Ethan Okula's stomach hurt so badly his legs buckled beneath him.
He was moaning when a teaching assistant at Julia De Burgos Elementary in North Philly took him to the school nurse on Feb. 10. The nurse placed him in a wheelchair because he was too weak to sit up in a chair and kept falling to the floor.
Ethan vomited and fell asleep. He defecated in his pants.
He was 10 years old and he was dying, and no one seemed to realize it.
Ethan had been failed by adults his whole life. Now, when he needed help the most, he was about to be failed by the child-welfare system charged with caring for him.
In fact, Ethan's story is one of wholesale, systemic failure. And it's far from the exception in our city's embattled Department of Human Services.
The city's report on his death, compiled by a team of health professionals, social workers, and prosecutors, is just the most recent one to land on my desk. I'm so tired of reading them.
On Thursday, Mayor Kenney announced Cynthia Figueroa, a former deputy DHS commissioner and the president of Congreso de Latinos Unidos, as the agency's new commissioner.
Figueroa, who replaces acting Commissioner Jessica Shapiro, now faces the task of reforming the agency that had its license downgraded in May, when state auditors cited the swamped agency with dozens of violations of child-welfare laws, including falsified visit reports and sloppy casework.
I don't know if the state auditors read Ethan's file. I hope it's one of the first things Figueroa does. It will help her realize just how much work she has to do to protect the city's vulnerable children.
Ethan was one of the most vulnerable.
Ethan was intellectually impaired. Born at one pound, he had hearing and vision issues. He had medical problems, including a serious bowel condition.
He landed in foster care when he was 7. His father beat him and his brother - "I was going to give the kid another shiner," his dad said at one point, according to the report - and withheld a breathing machine Ethan needed daily.
Last summer, a previous foster family locked Ethan out of their home, leaving him in the summer heat with his belongings - his glasses, inhaler, and hearing aids - before a social worker could come and take him away, the report said.
That's when Ethan was placed in a foster home through the Northeast Treatment Center, one of 30 city agencies that provide foster-care services for DHS. There are about 180 children from DHS in foster care in Northeast Treatment, said Regan Kelly, the company's president.
At 9:35, on the morning of Ethan's death, the school nurse called his foster mother, but she said she could not come to pick him up. She had taken him to a hearing doctor the day before and could not leave work.
The nurse waited with Ethan as he writhed in his wheelchair until about noon, the report said, when she had to leave to teach a CPR class. He was left in the care of a teaching assistant and a school police officer.
The nurse, who was not named in the report, "clearly missed how sick he was," investigators concluded, and noted that an official complaint could be made against her nursing license.
The assistant and the school officer waited with Ethan until 1 p.m., when Ethan's foster mother sent a friend to pick him up.
They should have called 911, the report said. They didn't. They told investigators they had recommended that Ethan be taken to the hospital.
But the friend, a woman who spent time in the foster mother's home, seemed more concerned that the boy might dirty her Mercedes than she was about helping him.
Seeing Ethan in the wheelchair, the woman cursed and told Ethan to "stop making scenes," the report said. Learning Ethan had defecated in his pants, she at first refused to let him in her car.
"He's not getting in my Mercedes-Benz," the report quoted the woman as saying.
She relented only when the school gave her trash bags to cover her seats, the report said. When Ethan was unable to sit up in the car, she yelled at him to "get up" and "pulled him up by his shirt."
The woman told the school staff she wasn't taking him to the hospital. "He pulls this at home all the time," she said, according to the report. He was going home to his room, she said.
School staffers who witnessed the exchange were required to notify DHS of the woman's verbal and physical abuse of Ethan, the report found. They did not.
School District spokesman Fernando Gallard told me the district conducted an extensive investigation of the circumstances that led up to Ethan's death. The nurse was suspended with intent to dismiss, and two other employees were disciplined for their inaction.
The investigation continues, he said: "We need to figure out what went wrong and how we can improve for our students."
When Ethan was taken home from school that day, he lay on a couch until 7 p.m., when his foster mother finally called an ambulance. By then, he was unresponsive, and likely had been for about an hour.
He was dead upon arrival at Hahnemann University Hospital, but doctors still tried to save him.
A medical examiner ruled that Ethan died from bowel obstruction, a likely complication of his medical conditions.
The report said: "The physician noted that the absence of any family arriving to the hospital during or after the emergency was concerning to him."
On the night of Ethan's death, his foster mom lied to a DHS case manager, saying she had picked him up at school. A Northeast Treatment supervisor initially told investigators the mother was one of their "stronger foster parents," the report said.
But the review panel found differently. And it said Northeast Treatment's oversight of the foster home was "severely lacking."
Ethan should not have even been in the care of his foster mother. Her training was not up-to-date and the certificate licensing her home for foster care had lapsed.
The foster mother had a criminal history - including arrests for forgery and theft - that the report said was not documented in her file. The offenses, dating from 1979 to 1982, would not prohibit her from being a foster parent, the report found, but knowing about them could have helped Northeast Treatment assess her suitability as a caregiver. (The agency told me it knew about the foster mother's criminal past and it did not disqualify her.)
The foster mother was "not well educated" about Ethan's medical needs, the report found. "His routine medical care was not being met," it said.
Records of Ethan's care were incomplete, with some details of his treatment added only after his death.
On Thursday, Northeast Treatment vice president Deszeree Thomas said a "thorough external review" of the case led the agency to fire four employees involved in Ethan's care - a program director, a case manager supervisor, a foster parent supervisor, and a case manager.
"We are deeply saddened by the tragic death of this child," she said in an email. "We continue to be very transparent about the issues his death illuminated for us."
All of the agency's foster parents are being retrained for recertification, she said.
Ethan's foster mother has been decertified as a foster parent and DHS has taken steps to ensure that no other children are placed in her care. And her name has been placed on a national registry to alert other states of her foster-care history.
The woman has retained a lawyer, the report said, and she and the friend who picked Ethan up at school are no longer cooperating with DHS and city officials investigating the death.
A woman who answered the door of the foster mother's home Thursday said that the foster mother was at work and that she would pass on my request to talk.
The woman, who said she was not the one who picked Ethan up at school that day, said the boy was a "sweetie pie." She did not say anything more.
The report found still more failures in Ethan's case by Turning Points for Children, one of the 10 community umbrella agencies DHS contracts with to handle the bulk of its child protection and foster-care services.
The agency failed to schedule follow-up medical appointments for Ethan even as his primary physician urged them to do so, the report said.
His care suffered in the confusion as DHS turned over many of its services to private contractors, the report said. His critical medical information wasn't even completely entered into the agency's database.
City officials said they were saddened by Ethan's death and the disturbing details laid out in the report. They said they would seize on the report as a guide for improvement.
"It is heartbreaking when any child dies, but this case is particularly troubling," said Eva Gladstein, the city's deputy manager for children and families.
Ethan Okula was 10 years old when he died a wholly preventable death. If one person had spoken up, taken action, gotten him to the hospital, Ethan would be alive today.
Instead he was buried in a cemetery without a tombstone.
Ethan's death was a failure of individuals that became a failure of a system when one by one they did nothing, or did the wrong thing.
He was failed by the adults in his life, by the system charged with his care. Now, it's up to the system to make sure it doesn't fail him in death. It's up to the new commissioner, and those who work for her, to realize how much work they have to do to save the next Ethan.