Another life lost on DHS's watch, The agency sent Omega Leach, atroubled 17-year-old, to a Tenn. youth facility in May. A month later, hewas dead.

Another life lost on DHS's watch
The agency sent Omega Leach, a troubled 17-year-old, to a Tenn. youth
facility in May. A month later, he was dead.
By John Sullivan and Craig R. McCoy
Inquirer Staff Writers


http://www.philly.com/inquirer/front...HSs_watch.html


The City of Philadelphia decided a trip south was best for Omega
Leach, an angry teenager who got in trouble for stealing a car.

In May, the 17-year-old arrived at the Chad Youth Enhancement Center
outside Nashville, a mental-health facility for troubled teenagers
approved by the city's Department of Human Services.

His stay was brief.

Leach died after a physical confrontation with staff on June 3. He tried
to choke one counselor, and another staffer pushed Leach facedown to the
floor and pulled his arms behind his back, police said.

Investigators are checking whether the restraint was applied improperly,
preventing Leach from breathing. He was pronounced dead the next day in
a Nashville hospital, about 15 hours after the confrontation.

"There's no doubt that the kid had an attitude and probably needed to be
locked up somewhere," said Sgt. Brian Prentice, of the Montgomery
County, Tenn., Sheriff's Office. "It doesn't mean he has to be dead."

Leach's death was one more lost life on DHS's watch. As with other
Philadelphia youths committed to such centers, his care was DHS's
responsibility. The agency was paying Chad $285 a day for his treatment.

Questions have been raised about the center before. In 2005, a
14-year-old Long Island girl died there of heart failure as she was
being escorted by a counselor.

Although Chad staff was not blamed in her death, Tennessee officials
quit placing teenagers there. New York did, too.

But not Philadelphia.

On DHS's recommendation, judges and social workers continued to send
children to Chad, even though the agency's own reports consistently
criticized its performance, an Inquirer review shows.

After the newspaper began asking questions about Chad and the two deaths
last week, officials in Philadelphia and Tennessee began to take action:

Tennessee's child-welfare agency banned new placements at Chad and said
it would force the facility to improve restraint procedures.

Philadelphia's DHS also froze admissions to Chad. The department said it
was putting into place "a contingency plan" for relocating 45 city
children still at Chad, pending further investigation. Some of the
children are delinquents. Others had been neglected or abused.

A Philadelphia judge criticized DHS harshly for failing to inform the
courts of the 2005 death and said he would insist on better communication.

"It's disturbing to the point that it's unacceptable," said Kevin
Dougherty, administrative judge of Philadelphia Family Court.

Chad and its corporate owner, Universal Health Services Inc. of King of
Prussia, declined to respond to detailed questions. They did issue a
statement defending the facility's record.

UHS owns more than two dozen hospitals and 110 behavioral-health
facilities in 33 states. It bought Chad and 29 other facilities the
month after the Long Island girl died. The deal was worth $210 million.

"We have a reputation and history of being a high-quality provider of
behavioral health and substance-abuse services to troubled youth and
their families," said Duwayne Glaser, Chad's chief executive officer.

He said Chad's training exceeded industry standards.

Chad helps "troubled kids to get better," the statement said. "We take
the responsibility of their safety and care very seriously."

Philadelphia's child-welfare agency has been scrambling to remake itself
since an Inquirer investigation last fall explored a string of deaths of
children under DHS protection.

DHS has undertaken a host of reforms, including new procedures to
evaluate the safety of children. Its workers visit the most vulnerable
children more often and has hired more nurses to spot medical problems.

In a tough report released four days before Leach's death, an expert
panel appointed by Mayor Street said "significant system failures" at
DHS had let children die needlessly.

In particular, the report criticized DHS oversight of the private
agencies that receive millions of dollars to work with the city's
troubled children.

Although Philadelphia has sent scores of teenagers to Chad, paying it $6
million in the last three years, city and state social workers failed to
closely monitor how it was treating those children.

For example, in 2006, Pennsylvania child-welfare officials sent out a
directive strongly discouraging restraint techniques except as a last
resort.

