Every month or so, for the last five years, a manila envelope has arrived in my mailbox at the Inquirer and Daily News.

Inside are details that are almost impossible to stomach: the city's review of the deaths or grave injuries of children in its care. Kids who, under the watchful eye of the Department of Human Services, were beaten to death by their parents.  Tortured. Burned. Shot. Starved. Thrown out of windows. The many ways an adult can inflict suffering on a child — it's all in those envelopes.

Tahirah Phillips was 4 when she was shot by her father, Maurice Phillips, as she watched tv in their West Kensington home.
Courtesy 6abc/WPVI-TV
Tahirah Phillips was 4 when she was shot by her father, Maurice Phillips, as she watched tv in their West Kensington home.

In these reports the city offers self-examination and recommendations: what it did, what it failed to do, what it has to do next. This summer, it has become chillingly clear that the city agency charged with the welfare of our most vulnerable children knows full well what it has to do. And too often it just can't get it done.

As my colleague Julia Terruso has shown in her reporting, the agency has had to teach itself lessons that it said it was supposed to have learned years ago. These are basic tenets of child welfare: If one child in a home is in danger, they all are. If your employees are negligent and your files incomplete, children will get hurt. And if someone calls three times in a year about a child in peril, throw everything you can at that house. Now.

This summer, more envelopes arrived.

There was the case of Felicia Hickson, who, as Terruso reported last month, threw her 2-year-old son out the window of her North Philadelphia home in March while high on PCP. Officials had removed two of Hickson's children when she was deemed unfit. They left the 2-year-old. Somehow, he survived the two-story fall.

Officials determined that case mangers from Northeast Treatment Center (NET) had severely botched the family's care, citing a slew of shoddy casework.

I remembered Khalil Wimes well. In 2012, the 6-year-old was starved to death by his parents in South Philadelphia after the agency fought to remove seven of his siblings from his parent's care. They left Khalil. His parents slowly starved him.

I remembered Ethan Okula. The 10-year-old died from a stomach illness last year while in the care of his North Philadelphia foster mother. Caseworkers at NET had failed to spot the woman's criminal history, or that she lacked training and certification.

NET, which receives $16 million annually in taxpayer funds, is one of 10 community umbrella agencies that DHS hires to care for children. In Ethan's case, NET fired four supervisors. In Hickson's case, NET fired two more workers. They are not shying away from their responsibility, they say.

An envelope also arrived telling Tahirah Phillips' story. The 4-year-old was shot to death by her father last year at home in West Kensington. High on marijuana, Maurice Phillips had been aiming at the television, police said. Before fleeing, he punched Tahirah's 5-year-old sister, wiping blood on the child, trying to pin the blame.

And another envelope told of Sani Holmes, a 4-year-old from North Philadelphia who killed herself with a gun she found in her father's closet.

Both cases were marked by gross mismanagement and institutional neglect, officials found. Child welfare workers missed opportunity after opportunity to get the child out of harm's way. In reviewing Sani's death, officials talked about a long-ago proposed red-flag system for homes where three complaints had been called in over a 12-month period.

A red-flag system was a good idea when first proposed in 2009. And it was a good idea four years later when they finally put it in place. It's a good idea now.

But now, after all these years, in the wake of yet more deaths, DHS said that it cannot actually enforce this commonsense reform. There are, it said, just too many children with three or more cases in a year for DHS to track. Officials say they are are still trying to figure out a way to isolate the kids in most danger.

DHS says the problems are not systemic. It takes care of thousands, officials say, and deaths are rare. They say it is not fair to judge a child-welfare system solely on fatalities.

So far, six children have died or nearly died in DHS's care this year. Nine died or nearly died last year. DHS is grading the agencies it contracts for care, but doesn't weigh fatalities. Officials at DHS are confident progress is being made. They are hiring more people and training them better, they say.

"A wake-up call" is what DHS called the Hickson case.

All these reports, all these envelopes, all these recommendations were born out of the city's worst case of child abuse: the 2006 death of Danieal Kelly, a 14-year-old disabled girl who wasted away in her Mantua home in plain sight of DHS. It goes without saying that workers on the front line have a terribly difficult job. And progress has no doubt been made. DHS has gone from an agency that buried its mistakes to one that sends them to me every few months.

The most painful thing about the envelopes is not that they don't stop coming. The world can be a cold place; people do terrible things. The most painful thing is reading the same recommendations over and over. For Danieal. For Khalil. For Ethan. For Tahirah and Sani. For a little boy heaved out a window.

The most painful thing is knowing there is a child out there now, smiling, laughing, believing someone's looking after him or her – whose life will be lost and then boiled down to some recommendations. Ones I have been reading about for way too long.