Murray: MultiEthnic’s man on the scene was essentially a ghost employee concerned only with falsifying paperwork while Danieal went through her final agonies. His conduct amounted to involuntary manslaughter, endangering the welfare of a child, recklessly endangering another person, forgery, tampering with records, tampering with or fabricating physical evidence, tampering with public records, and criminal conspiracy.

Mickal Kamuvaka: The MultiEthnic director organized and perpetuated the fraud that led to Danieal’s death, and gave false testimony about it to the Grand Jury. We believe she should be prosecuted for the same offenses as Murray, plus perjury.

...

page 19

Section VIII – DHS: A History of Child Deaths and Failed Reforms


page 82

The Responsibility of DHS

DHS Workers

Being born to parents as neglectful as Andrea and Daniel Kelly was a tragedy for Danieal, but it did not have to be her death sentence. The Philadelphia Department of Human Services, which is now one of the best funded human services agencies in the country, spends hundreds of millions of taxpayers’ dollars every year on services intended to protect children in such unfortunate situations. Five hundred of the agency’s 1,600 employees are in its Children and Youth Division, the section devoted to protecting children from abuse and neglect. And these are not even the people who provide the actual services to Philadelphia’s children. DHS’s employees are just the decision makers and overseers. DHS contracts with private agencies that actually perform the social work, either outside the home – in institutions or foster homes – or by providing services to children in their own homes.
The prevailing public perception of social work is that caseworkers are overwhelmed by the sheer volume of their cases and this is why, sometimes, children tragically fall through the cracks. But this was certainly not what the Grand Jury observed in Danieal’s case. DHS employees – the social workers and the multiple levels of supervisors and administrators above them – are hardly inundated with large caseloads. Social worker Laura Sommerer, for example, oversaw 18 cases while she was serving Danieal – and, again, she was not providing direct services to any of these families. Each supervisor and administrator had only five employees reporting to them.


DHS workers did not have to do a lot to protect Danieal. Their role was simply to investigate the reports of her neglect, determine that she needed services, and then monitor the provider agency to make sure that it was delivering the services she needed. The Child and Youth Division Policy Manual clearly detailed the DHS workers’ tasks and a timetable for performing them.
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 received a total of 11 reports that the Kelly children were being neglected or abused. The first time a DHS social worker was called to investigate a report of Danieal’s neglect was in August 2003. The social worker found an 11-year-old girl with cerebral palsy, who was not in school, who was receiving no services for her disability, who was not getting even routine medical care.
That very day, the DHS worker should have opened Danieal’s case for services. At the very least, this would mean getting her to a doctor and enrolling her in school. These very minimal steps are all it would have taken to keep Danieal alive. Over the next three years, there were many more such occasions on which the simplest of interventions – or even a measure of humanity – would have saved this girl’s life.
The Grand Jury has identified several DHS employees any one of whom would have prevented Danieal’s appalling death merely by doing their jobs as spelled out in the policy manual. The fact that so many workers failed Danieal, however, speaks to a larger problem than some profoundly negligent DHS employees: it reveals an agency that is broken.


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Dana Poindexter
The social worker who first – and for the longest – failed Danieal is a 16-year DHS employee, Dana Poindexter. Incredibly, Poindexter is still a DHS “child protective social worker” in the department’s intake unit. His job is to investigate reports of child abuse and neglect that are received through DHS’s hotline. After reviewing hotline reports and interviewing the person who made the complaint, intake workers are supposed to visit the reported family, talk to parents and children, inspect the home, investigate the substance of the report, and assess the risk to the children. Depending on what type of neglect is alleged (medical or educational neglect, for example), the intake worker might be required to make what DHS refers to as “collateral contacts” – with doctors, schools, or other family members – to determine whether the children are being properly cared for.
Intake workers are required to write up assessments based on their investigations and to decide whether DHS should “accept the family for services.” (Available services range from those provided in a child’s home, aimed at protecting the child from neglect or abuse, to the removal of the child and placement outside the home.) The policy manual requires that intake workers complete investigations and assessments within 60 days of the abuse or neglect report. This includes deciding whether the facts alleged in a report are true and, separately, whether to provide services to the family or to close the case.
New reports of Danieal’s neglect kept coming back to Poindexter because he never investigated or closed earlier reports.
Thus, when the intake worker Poindexter was first assigned, on October 8, 2002, to investigate a complaint about the dismal conditions in which Andrea Kelly’s children

