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.
Travon Morris, 5, died in February from burns that he suffered when his mother, Sheila Avery, forced him into a tub of scalding water. Prosecutors in that case, in which Avery was sentenced to 20 years in prison, complained in court that the system returned the boy from a safe foster home to an abusive, troubled parent and provided little follow-up care.
Determining the responsibility of Social Services or the courts in these cases is difficult, because their officials refuse to discuss the deaths or release records.
But criminal court files and interviews suggest that all strands of the safety net broke for David Carr, the 2-month-old whose ashes sit in a container on the shelf of a relative's worn rowhouse in West Baltimore. He was abused, and social workers and the juvenile courts failed to save him despite knowing that he was being born into a violent family.
Critics also point to the criminal court system. Prosecutors and Baltimore Circuit Judge Allen L. Schwait decided against a prison term for Keisha Carr on June 28, 2002, when she pleaded guilty to child abuse for breaking her first son's arms and legs.
Instead of sentencing her to 15 years on the abuse charge, the officials offered a plea bargain that let Carr go home. An assault charge was also dropped.
Jim McComb, chairman of the Coalition to Protect Maryland's Children, said he found it disturbing that the courts and Social Services failed to consider Carr's guilty plea to child abuse charges as a reason to put the children in foster care.
"When you have a woman who has admitted to abusing a child and having mental illness problems, it is really unconscionable and irresponsible that the system would not follow up and protect the children," McComb said.
The juvenile courts - which handled the custody portion of the case - also made mistakes, according to critics. On Oct. 1, 2002, Juvenile Court Judge Joseph H.H. Kaplan allowed the abused baby, James Carr IV, to return home to his parents, provided that his mother's contact with him was supervised by her husband or another adult.
James Carr IV was then badly treated by his family, suffering such severe malnutrition that he had to be hospitalized, according to a source familiar with juvenile court records, which are sealed.
"I have no independent recollection of it," Kaplan said of his custody decision. "There have been hundreds of cases, if not thousands, between October 2002 and the current date."
'She went through a lot'
Keisha Carr's story underscores the difficulties of a life racked by mental illness and extreme poverty - the kind of desperation that Social Services workers struggle to deal with every day.
Carr is a ninth-grade dropout who for a while worked the night shift as a security guard at a Baltimore-Washington International Airport parking lot.
Her mother and her family live in a red brick public housing rowhouse in the 800 block of W. Fayette St. on the west side, where gunfire and boarded-up doorways are common.
A recent visit to the house, where David Carr died in a second-floor bedroom, revealed walls pockmarked with holes, scuffs and pen marks, but decorated with a cross. Mounds of dirty blankets were heaped on a couch with frayed armrests.
A brown baby doll, stripped of its clothes, lay face down on filthy linoleum, while scores of roaches scurried across the floor, walls, sink, couches and visitors' shoes.
Keisha Carr's mother, Geraldine Bass, 42, a nursing home assistant, heaved some of the blankets off a sofa so a guest could sit and listen to her daughter's story.
She said Carr was a troubled girl who was tormented by her peers because of her half-white, half-black heritage and light skin color, Bass said.
"She went through a lot of depression growing up because she was racially mixed in an all-black neighborhood, and they gave her a hard time," Bass said. "She thought she was ugly, but she was a beautiful girl."
At 18, she met a divorced former military man named James Alexander Carr through a friend. He was 10 years older and liked to push her around and control her, her mother said.
His family saw the relationship differently, with James Carr struggling to manage a partner who was disturbed and mentally limited.
"I always thought she was a little off, but I never thought she was dangerous," said his father, William Carr. "She was just weird. But how do you tell your son to get rid of his wife?"
Keisha Carr suffered an emotionally painful miscarriage and was overjoyed when she finally gave birth to her first son, James Carr IV, on Oct. 26, 2001, her mother said.
"When she finally had James, she would rub her cheek on the baby's cheek and smile and say, 'My boy, my boy.' She loved her son," Bass said.
Although the couple seemed close, behind the scenes Keisha Carr was suspicious of her husband, angry and self-abusive, according to a transcript of a taped interview she later gave to police. She tried to kill herself and required hospitalization for mental illness in 2000 and 2002, according to court records.
