Third of four articles

The pattern was painstakingly documented. Fragile, sick babies were born to mothers in the District who had been abusing drugs or mistreating their children. Doctors and nurses noted their fears for the newborns' safety.

Still, the babies left the hospital with their mothers. And little was done to protect the infants -- even though a government panel repeatedly warned that they could die unless the city took action.

Eleven drug-exposed or medically frail newborns died from 1993 through 2000 after they were released to parents whose troubles were well documented by hospitals and social workers, according to previously confidential records obtained by The Washington Post.

The babies got lost in a system where no one assumes direct responsibility for them. Vague legal definitions and poor communication among caregivers hamstring those who would like to help, according to a review of case files and dozens of interviews conducted by The Post.

In the District's neonatal wards, few rules govern whether and when hospitals should release fragile, drug-exposed babies to troubled mothers. Hospital workers can call the D.C. Child and Family Services Agency when they are worried about sending an infant home, but each hospital makes those decisions differently.

In some instances when a sickly baby died, the hospitals did not notify the agency about the birth. In most cases, though, the agency failed to respond to the hospitals' calls, leaving babies in the hands of parents who were ill-equipped to care for them, according to government records.

"We do not have time to take care of everyone," agency social workers sometimes told hospital employees, according to a confidential survey of hospital staff members obtained by The Post.

"Child and Family Services says, 'We just can't handle all these cases,' " said Elizabeth Siegel, a lawyer who is a member of the D.C. Child Fatality Review Committee, a panel that examines the deaths of District children. "I say, 'We can't handle all these deaths.' "

Saying a Prayer In her four years at the George Washington University Hospital's neonatal unit, hospital social worker Mary Kardauskas had seen her share of premature, drug-exposed babies. In October 1998, a baby girl named Tyrika Michelle Perry caught her eye.

Tyrika, a twin, was born six weeks early and weighed 4 pounds, 3 ounces. Her twin had serious respiratory and intestinal problems and was sent to another hospital.

Tyrika also had respiratory problems, though not as serious as her sister's. But Tyrika cried inconsolably as she suffered withdrawal from the cocaine her mother had used. Kardauskas was concerned.

She called Child and Family Services, the District's child protection agency. Kardauskas worried that the mother's drug use would affect her ability to care for the drug-exposed baby. The agency, which at the time was entering its third year of operation under a federal court order, is supposed to assess such calls and decide whether to monitor the family.

But a city worker told Kardauskas that the agency's "quota" of children was full and that it was unable to accept any new cases, fatality committee records show.

Agency officials now say that should never have happened. "Our quota is never full," said Karen Morgan Fletcher, an agency supervisor.

Hospital workers across the city have long expressed frustration that there is no law in the District that required the city to take further action. "Hospitals are told that the agency cannot act on simply drug-exposed babies without any other concerns," a report from a fatality committee file said.

On Oct. 8, 1998, hospital workers sent 6-day-old Tyrika home to her mother, providing her with an apnea monitor that would sound an alarm if the baby stopped breathing. They told the mother when and how to place the device on Tyrika.

After Tyrika left the hospital, Kardauskas said a prayer. It was a ritual she repeated every time a frail baby went to a home that Kardauskas knew would not be monitored by city social workers.

"These babies can't call 911 if they get into trouble," Kardauskas said.

'It's Crazy' Drug-exposed babies are often born to mothers already known to District social workers because they neglected or abused their other children. The babies frequently are premature, with drugs in their blood, low birth weight, respiratory distress or deformities.

Social workers, doctors and city lawyers disagree about how deeply the government should intervene in these cases. The debate pits those who believe that mothers and children should be separated only as a last resort against others who argue that the government needs to do more to protect children from unsafe homes.

At the core of the debate is the question of whether drug use by pregnant women should be considered neglect or abuse under District law. Right now, it isn't.

"You have to make the connection between drug abuse and neglect to take away a mother's baby," Morgan Fletcher said. "You have to prove that substance abuse precludes a mother from being a good parent. There are functioning drug-addicted parents. You can't take their babies."

Others say that puts babies at risk.

"It's crazy," said Anne Schneiders, an attorney for neglected and abused D.C. children. "You have to wait until the newborn is neglected or hurt."

For years, some District child welfare advocates have been trying to change the law to classify drug use by pregnant women as neglect or abuse, following the lead of several states. If the law were changed, social workers would be required to monitor the babies or prevent them from going home with their parents.

At least 18 states have passed laws requiring some degree of government intervention -- ranging from investigations to removal of the child -- when a mother gives birth to a drug-exposed infant.

Last year, the Ohio Supreme Court ruled that a baby born addicted to cocaine is an abused child. In May, a South Carolina woman became the first mother in the nation to be convicted of homicide by child abuse for giving birth to a stillborn, crack-exposed baby.