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lived (mother and children squatting in a house with no gas, no water, no working toilets, and a collapsed roof), his involvement should have ended within 60 days – by December 8, 2002. It should have ended by then with a decision either to provide the Kelly family with services or to close the case if the social worker found that the children were not at risk. But Poindexter did neither of these things. Instead, he merely failed, without explanation, to complete the investigation. Because he did not do the necessary paperwork either to pass the case on to someone else or to close it, it languished in his office until the next complaint came in.
Although Danieal would not move back to Philadelphia from Arizona for another nine months, Poindexter’s inaction in 2002 had serious consequences for her wellbeing. For it is DHS policy that if an abuse or neglect investigation is not properly closed by the intake unit, then any subsequent report of abuse or neglect will automatically be assigned to the intake worker who did not complete the original investigation in the first place. This means that Danieal, who was trapped in a wheelchair and neglected by her parents, would be denied DHS’s protection. She was left helpless because, no matter how many relatives or neighbors reported her neglect, and no matter who in DHS received those reports over the next three years, her case was always reassigned back to Poindexter. And he did nothing to help her or her family.
Because Poindexter did not complete an investigation of the October 2002 report, or any others for that matter, subsequent reports of Danieal’s neglect – in August 2003, in May 2004, in June 2004, and in April 2005 – kept being assigned back to Poindexter. Even though these reports – that Danieal was being neglected, that she was not enrolled in school, and that her medical needs were not being taken care of – were indisputably


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true, and easily verified, the social worker never conducted the investigations necessary to have them declared “substantiated” or to get services for the family. But he did not close the case either, because that also would have required paperwork. For nearly three years, Poindexter failed to complete a single investigative report, progress note, risk assessment, or any other document required by DHS.
Even in June 2004, when another DHS worker conducted the initial home visit and completed almost all of the necessary paperwork documenting Danieal’s unmet needs, Poindexter did not follow through and refer the family for services. Catherine Mondi, who had been employed as a DHS intake worker for 11 years, testified that the June 24 report was originally assigned to her, rather than Poindexter, because of some confusion about whether the family had ever had any previous contact with DHS. She explained that the report came into DHS as an emergency neglect report, meaning that it had to be investigated within 24 hours. The allegations were that Andrea Kelly was not properly caring for Danieal, that the child had no school placement, that she was receiving no services for her cerebral palsy, and that she was heard screaming at various times by neighbors.
Ms. Mondi investigated the complaint and found that indeed, Danieal had not been enrolled in school or received medical attention since returning to Philadelphia a year earlier. The house was overcrowded with 10 children in addition to Ms. Kelly, who was pregnant; her sister; and her mother, who was ill and on oxygen.
Ms. Mondi documented her findings in a report and prepared a risk assessment that rated Danieal at high risk of neglect. When she returned to her office and entered the family’s information into the computer, she discovered that the family already had an

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open case with another intake worker – Dana Poindexter. DHS policy required that she hand over her paperwork to him to follow up and obtain services for the family. Despite Ms. Mondi’s finding that the facts alleged in the June 20, 2004, report were true and that Danieal was being denied essential medical attention, as well as schooling that was required by law, this report was ultimately declared “unsubstantiated.” That determination was made in September 2005, over a year later, without any investigation ever having been completed. This meant that Danieal remained without services, and that her case disappeared again into Poindexter’s cubicle – to be neglected again until the next report came in.
Another social worker quickly determined that Danieal needed services.
This pattern likely would have continued until Danieal died, except that on September 13, 2005, a new neglect report was made to the DHS hotline by a neighbor of Andrea Kelly on Memorial Avenue. Because the caller did not provide Ms. Kelly’s name, an intake worker other than Dana Poindexter, Trina Jenkins, was assigned to make the initial home visit. Like Ms. Mondi, she immediately realized that DHS should provide services to the family. Andrea Kelly was living with eight children in a run-down two-bedroom apartment. None of the children was enrolled in school.
But the red flag, according to Ms. Jenkins, was wheelchair-bound Danieal, who the mother admitted “hadn’t had medical attention for a while.” Unlike Poindexter, who left reports uninvestigated for years and never obtained requested services for the family, Ms. Jenkins testified that she knew the first day, as soon as she saw Danieal and the number of other children, that she would recommend opening the case for services.