Through a bureaucratic oversight, that directive was never sent to Chad.
On Friday, state officials said they would make sure Chad got the message.

In Philadelphia, DHS officials struggled last week to explain why Chad
continued to earn their approval, even as DHS's own inspectors filed
reports that found the center consistently failed to meet many standards.

For example, one 2005 report said teenagers at the center had complained
that staff members had improperly used physical force to restrain them.
They also complained that staff members had sex with residents and
watched pornography with them.

Before releasing it, the city censored that section of the report,
saying it was related to the ongoing investigation and needed to be kept
secret. The contents were confirmed by sources familiar with the document.

Throughout last week, DHS released confusing, contradictory and, at
times, incorrect information about its dealings with Chad, particularly
what it knew about the earlier death.

On Tuesday, Arthur C. Evans Jr., the acting DHS commissioner, said in a
statement:

"We were not informed of the previous death. It was the Chad facility's
obligation to inform DHS of the 2005 death, but they did not do so."

By Thursday, DHS admitted that was not true.

The agency reversed course after learning that a former Chad executive
disputed its account. The executive said in an interview that he had
flown to Philadelphia to brief DHS officials about the girl's death.

A source at DHS said on Friday that Evans was initially misinformed by a
senior staff member.

Last week, Evans acknowledged failures in DHS's oversight but said a new
system would provide "a much more accurate picture" of the quality of
outside contractors such as Chad.

Steven Oakman heads the contracting office at DHS. "I'll have to refer
you to the commissioner's office," Oakman said on Thursday. "All of the
statements are coming out of there."

After Leach died, investigators descended on Tennessee, including teams
from from DHS, Family Court, and the Philadelphia public defender's office.

They joined local detectives, child-welfare advocates, and officials
from two Tennessee state child-welfare agencies in touring the Chad
grounds. The center is a 20-acre complex in Ashland City in rural
Montgomery County, northwest of Nashville, with a main classroom
building, a gym, and several dorms.

Prentice, who is supervising the criminal investigation, said the
Sheriff's Office had fielded a number of allegations over the years that
Chad residents had been assaulted, either by staff or by one another.

"There are reports all the time," he said. "There's a lot of runaways,
stories [from children] that 'We're being abused out there.' We've had
some broken arms, some separated shoulders."

Prentice said victims would stop cooperating with investigators,
apparently because they feared retaliation from staff or other youths.
No charges have been lodged in any incident, he said.

"They're mostly street kids," he said. "They think they're better off to
keep their mouth shut."

Investigators from Philadelphia recently spoke with about 20 city
children at Chad and heard allegations that raised "serious concerns,"
said Robert Listenbee, chief of the juvenile unit at the public
defender's office.

"The general feeling is that there are a lot of restraints, daily,
weekly and monthly," he said.

Before Leach died, Listenbee said, a child from Philadelphia sustained a
broken arm; since the death, another Philadelphia youth has suffered
facial injuries during a restraint, he said.

"We're concerned about how frequently they use restraints, the types
they use, and the quality of training they have received," he said.

A troubled young man

Outside the Leach family rowhouse in a battered part of Southwest
Philadelphia, the walls are adorned with posters with his photo and
words of farewell for "Manny," as he was known to friends and relatives.

His mother, Paulette Dolby, cried when asked about her son. She referred
reporters to a lawyer, Edith Pearce, who is investigating the death for
a possible lawsuit.

Pearce described Leach as an ordinary teenager who loved basketball and
video games and doted on his younger sister. He carried a grade point
average of 2.7 at Daniel Boone disciplinary school.

"My career goal is to be a lawyer," he wrote recently, in words quoted
in his funeral program. "I like helping people, so I plan to be an
affordable lawyer, and in that case I will have to go to college."

His father, Omega Leach Jr., 50, has been arrested nine times in two
decades and has served time for burglary and drug dealing.

The younger Leach also had a long history of problems. One psychological
report called Leach a "deeply troubled and difficult young man."

According to official records, police arrested Leach at age 14 after he
allegedly cursed and threatened students and teachers at his school,
Tilden Middle. He told one teacher he would "shoot him full of shells,"
police said.

