Twice in Bryanna Harris' short life, social workers investigated whether her mother was neglecting her.
Vernice Harris had abused and neglected her two older daughters, court documents show, prompting Baltimore's child protective services to take custody of them in 2002.
In a half-dozen court orders about the welfare of those girls, no mention is made of their baby sister.
Despite her sisters' removal and despite two reports that Bryanna was being neglected, social workers allowed her to live with her mother in a run-down East Baltimore rowhouse on 25th Street that police said was infested with cockroaches.
"They said everything was cool," Harris' live-in boyfriend, Leonard Rhodes, said she told him after an April visit by social workers.
Less than two months later, on June 5 at that same rowhouse, the ambulance came. Bryanna was dead after ingesting methadone, a heroin treatment drug, and being dealt a blow to her abdomen.
Police arrested Harris last week. She is charged with first-degree murder and is being held without bail.
A statement released last night by Brenda Donald, secretary of the Maryland Department of Human Resources, which oversees the city's Department of Social Services, called Bryanna's death "very disturbing."
Donald wrote that the situation "triggered the demotion" of a supervisor in July and prompted her to order an investigation by the agency's inspector general.
The police description of how Bryanna died appears to be the latest example in Baltimore of a youngster killed by a parent who has already abused another child.
In recent years, similar high-profile cases have prompted calls for the reform of child protective services, but few changes have been made, according to those who follow children's welfare issues.
"This shows the multiple failures taking place in the system," said Matthew Joseph, executive director of Maryland's Advocates for Children and Youth. "Baltimore City, and Maryland in general, unfortunately, are still in the dark ages when it comes to case practices."
Vernice Harris, 30, known in her East Baltimore neighborhood as Peaches, has a drug problem and a short temper with her children, according to former boyfriends and neighbors.
Charging documents in the murder case, as well as child welfare court orders for Harris' older daughters reviewed by The Sun yesterday, show that Vernice Harris has a history of abusing and neglecting her children, though she has never been criminally charged.
In March 2000, when her eldest daughter was about 2, social workers substantiated an abuse case against Harris. A neglect case, in April 2002, also was substantiated by social workers.
The Department of Social Services - a state-operated agency that includes child protective services - took custody of the older girls in 2002 and tried to place them with other relatives. The girls briefly lived with a maternal cousin but soon returned to shelter care, according to court orders.
By January 2007, social workers were telling the juvenile master supervising the permanent placement of the girls that Vernice Harris was uninvolved and "has mental health issues."
The mother had long since stopped attending court hearings, last saw her older daughters in April 2006 and did not ask about visiting them, the court order states.
None of the eight court orders reviewed by The Sun makes any reference to Harris' youngest daughter, Bryanna, and it is unclear whether the social workers for the older girls knew about her. Even if they had, state policy does not call for the automatic removal or monitoring of subsequent children.
Such a breakdown in the system was revealed four years ago in a report of child welfare recommendations written by Dr. Peter L. Beilenson, then the city health commissioner.
His calls for social workers to closely monitor the babies of parents who abused their older children went largely unnoticed until the May 2004 deaths of twin babies.
Emonney and Emunnea Broadway died of malnutrition while living with their parents in an abandoned Northeast Baltimore rowhouse. Six months earlier, the couple's 2-year-old daughter had been removed from their care because of abuse and neglect.
Beilenson, who left the city health department to run for Congress, said he thought child welfare officials were "seriously considering" a program to monitor abusive and neglectful women for new pregnancies.
"We recommended that [DSS] not close a case when a parent's rights are terminated and that case workers continue to check in with them every three to six months, mainly to see if they are pregnant," said Beilenson, now head of Howard County's health department. " ... These are clearly the highest risk parents around."
Dr. Joshua M. Sharfstein, the city's health commissioner, said, "It's something we're working on. It's something that clearly is a gap."
Sharfstein said he and Samuel Chambers, director of Baltimore's Department of Social Services, had spoken several times about starting a "birth match" similar to one now used in Michigan.
That kind of program would involve a database of abuse and neglect cases from social services and a database of new births from the Department of Health and Mental Hygiene. Sharfstein said he believes it also would require legislation, which has slowed progress.
Bryanna was born March 18, 2005. Within days, child protective services workers were investigating a report of neglect.
"Workers responded immediately with intensive family services, spending 35 hours in face-to-face engagement with Vernice Harris over four weeks," the human resources statement reads.
Rhodes, 35, who said he ended his relationship with Harris the day Bryanna died, considered himself a father figure to the little girl.
He called her "baby bear" and she called him "papa bear," he said. He said he tried to protect Bryanna from her mother - whom he said was often out of control.
"She kept Bryanna clogged up in the house, like a criminal or a dog," Rhodes said. "She really never wanted anything to do with her."
Harris would beat her youngest child "all the time for no reason" when the girl was asking for food or to be held, according to charging documents in the death.
Several neighbors said they saw the mother hit the girl. Frank Edwards, who lives across the street on 25th, said he told Harris not to hurt Bryanna.
On April 17, according to charging documents in the case, child protective services investigated its second complaint of the neglect of Bryanna.
Rhodes said he thought social workers came to the house just once, when he wasn't home, and talked to Harris.
The home was filthy and infested with cockroaches when homicide detectives visited it the night of Bryanna's death, two months later.
The statement from human resources indicates the "CPS worker went out immediately and determined that Bryanna was safe."
"The worker also contacted Bryanna's primary doctor, who expressed no concerns and confirmed that her immunization records were current. The worker conducted a satisfactory follow-up visit the next week in which he observed the child and interviewed Ms. Harris and her mother."
Rhodes and others said they wished they had reported Harris' abusive behavior. But they also wondered why the social workers didn't take the child when they came to the house in the spring.
"Why did they leave this baby behind?" Rhodes asked.