Death Spotlights Foster Care Problems

Donald Philips walked into a hospital last August and reportedly told mental health workers that voices were urging him to kill his foster child. Worried, they admitted him against his will and alerted child welfare workers.

A Los Angeles County social worker responded by interviewing Philips and his wife, who denied the allegations, and observing the child, Michael Ferguson, then 18 months old. With that, the case was closed and the child was left in the home.

At least three other social workers later learned of the allegations, but none checked into Philips’ mental health and its effect on Michael’s care, according to Department of Children and Family Services officials and the agency’s records.

Late last month, Michael was found dead, his face bloody and facial bones sunken, in the family’s room at the Dunbar Hotel on South Central Avenue.

Philips was arrested on murder charges in connection with the death last week. He is being held in Twin Towers Jail in lieu of $1 million bail.

Faced with the tragic and horrifying nature of Michael’s death, leaders of the Department of Children and Family Services launched an investigation and concluded among other things that agency representatives missed signs of caretaker unsuitability because the baby seemed healthy and happy with Philips and his wife, the baby’s grandmother.

At least eight employees face discipline for failure to follow up appropriately on the concerns about the child’s welfare. Anita Bock, head of the department, said the quick results are the product of her reforms of the massive agency, including fundamental changes in the disciplinary process and the method of review of child deaths and public complaints.

Bock has hired three analysts to promptly investigate child deaths and other high-profile cases and to review files at random to find and correct systemwide problems. The changes are intended to eliminate lengthy internal affairs investigations.

“The agency must hold its staff accountable because that’s what the public expects from us and that’s what we owe the children that we are here to protect,” Bock said. “I think the agency’s conduct should be--and is--open to the public.”

The file detailing the circumstances of Michael Ferguson’s death--which Bock asked the court to open after inquiries from The Times--shows how some of the agency’s most entrenched practices can lead to disastrous consequences when allowed to override potential danger signs.

In some senses, Michael appeared to be well off. He was a vibrant and affectionate boy who loved bananas, sneaking three at a time when he got the chance, relatives said. He was smart, too, learning his ABCs at 2 and reciting the Lord’s prayer with a talking stuffed bunny.

When Michael was born on Jan. 26, 1999, tests at California Hospital Medical Center revealed his mother had abused cocaine. He was the third child who social workers took from Debra Ferguson, alleging severe neglect.

An aunt who cared for Ferguson’s two other children could not take a third. Michael’s father was in prison, according to court documents and interviews. His maternal grandmother lived with his mother.

Social workers finally found a relative willing to care for Michael: Patricia Gray, his paternal grandmother.

“I did not want him to be lost in the system,” she said.

There is no indication in the file of how caseworkers evaluated her home or investigated the backgrounds of the foster parents, Gray and Philips, before leaving Michael with the couple when he was days old.

Bock said the department requires such evaluations before placement.

The family lived in a one-room apartment that was formerly a hotel room, but that was not mentioned in internal reports or reports to the court. Philips had a prior arrest record on felony charges that ultimately were dropped, according to the family services department. This was not mentioned either.

Rather, reports to the court spoke of a “safe, loving and warm home environment” with plenty of food, diapers and clothing for the baby. During monthly visits, the social worker assigned to the case noted developmental milestones: reaching and grabbing, weight gain, rolling over, the first few steps.

Then, on Aug. 19, Philips was hospitalized against his will at Kaiser Permanente for auditory hallucinations, according to department of family services records.

The hospital staff reported that Philips said voices ordered him to kill Michael before the toddler killed him, and other voices told him to kill himself. He told mental health workers that he had awakened holding a butcher knife that morning and that he “puts his hand on [Michael’s] mouth and watches [him] until he gets close to unconsciousness,” according to an emergency referral to the department.

Because Philips would be hospitalized for a few days, the call was given an investigative deadline of Aug. 21. But no one investigated that report, according to records.

On Aug. 21, the hospital called social workers again. Philips was due to be released that day. The call was given immediate priority.

A social worker visited the home a few hours after Philips was released. He told the investigator that he was “shocked and upset that the hospital staff had held him against his will.” He said he suffered from depression because of chronic pain, but not schizophrenia. He denied feeling suicidal or ever hearing voices.

“His demeanor and manner suggested to this [social worker] that he was in full control of his actions at this time,” according to the report. “He was pleasant throughout the investigation.”

Gray also assured the social worker that Philips had never hurt her or Michael or acted strangely. She seemed to the investigator to be “an able and adequate caretaker,” family services department records say. Michael looked healthy, and there were no marks on him.

The investigator also spoke to Michael’s regular assigned social worker. He said Gray and Philips were “outstanding caretakers who are taking exceptional care” of the boy.

Based on those interviews, the social worker concluded that Michael was safe.

Records do not indicate whether the investigator sought to find out more about Philips’ psychiatric diagnosis or whether he was prescribed psychotropic drugs or to elicit from treating doctors whether he could be dangerous. Bock said the investigator did not undertake that inquiry.

The case was closed, and no other officials followed up.

Gray, meanwhile, began the process of adopting Michael. In preparation, a separate social worker was assigned to assess the suitability of the home and prospective parents.

Court records show the department checked both Gray and Philips’ criminal records, verified Gray’s employment and sought a number of other documents.

There were a few snags, including the tiny size of the family’s home--which was mentioned to the court but not in great detail. When Philips said he could not remember the name of his previous spouse and did not provide proof of the dissolution of a prior marriage, Gray was allowed to continue the adoption on her own, as a single parent, although she and Philips would be caring for Michael together.

The adoption caseworker knew about the Kaiser referral, Bock confirmed, but did not check into the allegations.

In an interview Wednesday, Gray said she had never seen Philips abuse Michael. In the 12 years she was with him, she also never saw any signs of mental illness, she said.

“He always kept Michael clean,” Gray said.

She said Philips went to Kaiser last summer because he was depressed over the deaths of his mother and brother. He told her he said those things about the voices only to get out of doing something the nurse wanted him to do. Then she said he did it to try to help his case for disability payments from Social Security, a battle he’d been unsuccessfully waging since he was hurt in a car accident three years ago.

At one point she suspected Philips was abusing cocaine and confronted him, she said, but he denied it. Gray, a former addict herself, believed him.

According to Gray and the court records, Michael went to day care during the week, but Philips watched him every other weekend when Gray worked as a clerk at Martin Luther King/Drew Medical Center.

On May 27, Gray was scheduled to work the morning shift, she said. Gray caught the bus at 6:30 a.m., waving goodbye to Michael and Philips. She said Philips was depressed that morning because he’d recently been denied benefits from Social Security and had gotten a final public assistance check.

The radiology department was swamped that holiday weekend. Gray finally ate her lunch at 4:30 p.m. as she waited for the bus to take her home, she said. On the way, she stopped to buy Philips some shoes and finally made it home at 6:30 p.m.

When she got to her room, she said, Michael was lying in his crib, his head turned toward the wall. She thought he was asleep, but when she got near him, she said, she saw blood on his face.

“I rushed downstairs to have security call 911,” she said, then tried to wake Michael. “I thought he had a seizure until the police told me he was hit in the head.”

Philips was gone.

He turned himself in to police on June 6, the same day Michael was buried at Inglewood Cemetery.