Although the debate in the District remains unresolved, the fatality committee's files illustrate how babies have continued to die for the same reasons. The fatality committee began to examine the deaths of D.C. children in 1993 -- five years before Tyrika Perry was born. Committee members noted that medically fragile babies were going to unsafe homes and dying shortly afterward.

In 1994, the committee published its first report.

Its first goal: "Institute a city-wide policy that would require follow-up services to be provided to families of premature infants once released from the hospital."

Over seven years, the committee would recommend 46 more times that hospitals and social workers take steps to protect frail infants. But the warnings, many of which were confidential at the time, largely were not followed.

The year the committee issued its first report, a baby named Iesha Ferrell was born prematurely and weighed 2 pounds. Iesha and her twin sister were sent home to their mother with apnea monitors.

Child and Family Services had opened a case on Iesha's siblings the year before because of allegations that their mother was using drugs and alcohol and neglecting her children. But the agency failed to track the family, a fatality committee report states.

Records show that an agency social worker assigned to the case provided some services but "didn't address the mother's substance abuse problem." The worker then did not visit the family for more than a year "due to her heavy caseload," according to a fatality committee report.

The social worker didn't know that the premature twins had been born -- or were sent to a crowded two-bedroom home where nine children were living with four adults. A police officer would call the living conditions "deplorable."

Two months later, Iesha died. The D.C. medical examiner classified the death as sudden infant death syndrome, or SIDS, which is usually the cause given in the unexplained death of an infant. When her body was found, Iesha was not attached to the apnea monitor. In an interview with The Post, Iesha's mother denied using drugs. She also said that a nurse told her she could stop using the monitor after it set off several false alarms. But she told the police that she did not know the purpose of the monitor and hadn't used it for several weeks, according to a police report.

In its 1994 report, the committee noted Iesha's case and urged city officials to consider changing the law: "Explore legal barriers to removing newborns at birth from mothers who are addicted to drugs during pregnancy or mothers who have children currently in the child welfare system."

One After Another In December 1995, Keyona Debrew was born prematurely at D.C. General Hospital, weighing 4 pounds. Child and Family Services had previously removed several children from the mother after receiving neglect complaints.

Keyona's grandmother, Lucy Brown, told The Post that her daughter had a history of mental and behavioral problems. The daughter, herself a foster child, started having children at 15, Brown said. Keyona was her ninth. "She was living wildly because she was on drugs," Brown said.

On Feb. 11, 1996, about a month after D.C. General sent Keyona home, the infant was found dead in a roach-infested apartment. Keyona's mother told police she awoke to find Keyona sleeping on her chest, her male companion's leg draped over Keyona's head. The fatality committee said the police report did not indicate whether the man was interviewed. Keyona's cause of death was listed as undetermined at first, but it was later reclassified as a homicide.

When it reviewed the case later that year, the fatality committee noted the substance abuse and mental health problems of Keyona's mother and criticized the hospital and the agency. "No follow-up services were provided by the hospital or [Child and Family Services] after child's discharge," the committee wrote in a confidential report.

The panel also found that the social worker, Michael Wright, did not visit Keyona after she was born, even though he knew that the baby and her mother needed help. The committee concluded that social worker caseloads were too high and that the workers were not trained to help substance-abusing parents.

Wright said in a recent interview that he did all he could for the mother. He said she had denied being pregnant. He also said he could not visit the house after the baby's birth because of a blizzard early in 1996.

He said he was frustrated that the law did not allow him to do more.

"You cannot take the child just because the child is born addicted," Wright said. "You have to try and monitor the situation the best you can."

Lucy Brown blames her daughter. "It's not just Child and Family Services. Has anybody thought about these mothers who don't care a damn about themselves? I know what went on with my daughter, and I'm not proud of it."

Brown and her son said they did not know how to locate Keyona's mother, and The Post was unable to find her.

In 1997, Dennis Campbell was born prematurely at D.C. General. The baby suffered from respiratory problems and tested positive for cocaine and heroin, which his mother had used during the pregnancy, fatality committee documents show.

D.C. General staffers were worried that the mother couldn't care for Dennis, but no one called Child and Family Services, the records show. If the staffers had checked, they might have learned that Dennis's mother appeared in agency files because one of her other children had been born exposed to drugs.

About a week after Dennis went home, he died. The medical examiner ruled the cause as SIDS.

"The hospital should not have released [the] child without at least contacting Child and Family Services first," the fatality committee wrote in a confidential 1998 report. "Hospitals should always contact [the agency] when a mother delivers a substance exposed infant to determine whether the family was known to the child welfare system."

In 1998, the year after Dennis died, Thornell Price was born at D.C. General. He, too, had been exposed to cocaine. Hospital staff members were concerned about sending Thornell home because of how his mother acted at the hospital. "Her behavior was erratic, and she was stealing from the gift shop," an internal agency report says.