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Fortunately, Ms. Jenkins did not follow the DHS protocol that called for her to turn over the case and her paperwork to Poindexter. She testified that when she returned to DHS after the home visit, she spoke to Poindexter about the case:...

Ms. Jenkins ultimately made two additional home visits to ensure that the school-age children other than Danieal were immediately enrolled in school. She then made a referral to open the case for Services to Children in their Own Home (SCOH).

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Poindexter should have obtained services for Danieal in 2003.
Had the SCOH provider actually delivered the needed services, Trina Jenkins’s actions should have saved Danieal’s life. Had Dana Poindexter done his job properly, however, Danieal would have received services at least two years earlier – when the first allegation of Danieal’s neglect was assigned to the social worker. Instead, Dana Poindexter left that report “pending determination” – as the DHS database classified cases that were not acted on – until 2005, when it was deemed “unable to complete.”
That designation was simply false. Notes scrawled on the outside of a folder found buried in Poindexter’s cubicle indicate that the social worker interviewed Naomi Washington and Walter Ingram on September 2, 2003, concerning the report. Surely the social worker could have ascertained from these two that Danieal was not enrolled in school or getting medical care or services for her cerebral palsy. Indeed, Mr. Ingram testified before the Grand Jury that he was concerned about Danieal at that time because of her unexplained screaming, and that he was trying to get her father to take her to a doctor.
Poindexter was presented with a simple case of a disabled, school-aged child who was not in school and had no services or medical care. He should have immediately recommended her for services in September 2003. Surely in May 2004 and June 2004, when further reports came in that Danieal was still without any services, medical attention, or schooling, Poindexter should have acted.
Catherine Mondi and Trina Jenkins both knew, on their first visits to Danieal’s home, that she needed immediate services. In the two years that Poindexter was assigned to Danieal’s case, DHS received five formal reports of neglect about the Kelly children.

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Walter Ingram and Carolyn Thomas personally informed Poindexter on numerous occasions of Danieal’s desperate situation. All Poindexter had to do was to fill out some paperwork so others could help the girl. He did not lift a finger to do so.
Poindexter was indifferent to Danieal’s needs.
The social worker’s callous indifference to Danieal’s fate was revealed to the Grand Jury in numerous ways. Mr. Ingram and Ms. Thomas testified that when they called to tell Poindexter about Danieal’s neglect, the social worker told them it was none of their business. When Ms. Thomas confronted him in person, he put his hand up in her face to stop her from talking to him. In September 2005, he told his fellow DHS worker, Ms. Jenkins, that the girl whose protection had been in his hands for two years, and whose repeated reports of neglect were assigned to him to investigate, was not really his client – that she had just happened to live in the same house as his real client, Danieal’s aunt. That aunt, Andrea Kelly’s sister Necia Hoskins, testified that when Poindexter visited the house, “he just walked in the house, he didn’t even look at Danieal, he just seen the other kids and then left.” She said: “The man don’t do nothing but try to talk to women.”
In his own testimony, Poindexter told the Grand Jurors incorrectly that “it’s not against the [Child Protective Services] law for a parent not to take a child to the doctor. So even if the child did not go to a doctor, that is neither here nor there.” Dr. Richard Gelles, the Dean of the School of Social Policy and Practice at the University of Pennsylvania and an expert on child welfare, testified that Poindexter was “totally

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wrong.” He said that medical neglect is clearly defined under Pennsylvania law and that it is indeed unlawful to willfully deny a child necessary medical care.
Poindexter also told the jurors he was unaware that Danieal was entitled to go to school: “With regards to her educational needs, your guess is probably as good as mine on that note.” He appeared to suggest that Danieal not only did not need special services because of her disability, but that she was not even entitled to routine medical care or schooling: “So to the extent that the child had cerebral palsy, while that is a serious concern and certainly everybody would agree that, you know, it’s unfortunate when a child is afflicted with that, I didn’t get the sense that the child was in any danger or being denied anything that she needed.” Dr. Gelles was incredulous of Poindexter’s claim that he was unaware that the law required that Danieal be schooled. The child welfare expert suggested that for Poindexter not to know that Danieal was entitled (let alone obligated) to attend school, “he must have been asleep during his training.”
Poindexter failed to conduct or document investigations or assessments.
Poindexter testified under oath that he prepared many documents – risk assessments, progress notes, investigation summaries – relating to his “investigations” of Danieal’s neglect reports. Yet none of these appeared in the DHS file. (The paperwork completed by Catherine Mondi and Trina Jenkins, on the other hand, was in the file.) Nor could he find them on his computer. The Grand Jury has no doubt that that he never prepared these documents.
Rather than keep progress notes as required by DHS, Poindexter – when he did anything – kept handwritten notes on the back of printouts of neglect reports or on the


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outside of a file folder found amid trash at the bottom of a box in his office. The notes make clear that Poindexter did next to nothing to investigate the repeated complaints of Danieal’s neglect. In August 2003, when an anonymous caller reported that Danieal’s father beat the children and left them alone, Poindexter’s entire investigation is recorded in the following notes:...