"I use to throw bottles, glass and stuff at him 'cause I thought he was cheating on me," she told police. "I found letters from his old girlfriends. There were several times I cut my hand up. It was times I scratch my face up, my arms and pull my hair. I got bald spots cause I keep pulling my hair. ... By hurting myself, just cutting myself up, I want the pain to go away."
Child abuse case
On Jan. 18, 2002, the couple took their 2-month-old son to Johns Hopkins Hospital, telling doctors they had noticed a swelling in his left arm.
An examination found that both of the baby's arms and legs had been broken, court records said.
On June 28, 2002, Keisha Carr agreed to plead guilty to child abuse if the judge gave her three years of probation. Two conditions imposed by the court were that Carr had to take parenting classes and attend individual psychological counseling sessions at the Healthy Start program at 1622 N. Carey St., which helps poor mothers, according to court records.
Social Services workers temporarily placed the abused baby with an aunt, hospital records show. But the juvenile court, on Oct. 1, 2002, allowed the child to return home to his parents.
Reed-Vance, the deputy director of Healthy Start, said her organization shared lots of information about Carr's mental illness problems with Social Services, including that Carr was hospitalized for depression for five days in the spring of 2002.
Carr dropped out of the psychological counseling in November 2002 after fighting with her counselor, and the program immediately reported this to Social Services, Reed-Vance said.
But the warning passed on to Social Services did not lead the agency to ask the courts to put Carr's son and expected baby in foster care.
On Nov. 6, 2002, Social Services workers visiting James Carr IV concluded that he was underweight and malnourished. The agency filed an emergency court motion to remove the baby from the home, arguing that the parents were not feeding him regularly or following through with medical care.
The court granted the motion, allowing Social Services to put the baby in a hospital until he gained weight and became healthier, according to the source familiar with juvenile court records. Then the child returned home.
Second child is born
On Nov. 26, 2002, while Keisha Carr was still on probation for abusing her first son, she gave birth to her second child, David A. Carr. Keisha struggled trying to raise David, who was often congested, cried constantly and threw up after he was fed.
"James and I had a hard time taking care of David. We had a problem getting a job and Social Services were giving us the run around," Carr wrote in a letter in court files. "We had big financial problems."
The juvenile court took custody of James Carr IV away from his parents on Dec. 4, 2002. The child was placed with an aunt, but she soon allowed the child to return to his parents.
A young life is lost
James Carr IV may have been in his parents' bedroom as his baby brother was beaten to death Feb. 12, according to witnesses and family members.
About 9:30 that night, Keisha Carr banged on the door of a neighbor's home, screaming that someone should call 911 because her baby had stopped breathing, according to the neighbor, Dawn Mosley.
"I ran back over to her house, and saw the baby was pale white," said Mosley, 28. "And it scared me so much because when I touched him he was so cold."
The autopsy of David Carr showed that he died of homicide by "blunt force trauma," suffering a broken skull, a shattered leg and multiple fractured ribs.
Some of the bones showed signs of being broken, healed and then fractured again. This suggested that he had repeatedly been beaten or shaken over eight weeks, according to court records.
Police said Keisha Carr confessed to smashing the child's head against the crib and shaking him as an expression of "extreme emotional distress" toward her husband, who she suspected was having an affair.
In her defense, Keisha Carr claims that detectives persuaded her to give a false confession. She said her husband was the only person with the baby in the hours before his death, and asserted that her husband told her that he intended to confess to the killing, according to a letter she sent to Circuit Judge John M. Glynn on Sept. 23.
But Keisha Carr said in the letter that she decided to confess instead because detectives told her that if she took the blame, she would likely be put in a mental hospital or given probation, meaning that neither she nor her husband would go to prison. Her husband has not been charged and could not be reached for comment.
"The honest to God truth is that I do not know what happened to David," Keisha Carr wrote in her letter to the court.
While she was in jail awaiting trial, she gave birth to her third son, Michael Carr, on Dec. 20. At this point, the child protective system finally kicked into gear, with Social Services placing Michael Carr in a foster home with his surviving brother, James Carr IV. But it took a baby's death, murder charges and jail to inspire the protective action.