An exhaustive investigation into the death of a 7-year-old boy who drowned while attending a Philadelphia day-care center run by a woman with a long criminal record found that state officials missed numerous chances to shut down the facility before the boy's death.
The scathing report into the death of Isear Jeffcoat, released Tuesday by the state Department of Public Welfare, detailed mistake after mistake by the agency, including its failure to act even after its own staff concluded that the woman who ran the center was posing as her sister to hide her criminal past.
DPW Secretary Beth Mackereth said Tuesday that her agency had made a series of changes to fix problems revealed by the "horrible tragedy" of Isear's death.
The boy drowned June 29, 2012, in a jammed and dirty swimming pool while enrolled at Tianna's Terrific Tots, a day care center run by Tianna Edwards.
Edwards, 31, is behind bars, awaiting trial on manslaughter charges in the death. She is also charged with collecting welfare checks even while her day-care operation was being paid more than $1 million in taxpayer money - subsidies from the welfare department to help low-income families obtain day care.
After Isear's death, DPW also shut down two day-care centers operated by Edwards' mother, Emma Cox-Watson.
In an interview Tuesday, Cox-Watson said Edwards had not committed identity fraud, but had been a partner with her sister Nikita Smith in the day-care centers.
"They went into business together," she said.
Cox-Watson said her daughter was being made a scapegoat.
"DPW will say whatever they have to say now to make themselves not look bad," she said. "They're trying to clean up after themselves by putting all the blame on my daughter."
Among other reforms since the death, Mackereth said, her agency has increased unannounced inspections of day-care centers, newly required operators and enrolled children to be present during all inspections, and reemphasized the need for staff to check identification.
The 77-page report was prepared by a team of four lawyers from the Philadelphia firm of Conrad O'Brien. The team was led by Louis C. Bechtle, a partner and former federal judge.
The team found that the two day-care sites run by Edwards had amassed 69 violations since 2008 but were not closed by the state agency.
It found that Edwards had posed as her sister to mislead state officials and that even when investigators penetrated the ruse, the agency did nothing.
In part, it attributed the delay to social workers' erroneous belief that a shutdown would impede a separate investigation by the state's inspector general into allegations that Edwards was padding enrollment to boost her subsidies.
Yet even after the agency was assured that it could close down her operation and not interfere with the fraud probe, it did not act.
"There were a lot of players in the mix here," Mackereth said. "We did not want to upset their investigation. There was a lot of missed communications."
The agency suspended five employees during the investigation into the death, including a DPW lawyer and bureau director, a spokeswoman said. Of the five, one was fired, two have quit, one was reinstated, and one remains suspended. The agency refused to name the employees.
Over the years, the report says, Edwards has amassed a long criminal record, including convictions for insurance fraud, a string of shoplifting cases, carrying an unlicensed firearm, and providing false identification to law enforcement.
Though her record permitted the state to bar her from operating a day-care center, she ran two, a little over a mile apart in North Philadelphia.
One was a facility for 14 children on Germantown Avenue. The other, on Rising Sun Avenue, had room for 38 children.
Month after month, the state kept fielding complaints about her operations. Among them: Edwards was posing as her sister, drugs were being sold out of a facility, and a van driver for her operation once ran through a center brandishing a gun.
The agency staff took its time looking into some allegations and sometimes never investigated them at all, the report says.
After three "identity complaints," as the report calls them, a DPW staffer - three months after the first allegation was received - "directly confronted 'Nikita Smith' and asked for her photo identification."
However, the report says, the staffer then never looked at the photo.
Four months later, city prosecutors summoned two state social workers to a meeting, informing them they had arrested Edwards on auto-insurance fraud charges in connection with the torching of a Jaguar she had purchased in a sister's name.
At this Dec. 1, 2011, meeting, prosecutors showed two social workers pictures of Edwards and Smith. They then realized that Edwards had been posing as her sister.
Even so, agency lawyers urged caution, saying DPW needed stronger proof, the report said.
The inaction continued into 2012.
In April 2012 - two months before Isear died in the filthy pool - the state did shutter the Germantown Avenue facility. It had fire-safety violations, broken furniture, and unqualified staff, among other violations.
"These violations constitute gross incompetence, negligence, and misconduct in operating a facility and are likely to constitute immediate and serious danger to the life or health of the children," read an inspection report.
The result: an immediate emergency removal order.
Despite that, Edwards' facility on Rising Sun - the one Isear attended - was never inspected and continued to operate, the report says.
That spring, the report says, some social workers grew upset at the lack of action. One top agency social-work manager was quoted in the report as viewing matters then as "a time bomb waiting to explode."
In May 2012, social workers, agency lawyers, and staffers from the state Office of the Inspector General held a conference call on the case.
According to the report, an agency lawyer and manager told the Conrad O'Brien investigators that inspector general's staffers on the call told their agency to "stand down" so the inspector general could investigate financial fraud by Edwards.
As it happened, the investigation found, the inspector general never did aggressively investigate the case. Sources say the money issues are now under federal investigation.
In any event, the report says, others on the May conference call did not recall any advice to stand down.
In fact, the report says, an agency lawyer later summarized the call as recommending "action on Nikita Smith. . . . Tianna Edwards is operating illegally.
Those notes recapitulated a May 21, 2012, call. Nothing happened. On June 29, Isear was dead.