The severely disabled boy was kept in bed so long he moaned in pain. He suffered a broken leg for reasons no one has ever determined.
By February 2002, his physician and child welfare workers had grown increasingly worried that the boy wasn't getting the care he needed at a group home for foster children in Randallstown. On March 4, the caseworkers asked other facilities to take Lee, who had cerebral palsy. But it was too late.
The next day, he was rushed to the hospital with a 105-degree fever. His temperature soared to 108 degrees. People who had grown close to the boy called Lee or "Smiley Wiley," a nickname reflecting his sunny disposition, were shocked that he might die.
"He was a medically fragile child, yes," said Christine Bory, who served as Lee's surrogate parent during school planning meetings. "But terminal? No."
His death two weeks later should have prompted an investigation by the Department of Human Resources, in accordance with its policy. But it did not. The only inquiry was a response to his school's complaint about his care - so cursory that no effort was made to determine whether he had been neglected at the home.
The regulatory breakdown in Lee's case illustrates a broad failure by the state to protect the interests of 2,700 youths who live in 330 privately run homes in Maryland. The state licenses and funds the facilities but does not routinely hold them accountable for the quality of care they provide - putting children at risk.
"It's a scandal waiting to happen," said David B. Mitchell, the former chief Juvenile Court judge in Baltimore City Circuit Court, who still hears cases. Monitoring is so poor, he said, that orphanages may have provided better care than some group homes that replaced them.
"We know what's happening," he said. "We're not properly funding, staffing and monitoring."
The Sun has documented the state's failings by systematically examining the regulation, spending and care at 25 companies that ran 120 homes, a sampling of more than a third of the total.
Reporters interviewed 150 group home staff members, doctors and nurses who treated the youths, and social workers and advocates assigned to their cases. They studied 15,000 pages of medical reports, case files and a decade of group home records obtained under the state's Public Information Act. And they consulted with lawyers, social workers and other experts.
The Sun's investigation found that:
Regulators often license unqualified operators and then largely rely on them to police themselves. Homes escape scrutiny by ignoring requirements such as reporting a serious injury.
Supervision has been so lax that children were injured because counselors weren't present or paying attention. At a few group homes, police have investigated allegations that boys were having sex with prostitutes or other women brought there by employees. Staff members at several group homes have been accused of furnishing drugs and alcohol to residents.
The department's files show that one child died of complications from cerebral palsy, another from a viral infection. Two girls were found not breathing; two others died after being hit by a car. One boy died in a head-on collision with a dump truck after stealing a car; another fell from a van. One girl committed suicide. Six children were murdered, none in a group home, most after running away.