A teenage girl developed an infection because she could not bathe.
Suicidal and aggressive teen-agers mingled with abused children and neglected toddlers.
Overworked and frightened case workers were ill-prepared to deal with youths with severe mental illnesses.
Those are some of the things that went wrong in 2005 when a downtown office building was used to house at least 168 foster children, two of them for as long as 40 nights, according to lawyers representing Baltimore's 8,000 foster children in a long-standing consent decree.
In legal documents filed Monday in U.S. District Court in Baltimore, the lawyers requested that a federal judge appoint an independent monitor to finally force reform of the city's troubled foster care system.
State and city social services officials say conditions have significantly improved and that only a few children stay at the state office on Gay Street, and only for a few hours at a time. They say advocates should give the state's new head of social services more time to revamp the dysfunctional system.
"The number of kids that are there for more than 30 minutes or an hour have dropped dramatically," said Samuel Chambers Jr., director of the Baltimore Department of Social Services, a division of the Maryland Department of Human Resources. "That is because we took progressive steps to address that situation," he said.
The lawyers representing the foster children, Mitchell Y. Mirviss and Rhonda Lipkin, counter that at least 50 more children have stayed at the office in recent months, one as recently as Oct. 27. They say the state and the city have persistently failed to comply with the 1988 consent decree.
"It says a lot about the callousness of the system and the individuals involved that they could see children in these conditions and not do anything," said Lipkin, who with Mirviss was allowed access to detailed information about the shelter this year. "It also does not bode well for change in the system."
State officials have been reviewing the attorneys' charges - spelled out in more than 500 pages - and said they will file a response in coming weeks.
On Tuesday, they said they had responded quickly and effectively to the situation at Gay Street. They said they expect to unveil early next year a program aimed at helping psychologically fragile teenagers that should add much-needed resources to the city's foster care system.
Chambers, who has been in his position for about three years, said that he reviews reports daily on the number of children staying at the Gay Street office and that he has taken a personal interest in finding a long-term solution to helping older foster children with complex mental issues. A significant number of those who stayed at the office in 2005 were teens with a history of mental illness. Several were brought to the office directly from mental institutions.
"This has been a labor of love for me," Chambers said of the new teen program. "I had hoped to have something inked six months ago, but it is slow going when you are trying to create something that doesn't exist."
A spokesman for Human Resources Secretary Brenda Donald said it is important to put the lawyers' report in context.
"This is a then-and-now story," said spokesman Norris West. "In June 2005, we looked at the reports, and the average stay for children at the Gay Street office was 5.8 hours. In October 2007, it was 1.9 hours. That change is really important to point out."
Still, the details of what happened at the office when it was serving as an illegal shelter are chilling. Mirviss and Lipkin used the state's Public Information Act to gain access to the files of dozens of foster children who stayed at the office in 2005 and also reviewed staff memos and e-mails.
The office operates 24 hours a day but was never intended to house children. A lawyer for the state acknowledged that the agency was breaking the law by keeping children there, Mirviss and Lipkin said.
"The Gay Street fiasco was, for me, the worst moment I have ever experienced in this particular case," said Mirviss. "I had great hopes that the state would use that disaster as a springboard for real reform. It is very disappointing that they have done so little since then to cure the underlying problems."
Mirviss said his stomach churned when he read staff reports that detailed daily life at the shelter.
At a social services department meeting in May 2005, staff members ticked off the many "safety and liability" issues the shelter presented, Mirviss said, including "children who fight with each other, children who do not comply with staff instructions, children on medication and children who walk out of the facility to smoke or sell drugs."
Staff members also expressed concern that they had too much work to do during the night to keep an eye on teens who might be sexually active. That was of particular concern during a three-day period in May 2005 when there were 11 youths staying at the office building, including three teenage girls and two teenage boys.
"Their behavior placed the younger children and staff at risk for harm," a staff member later wrote in a report reviewed by Mirviss and Lipkin. "The girls continue to argue and want to fight each other. The police were called to help control the situation, but they never arrived," the staff report said.
A few days later, in April, a girl with severe psychiatric problems became agitated and threatened a worker, court documents say. Police were called, and the girl was taken to a local hospital for evaluation. She returned later that same night and once again became abusive. Early the next morning, she left the office and did not return. She was reported as a runaway, the documents said.
Hygiene was also a problem at the shelter, according to the report. There are no shower facilities at the office, and some children went days without bathing. In one case, a young woman developed an infection as a result of not being able to wash herself, the lawyers reported. The infection was so bad that she had to be taken to a local hospital to receive antibiotics, they said.
"Some of the young ladies go 2-3 days without taking a bath or a shower," a staff member wrote in a memo. "They do not smell fresh - they stink. The room at Gay Street stinks."
Many of the children who stayed at the Gay Street office also missed school, according to the lawyers' report. One young woman missed two weeks of school while her caseworker tried to find her a new place to stay. Chambers noted that a 14-year-old girl who was staying there had not been in school for several days.
"We had an opportunity to meet the mentor that had been assigned to supervise this young lady," Chambers wrote in a June 7, 2005, memo to a superior. It goes on to say that the mentor had been "driving this young lady and approximately three others around town for the day to occupy them. None of them were in school, which is particularly troubling."