Poindexter never determined if the report was true or if the children needed protection.
Following the May 2004 report of medical neglect, Poindexter’s file shows no investigation at all. When another complaint came on June 20, 2004, Catherine Mondi investigated and found that Danieal was at high risk. Ms. Mondi’s actions resulted in a doctor at a health clinic in Danieal’s neighborhood, the Woodland Avenue Clinic, prescribing treatment for her disability. On June 29, 2004, Dr. Heather Ruddock provided a referral to Danieal for the Cerebral Palsy Clinic at Children’s Hospital’s Children’s Seashore House, as well as for other services. But Poindexter never followed up to ensure that she got the services the doctor ordered.
That Poindexter knew of the doctor’s orders for Danieal’s treatment was evident from sketchy notes that he wrote on the back of a printout of the May 2004 report that was called into DHS. His only contact regarding either the May or June 2004 report is

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recorded on July 17, 2004. Notes from that date record that Andrea Kelly was pregnant and that she was receiving $493.00 a month in Social Security income (S.S.I.) for Danieal’s care. Poindexter also listed the services Danieal was to get: “Wheels Program, Woodland Ave. Clinic, Rehabil, C.E.P., Children’s Hospital, Wheelchair.”
Despite his obvious knowledge that a doctor had instructed Andrea Kelly to get medical care for Danieal, Poindexter did nothing when she persistently failed to do so. Seven months later, in February 2005, Poindexter wrote a few additional notes indicating that Danieal still had not been to the Children’s Hospital’s Cerebral Palsy Clinic at Children’s Seashore House. (There is no explanation why the intake worker was visiting the Kellys more than seven months after he should have made a determination to get Danieal services.) The notes suggest that Andrea Kelly was again telling Poindexter that Danieal would be receiving services beginning in April 2005. The social worker again did nothing to verify this information or to complete his “investigation.”
Dana Poindexter’s excuses and backdated documentation have no credibility.
Poindexter’s “file,” such as it is, on the Kelly family reveals absolutely nothing being done in response to the report that came into DHS on April 20, 2005 (that Danieal still had not received medical care, that she was left dirty, urinating and defecating on herself, and was heard screaming by neighbors). Poindexter told the Grand Jury that he was just about to pressure Andrea Kelly to get medical care for her daughter and to finally verify if the child had received any care, when the family disappeared. The Grand Jury finds this excuse absurd on many levels.

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First, it is impossible to believe that after almost two years of neglecting reports of Danieal’s mistreatment, Poindexter was poised to spring into action. Second, his job was not to provide services to the family, or to schedule doctor’s appointments; his job was merely to gather information and write up an assessment so that a determination could be made whether the reports of Danieal’s neglect were substantiated and whether the family needed services. He did not need to see the family again to do this. He knew where Danieal was supposed to be treated and he could determine that she had never been seen through the medical records (or lack thereof). Similarly, the school district could easily have told him that Danieal was not enrolled in school (although he clearly knew this already). Finally, Poindexter could certainly have found the Kelly family had he tried. He could have contacted any one of the relatives or friends he knew of: Necia Hoskins, Naomi Washington, Walter Ingram, or Carolyn Thomas. Or he could have found where Danieal’s S.S.I. check was being sent. Poindexter handled the April 2005 report exactly as he had the others – he failed to conduct an investigation.
The only document prepared by Poindexter relating to his investigations of years of neglect reports regarding Danieal’s case was one piece of paper, a short summary entitled “Case record 11/20/03-6/20/04.” It stated:..