"His mother is very afraid of him and his behavior," police wrote. The
teenager "is out of control."

The city tried to straighten him out. In January 2005, just before Leach
turned 15, he was sent to a private facility in Virginia.

By the time he was 16, Leach was back in Southwest Philadelphia. In
December, police arrested him for racing through his neighborhood in a
stolen Nissan.

Family Court found that Leach was a delinquent, as social workers
labeled him with this diagnosis: "conduct disorder."

This time, a judge sent him to Chad. He arrived May 2.

DHS had been placing children from neglectful or abusive homes there
since 2001.

In 2006, Family Court judges began using the facility as a destination
for a different class of children - those, like Leach, who had committed
crimes.

Dougherty said his judges assumed that Chad was a good option because
DHS had a long history of using it.

He said it was important that DHS and the courts "develop a protocol" to
make sure judges know much more about the places where they are sending
children.

Mediocre reviews

Even as the city accelerated its use of Chad, DHS continued to find
problems.

Over the past four years, Chad's best evaluation found it met just 46
percent of DHS standards. Even so, DHS ranked the place "average" each
year - and kept it on the approved list.

In 2005, Chad met only 34 percent of applicable standards. The reports
found that Chad appeared clean, but faulted it for poorly documenting
its service and for communicating inadequately with residents' families.

Estelle Richman, Pennsylvania public welfare secretary, said that
performance was unacceptable.

"I would say 40 percent out of 100 percent is a problem," she said.

The DHS commissioner at the time of the death, Cheryl Ransom Garner,
faulted Chad for not reporting critical incidents to DHS. "We were
hearing about them from the kids," she said.

She said the agency checked out some of the reports but could not
confirm them. On balance, she said, Chad appeared to be serving children
well.

Nowhere in the thick stack of DHS reports on Chad is there a mention of
the death of 14-year-old Linda Harris on Sept. 18, 2005.

At the time, Chad officials said she collapsed suddenly while being
escorted to a "time-out room" after an emotional outburst.

Harris, who took antipsychotic medicines, had a history of going into rages.

The Nashville medical examiner later ruled she had died of natural
causes brought on by a heart problem and asthma, aggravated by "morbid
obesity." She was was 5 feet, 7 inches tall and weighed more than 300
pounds.

Michael G. Lindley, one of Chad's former owners, said the staff bore no
blame for her death. He said Harris collapsed from a heart attack just
moments after a counselor grabbed her arm.

While a Tennessee child-welfare investigation cleared the facility and
its staff of any wrongdoing, the state nonetheless decided to stop
placing its children there.

"We made a determination it was not worth the risk," said Randall Lea,
assistant to the commissioner of the Tennessee Department of Children's
Services.

Last week, Lea likened the decision to that of a restaurant inspector
who gives a restaurant a 72, when passing is 70 - but then chooses not
to eat there with his family.

"There's a gap between minimum acceptable standards and optimum
practices, and every agency has to decide what they will settle for
within that line," Lea said.

After Linda Harris' death, New York authorities also stopped sending
juveniles to Chad and other out-of-state facilities.

"We generally like to have an extremely high confidence level on where
we place children," said John Desmond, director of probation in Suffolk
County, which had sent Harris to Chad shortly before she died.

"If we have questions about safety, we will not use that facility."

As for Philadelphia, it stopped sending youths to Chad for several
months in 2005, but eventually resumed. Ransom Garner, who said she met
frequently with Chad officials, said she did not recall discussing
Harris' death.

At last count, DHS had 1,554 children in residential centers such as
Chad. Of these, 233 were placed outside Pennsylvania.

Under agency procedure, DHS first tries to place all youngsters inside
the state. Officials say they send them outside Pennsylvania only as a
last resort.

A videotaped scuffle

As sheriff's investigators in Tennessee set out to figure out why Leach
died, they caught a break: Part of the death struggle was caught on video.

An account of the staff's confrontation came from Prentice, who is
supervising the probe.

