In November 2002, a health counselor called the Baltimore Department of Social Services in fear, warning that a 22-year-old mother convicted of breaking her baby's arms and legs had abandoned a court-ordered psychiatric treatment program.
The nonprofit Healthy Start program alerted Social Services that Keisha L. Carr might injure her son again. Carr was suffering from severe depression but often didn't take her medication. And she was about to give birth to another child, which her counselors feared could trigger a mental crisis that could put her 1-year-old son and the newborn at risk.
"We alerted Child Protective Services ... and said they need to keep an eye on Keisha because we couldn't," said Maxine Reed-Vance, deputy director of the Healthy Start program. "There was no reason Keisha had to be left with her children. ... She was a sick little girl."
Despite the alarm, Social Services failed to protect Carr's children or place them in foster homes. And three months later, the counselor's fear became reality: Carr's newborn son, David, was beaten to death, his skull smashed, at the same age that his older brother James' arms and legs had been broken, according to court records and interviews.
Carr was charged with murder, and her trial is scheduled to begin Wednesday in Baltimore Circuit Court. Although police say she acknowledged killing the child, she has since said that detectives tricked her into confessing.
The death was a tragedy of a sort that happens with unfortunate but numbing regularity in the city. Child welfare advocates say that the state's child protection system often ignores obvious warning signs, such as past child abuse in a home or a caretaker's mental illness, and that children die with little or no intervention from the juvenile courts or the Department of Social Services.
"This is a major concern that needs to be addressed, especially when the safety of children is at stake," said James E. Craigen, a Howard University professor of social work who is chairman of the city's Social Services Commission.
The number of children who die after entering the state's child protection system is unclear, although the city Health Department estimates that it may be as many as 10 a year.
The factors leading to the deaths are many, including the breakdown of families burdened with poverty and drug addiction, a poorly funded Social Services agency with a history of bad management and poor morale, a lack of good foster homes, and a juvenile court system that is reluctant to remove a child from a biological parent's home, say those who push for reform of the state's child protective system.
The 274 Child Protective Services caseworkers in the city investigate an average of 538 new child abuse and neglect allegations every month, with each worker juggling up to 20 cases at a time. The Child Welfare League of America recommends no more than 17.
Stephen Berry, manager of in-home family services for the state Department of Human Resources, which oversees the city's Social Services Department and Child Protective Services, refused to discuss the Carr case, saying he is obligated to protect the privacy of the family.
But Berry said that, in general, it is difficult for the agency to figure out which children to remove because almost all the families have histories of child abuse, but the parents often attempt to deceive caseworkers and the courts.
"Deaths happen because families can be extremely dangerous places for children," Berry said. "Most of our workers are extremely devoted. So the allegation that they are not doing everything they can to help protect children is an affront to us. When a child dies, it's a shock for everyone here."
Norris P. West, a spokesman for the state Department of Human Resources, said most of the decisions in the Carr case were made under a previous administration. Human Resources Secretary Christopher J. McCabe took office Jan. 20 last year. McCabe and Gov. Robert L. Ehrlich Jr. are proposing to increase spending on child welfare services statewide by $51 million next fiscal year, West said.
"We inherited a lot of problems in Baltimore City," West said. "We also recognize that we need to do a better job in trying to be attentive to the needs of children. We are trying to reform the system."
Two other recent criminal child abuse cases also revealed flaws in the state's child protection system.
Ciara Jobes, 15, was whipped and starved to death in December 2002 while in the care of a guardian, who has been charged with murder. Jobes' death came after the juvenile courts and Department of Social Services failed to check the mental-health history of her guardian, Satrina Roberts, although she had been receiving federal disability aid for schizophrenia and bipolar disorder.