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This document, prepared in October 2005, was never placed in Danieal’s DHS case file.
Poindexter testified that his administrator, Martha Poller, asked him to write this summary in the fall of 2005. And it was only because Trina Jenkins was trying to help the family – and could not do so until Dana Poindexter and Martha Poller took some action on the previous reports – that this pathetic account was composed at all. The summary is not only self-serving, written to justify the social worker’s own inaction, it is also almost certainly false. There is not a shred of evidence to support Poindexter’s claim that he contacted the family or visited the household – even once – between November 20, 2003, and June 20, 2004. By the time he wrote the summary in October 2005, Poindexter knew that Danieal had never received services for her cerebral palsy.
The summary also demonstrates that the social worker did not do any of the assessments, summaries, or progress notes that he was supposed to. Had he done the routine paperwork, this summary would have been unnecessary. It reveals that he knew, even in 2004, that Danieal’s mother was not in fact following through on getting services for her daughter, since the social worker wrote that he had to “admonish” her on “several occasions.” Notably, the summary makes no reference to three other pending reports (October 2002, August 2003, and April 2005) that Poindexter was assigned to investigate.

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Poindexter’s dereliction in the Kelly case was not an isolated incident....

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Poindexter’s supervisors

As in any large organization, DHS has safeguards so that something as important as the life of a child is not left solely in the hands of one low-level employee. At DHS, these safeguards are policies and procedures and the supervisors who are supposed to apply and enforce them. There are, in fact, several procedures spelled out in the Children and Youth Division policy manual that should have protected Danieal had any one of Poindexter’s supervisors followed them. But none did.
First, the policy manual states: “By the 10th calendar day after the date of [a neglect] report, the [intake] supervisor will review the report to determine the safety of the child, the progress made toward reaching a determination and/or accept for service decision. . . .” It then states that “the supervisor will maintain a log of these reviews which at a minimum will include entries at every 10 calendar day intervals until a determination is made.” And, finally, in what should be a save-all, safety net provision – in case the worker does nothing he is supposed to, and the supervisor is unable to make him – the manual states: “an assessment in pending open status is opened and accepted for service on the 60th day of the referral unless the determination to close the case has been made.” Had just this last procedure been followed, Danieal would have been provided services years earlier.

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By failing to do their jobs, Poindexter’s supervisors facilitated his neglect of the children whose cases he ignored. They failed to demand that he comply with the agency’s policies, and then they covered up his dereliction and their own.

Janice Walker

Dana Poindexter’s immediate supervisor, until she was promoted in July 2006, was Janice Walker, a 30-year veteran of DHS. She supervised Poindexter and four other intake workers. She testified that when Poindexter transferred from another intake unit into hers in July 2003, he brought with him between 70 and 90 open pending cases – that is, cases where there had been an abuse or neglect report but no decision had been made either to open the case for services or to close it. The Kelly family was one such case, having been assigned to Poindexter in October 2002.
Ms. Walker is listed as Poindexter’s supervisor on the first report of Danieal’s neglect and abuse in August 2003 (stating that her father beat her and her brother and that he left them alone in the apartment with the 12-year-old brother caring for his disabled sister). There is no evidence that Ms. Walker did anything to supervise Poindexter or to prod him to investigate either that report or another that came in November 2003. This latter report alleged that one of the other Kelly children was being sexually abused (the details of which are not germane to the Grand Jury’s investigation and should remain confidential). Yet she permitted these serious abuse reports to languish for two years without any determination as to whether they were true.
Ms. Walker testified that she did discuss the May 2004 and June 2004 neglect reports with Poindexter (the reports about Danieal’s going without medical care, school,

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or services for her disability; about the screaming heard by neighbors; about how Danieal’s mother was overwhelmed with numerous children in the house). Ms. Walker said that she “wanted to know why did we have this child who had cerebral palsy sitting in a wheelchair and not being serviced, i.e., being picked up by the little yellow school bus and taken for some type of program during the day.” She said that she told Poindexter about services that the United Cerebral Palsy Association could provide. And yet, Ms. Walker did not demand that Poindexter do the paperwork necessary to get these services for Danieal. Instead, she concurred in a very belated (September 2005) determination that these reports were “unsubstantiated,” which means unproven. This is incomprehensible, since it is irrefutable that Danieal was not in fact enrolled in school, that her mother had eight children in the home and was pregnant at the time, and that Danieal had not been receiving any services for over a year. (Carolyn Thomas, who knew the situation well, was one of the reporters who informed DHS.)
Ms. Walker claimed that Poindexter had told her that Danieal was getting medical care and that she was connected to Children’s Seashore House. She could not say, however, whether the social worker had verified this information, or even that she had asked. In fact, Danieal never received services from Seashore House. Ms. Walker sought to justify finding the two separate neglect reports “unsubstantiated” based solely on these flimsy, and untrue, assurances from Poindexter.
Fully aware of Poindexter’s dereliction, Ms. Walker never insisted that he do his job.
Ms. Walker admitted that Poindexter should have completed an investigative packet, including a risk assessment document, a protective services investigation