The hospital asked Child and Family Services to remove Thornell from his mother's care. But a social worker said there was not enough evidence to support a neglect complaint, and D.C. General sent Thornell home. At 6 weeks old, the baby died, showing signs of malnourishment, fatality committee records state. The apartment also lacked food and electricity. "The baby should not have been discharged to the mother," fatality committee members said. They termed the agency's investigation "inadequate."

Thornell's mother, who had three other children, had been reported several times to Child and Family Services on allegations of neglect. One time, a U.S. Marshals Service employee notified the agency that she had appeared intoxicated in the courthouse cafeteria and dropped an infant on the floor several times. But a social worker said she was not able to find enough evidence to support a finding of child neglect.

"My daughter was taking drugs," said her father, Willie Price. "That was a known fact. The hospital shouldn't have released the baby into her hands. It was like suicide. It was just a matter of time."

Thornell's cause of death was listed as "undetermined" by the medical examiner.

"There are no standards, policies, procedures or consistent practice for dealing with substance abusing mothers, especially of newborns addicted to drugs," the committee wrote.

Thornell's mother is now in a drug rehabilitation program and said recently she is trying to put her life back together.

"They could have stepped in and said, 'You should get yourself together and then you can have the baby,' " said her father, Willie Price. "But they should not have put that baby in her hands. If they had given my daughter a blood test, they would have found nothing but drugs in her blood. A common person on the street could have looked at her and that baby and not released him to her."

Case Closed

By the time Tyrika Perry was born in 1998 at George Washington University Hospital, the fatality committee had made 32 recommendations to city officials to protect high-risk, medically fragile newborns after the deaths of Iesha Ferrell, Keyona Debrew, Dennis Campbell and several other babies. None of the recommendations was followed.

After Tyrika's drug-exposed birth, hospital worker Mary Kardauskas alerted Child and Family Services, where an unnamed worker declined to take the case, saying the agency had reached its "quota," according to fatality committee records.

Another agency worker called Kardauskas back three days later, after Tyrika had been sent home. Kardauskas said she told the worker that the medical staff at George Washington was "very concerned" about Tyrika going home. This time, Child and Family Services opened a formal case to monitor Tyrika and sent social worker Nadesia Henry to check on her.

Henry wrote in a report that the apartment was tidy, organized and well-stocked with food. Although the baby's mother said she had used cocaine and marijuana while she was pregnant with Tyrika, she told the social worker she didn't need drug treatment because she wasn't addicted.

"She considers herself a social drug user," Henry wrote in the report.

On Oct. 27, 1998, Henry filed her report to agency supervisor Rula Swann, recommending that the case be closed "because there were no other issues of child neglect."

Five months later, on March 22, 1999, Tyrika's mother awoke to find the baby dead inside her blue playpen. A jacket covered her body.

"I started hollering," she recalled in a recent interview.

Tyrika's apnea monitor was not attached. Her mother said a doctor told her she didn't need to use the monitor if the baby was improving.

An internal Child and Family Services Agency review faulted the handling of the case: "The CFSA worker was not adequately prepared to provide services on this case and needed more guidance in understanding and assessing risk with substance abusing parents and the medically fragile child."

Henry, the social worker, declined requests for comment.

"I have decided that it is in my best interest that I do not attempt to communicate with you, as I have no new information to contribute," Henry wrote to The Post.

Swann declined to comment through an agency spokeswoman.

The fatality committee criticized the death scene investigation as "inadequate." This past spring, two years after the event, Medical Examiner Jonathan L. Arden classified the baby's cause of death as SIDS.

Today, Tyrika's mother, who says she no longer uses drugs, works as a medical clerk. Tyrika's twin survived, but her mother still grieves for the baby she lost. The walls of her home are covered with photos of Tyrika. She keeps the playpen under a bed and one of Tyrika's pacifiers on her key chain.

"It was rough for a long time," she said.

Kardauskas, who now works at another hospital, said she has always dreaded the day she would receive a call or read about the death of a newborn who she knew needed help. When she first heard about Tyrika, she couldn't initially recall details of the case. There had been so many Tyrikas over the years, and so many warnings she had called in to Child and Family Services.

"I always heard from the agency, 'Give the mother a chance,' " Kardauskas said. "Indeed, people do deserve a chance. But who was advocating for this child? What about her chance?"

Database editor Sarah Cohen and Metro researcher Bobbye Pratt contributed to this report.

Early warning: Mary Kardauskas, then a GWU Hospital social worker, called the D.C. child protection agency with concerns about Tyrika Perry.A twin who died: A photo of Tyrika Perry, who died at 5 months in 1999, is held by her sister.Medical problems: Tyrika was born six weeks early after being exposed to cocaine. She had a heart murmur and breathing problems. She was found dead in her playpen; SIDS was cited as the cause of death.Concerned about children: Sharan James, left, and Elizabeth Siegel, members of the fatality committee, attend a D.C. Council hearing in June.