A counselor confronted Leach about 2 p.m June 2 and told him to leave
his dormitory room. Residents are not permitted to stay in their rooms
all day.

Leach responded by shoving and trying to choke the counselor. A camera
focused on the dorm hallway caught what happened next: "You see them fly
out in the hall, with the juvenile actually being the aggressor."

The pair then tumbled back into the same room, out of the camera's view.
Another counselor and a nurse run into the room, and the first counselor
walks back into the hallway, visibly exhausted.

Inside the room, according to statements from Chad staff, the new
counselor applied a restraint technique as the nurse slipped a piece of
plastic under Leach's chin so he could breathe.

According to the statements, it appeared that the counselor, though not
sitting on Leach, was putting his weight across him, while bowing his
arms back, Prentice said.

That may have crushed Leach's diaphragm, he said.

According to a digital timer on the video, the counselor and the nurse
stayed in the room with Leach for 20 minutes. Finally, they emerged and
frantically began seeking a defibrillator.

Prentice said he could not say how long Leach was under restraint.

According to a 2006 report on restraint techniques issued by
Pennsylvania child-welfare officials, "research indicates that most
deaths occur within the first six minutes of restraint."

As yet, the medical examiner has not determined the cause of death.
Toxicological results are not back.

An autopsy did find that Leach, like Linda Harris, had an enlarged
heart. His body bore no bruises or signs of having been choked, Prentice
said.

Prentice said he was deeply troubled at the second death of a teenager
in the facility. He said he expected a long investigation that would
focus in part on the training given the two counselors, both new hires.

"We have a a lot more to do," he said. "We've got to stop this. One is
too many. Two is ridiculous."

Read a panel's report on DHS's failures, and recent news coverage, at

http://go.philly.com/dhs

Contact staff writer John Sullivan

at 215-854-2473 or .

Inquirer staff writer Nancy Phillips contributed to this article.



CURRENTLY CHILD PROTECTIVE SERVICES VIOLATES MORE CIVIL RIGHTS ON A
DAILY BASIS THEN ALL OTHER AGENCIES COMBINED INCLUDING THE NATIONAL
SECURITY AGENCY/CENTRAL INTELLIGENCE AGENCY WIRETAPPING PROGRAM....

CPS Does not protect children...
It is sickening how many children are subject to abuse, neglect and even
killed at the hands of Child Protective Services.

every parent should read this .pdf from
connecticut dcf watch...

http://www.connecticutdcfwatch.com/8x11.pdf

http://www.connecticutdcfwatch.com

Number of Cases per 100,000 children in the US
These numbers come from The National Center on
Child Abuse and Neglect in Washington. (NCCAN)
Recent numbers have increased significantly for CPS

*Perpetrators of Maltreatment*

Physical Abuse CPS 160, Parents 59
Sexual Abuse CPS 112, Parents 13
Neglect CPS 410, Parents 241
Medical Neglect CPS 14 Parents 12
Fatalities CPS 6.4, Parents 1.5

Imagine that, 6.4 children die at the hands of the very agencies that
are supposed to protect them and only 1.5 at the hands of parents per
100,000 children. CPS perpetrates more abuse, neglect, and sexual abuse
and kills more children then parents in the United States. If the
citizens of this country hold CPS to the same standards that they hold
parents too. No judge should ever put another child in the hands of ANY
government agency because CPS nationwide is guilty of more harm and
death than any human being combined. CPS nationwide is guilty of more
human rights violations and deaths of children then the homes from which
they were removed. When are the judges going to wake up and see that
they are sending children to their death and a life of abuse when
children are removed from safe homes based on the mere opinion of a
bunch of social workers.

BE SURE TO FIND OUT WHERE YOUR CANDIDATES STANDS ON THE ISSUE OF
REFORMING OR ABOLISHING CHILD PROTECTIVE SERVICES ("MAKE YOUR CANDIDATES
TAKE A STAND ON THIS ISSUE.") THEN REMEMBER TO VOTE ACCORDINGLY IF THEY
ARE "FAMILY UNFRIENDLY" IN THE NEXT ELECTION...