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summary, and progress notes from any interviews he conducted. Such interviews are supposed to include collateral contacts such as with schools, medical providers, and relatives. The policy manual requires that this assessment paperwork be completed within 60 days of a neglect or abuse report. Yet it is clear that Poindexter never completed these forms for any of his alleged investigations, and that this is why he was never able to close the case even though all of the reports were declared unsubstantiated. And it is equally clear that Ms. Walker neither insisted that he perform this work nor took action when the paperwork never materialized. This failure is appalling at many levels, not least because Ms. Walker’s job was to supervise five employees to make sure that they completed their investigations. If she did not do this, what on earth was she being paid for?
Ms. Walker testified that, while the assessment paperwork is “part of the formality,” she sometimes would go ahead and make determinations on reports based solely on a verbal discussion with the worker. The paperwork was to follow. This absurdly lax attitude about paperwork is undoubtedly one of the reasons why Poindexter had as many as 90 open cases, and why Danieal never received the services on which her young life depended. DHS procedures require that paperwork be completed and forwarded to an administrator in order to either provide services or close a case. If a worker does not complete the paperwork, cases remain in limbo – along with the neglected or abused children at the center of the cases – until the next report comes in.
Dr. Gelles, the University of Pennsylvania social work expert, labeled Ms. Walker’s admitted practice of determining neglect reports in the absence of a completed investigation or supporting paperwork an “abrogation of the supervisor’s responsibility.” He cited research showing that paperwork completed more than 24 hours after a contact

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was far less valuable than contemporaneous notes. Ms. Walker’s practice, he testified, allowed “the paperwork to degrade in its accuracy and relevance.”
Ms. Walker’s abrogation of responsibility went even further than she admitted, however. She never received the paperwork from Poindexter, because he never did it. Nor was it just paperwork that he did not do. He did not even do the investigations. He did not check to see if Danieal had received medical care for her cerebral palsy, and in fact knew that she had not. He knew that the reports of her medical and educational neglect were true, yet he never made that simple determination, which might have required just a few minutes of work, so that Danieal could receive services. He did nothing to get help for Danieal, and neither did Janice Walker.
Although Ms. Walker characterized Poindexter’s paperwork as “horrendous,” she let it slide and gave him satisfactory, and even superior, evaluations. (She explained that “satisfactory” is “the lowest thing you can get from me.”) She testified that she did not consider it a problem if a worker left cases open for a long period of time without either closing the case or forwarding it for services. She said this even though the policy manual explicitly prohibits precisely this behavior. Ms. Walker said that some of Poindexter’s cases were open for three or four years.

Martha Poller

How Poindexter was allowed to have cases open for years without doing his investigations became clear when Martha Poller testified. Ms. Poller was an “administrator.” She was the supervisor of the supervisor Janice Walker. Ms. Poller oversaw five supervisors, each of whom supervised at most five social workers, meaning


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Ms. Poller knew the proper procedures.
In her testimony before the Grand Jury, Ms. Poller demonstrated her familiarity with the procedures spelled out in DHS’s policy manual. She explained to the Grand Jury that there are two distinct decisions that need to be made on each neglect report that comes in. First, a social worker and supervisor need to make what DHS refers to as a “determination” as to whether the report is substantiated – that is, whether the facts alleged in the report are established. Administrators can be consulted in this decision, but they do not have to sign off on it.
A separate decision is whether the case should be “opened for services.” Ms. Poller said that it was common to decide that a family needs services even though a report was determined to be unsubstantiated. She described to the Grand Jury the process for deciding whether to provide services to a family:...

Ms. Poller at this point would review the file and had to sign off on any decision to open a case for services or to close the case. In her first of two appearances before the Grand Jury, the administrator testified that she never received this paperwork for the May 12 and June 20, 2004, neglect reports in Danieal’s case – meaning that the case remained with Dana Poindexter, with no action taken for 14 more months, until September 2005.
Ms. Poller testified that, as an administrator, she could track by computer when cases were assigned to her workers, and that she also received a list of their cases. She said, however, that when a “determination” was made as to whether a report in a case was substantiated or not, that case was taken off the list, even if it was not closed. Ms. Poller, in her original testimony, suggested that this was what happened in Danieal’s case – that the neglect reports had been determined unsubstantiated within 60 days of the report, and so they did not appear on her list as old, pending cases. Ms. Poller admitted that she was nonetheless aware that workers were sitting on old cases. Danieal’s, she said, was just “one of many, many cases that would not have stood out, especially.” To deal with this backlog, she testified: “I would just go to [my supervisors] and say, ‘please make sure your workers move their cases.’”

Ms. Poller did not follow DHS procedures and falsified case records.

A document found by detectives in the file at the bottom of Poindexter’s box revealed that, even though Martha Poller knew the proper DHS procedures, she chose not to follow them. And she did not demand that those under her supervision follow them either. The document found in Poindexter’s office, attached to the April 20, 2005, report, was a list of neglect reports. It listed no fewer than 11 neglect reports on the Kelly family.

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Sommerer failed to monitor, or meet, the family’s new SCOH worker....

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Sommerer failed to report MultiEthnic’s non-compliance and nonperformance – until after Danieal died.

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Sommerer failed to check on Danieal’s safety as required by law.

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Sommerer’s supervisors
Laura Sommerer’s indifference to Danieal’s plight was more than matched by that of her supervisors at DHS...

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Sommerer’s supervisors did not read the case file before Danieal died...

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Ingrid Hawk

Ms. Hawk was asked why the case was not given a higher priority, in light of the fact that Danieal was the only severely disabled child on her caseload. The supervisor answered:...

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Shawn Davis

Social Work Supervisor Shawn Davis took over the supervision of Laura Sommerer and the rest of her unit in April of 2006. Mr. Davis was a brand new supervisor, having just recently passed the supervisor’s test. According to his testimony, he received no supervisor training before he took over the position. He was put at a further disadvantage by Ingrid Hawk’s failure to keep progress notes or brief him on the cases she handed on...

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Valerie Mond
Both social workers and supervisors in this case ignored deadlines and DHS policies with impunity. The testimony of higher-ups revealed why: nothing more was expected...


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DHS’s Top Administrators

The blame for this total failure of supervision extends all the way up what DHS administrators, especially then-Commissioner Cheryl Ransom-Garner, refer to as the “chain of command.” Had the top officials viewed their administrative structure as a chain of responsibility, perhaps they would have insisted that lower-level supervisors actually perform their supervisory duties. No one between the level of commissioner and social worker was held accountable for the gross failures of responsibility that directly contributed to a child’s death.

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Program and operations directors failed to manage supervisors or hold them accountable...

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Cheryl Ransom-Garner
Cheryl Ransom-Garner, who was DHS commissioner when Danieal died, helped set the tone of unaccountability at DHS.

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Ms. Ransom-Garner concealed the horror of Danieal’s case from the mayor.

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Section V
The Responsibility of the Outside Agency

candymeat
Posts: 12
Joined: Tue Aug 16, 2011 2:12 pm

Re: Grand Jury Report - good wording -please read

Postby candymeat » Tue Aug 16, 2011 5:21 pm

i belive everything be cause if i didnt stand up to dhs my kids woukd be dead as well ,i only feel sorry for the child who dhs,neglected to save when i was the one who said kirkbride on 111n.49street was trying to kill all the shelter,(traverlers aid homeless families,and children,i also brought to the attention of all the dhs workers,oshua AND THE MAYOR OFFICE,AND DHS ADMINISTRATER A CHILD WILL DIE IF THEY DONT HELP,BOTH DIRECTORS,DHS,AND TRAVLERS AID TOLD DHS I WAS MAKING TROUBLE AND WHAT DID DHS DO THREATEN TO TAKE MY KIDS IF I BREATH A WORD,I LEFT AND TWO OF MY CHILDREN ,1- 95%AND THE OTHER TWIN 15%HAS LEADPOISIONING,AND NOW THEY LIE TO THE JUDGE TO KEEP MY KIDS ,IVE DONE WHAT THE COURTS ASKED ME BUT DHS ,ASKES THE JUDGE FOR ME TO DO MORE AND GO TO PLACES THAT WILL LIE FOR THEM,LAMONT BENNETT,MY NUMBER IS 267-456-9010,YA THINK,I CAN GET HELP??????THESE PEOPLE TRIED TO HELP MURDER MY KDS??????


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