The tragedies are chilling in their similarity.
Four-year-old Tahirah Phillips was killed in her West Kensington home in April 2016 when her father accidentally shot her in the head.
Two months later, Sani Holmes, also age 4, picked up a loaded gun in the closet of her North Philadelphia house and fatally shot herself.
In both cases, the city Department of Human Services had multiple warnings something wasn't right at home but failed to follow procedures put in place to keep children safe, two agency reviews of the girls' deaths have found.
"No one could have predicted family neglect [and] department neglect would end up in gunshot cases," said Frank Cervone, executive director of the Support Center for Child Advocates, which provides legal assistance to abused and neglected children in court. "But we know bad things are likely to happen in families that have had such recurrent problems and, really, such poor quality of practice from DHS."
The reviews, known as Act 33 reports, were conducted by administrators at DHS, the Philadelphia Law and Health Departments, city hospitals and police, as well as staff of the organizations assigned responsibility for both families. The reports were made public last week.
In the seven years that DHS provided services to Tahirah's family, six different organizations and 53 people were assigned to help the girl, her parents, and siblings. The panel reviewing her death summed the dysfunction up by saying: "Institutional neglect … plagued the family throughout their involvement with DHS."
When abuse or neglect are suspected and a call comes in to DHS about a family, the agency investigates. It then seeks to determine whether abuse or neglect are occurring. In Tahirah's case, DHS investigated and substantiated a slew of horrific claims.
The seven children lived in a house with no running water and warmed by hair dryers and space heaters, according to reports from her file detailed in the review of her death. The refrigerator had no food in it and most meals consisted of two cans of soup split among the children and a tablespoon of oatmeal each.
Children slept on trash bags in bedrooms that smelled of urine. They weren't allowed to go outside.
Maurice Phillips, the girl's father, was accused of beating the children, according to the report.
In November 2015, a caseworker responded to a call that Phillips had allowed his son to hold his gun. The caseworker was told the father had a permit and the allegation was not investigated further.
Tahirah would be accidentally shot by her father two years later while she watched Spongebob Square Pants with her siblings.
Any one of these reports could have prompted DHS to remove the children from the home, the team that reviewed the cases wrote. But with so many hand-offs, it's unclear whether the assigned caseworker even knew the family's history, according to the report.
Asociación Puertorriqueños en Marcha for Everyone (APM), the organization working with the family since 2013, blamed its staff turnover and heavy caseloads in part for the case failures.
When caseworkers leave, a supervisor fulfills their duties until a new one is assigned. "During such periods, it is typical for no substantial work to be done on a case," the report found.
APM declined to comment or provide information on the employment status of the caseworkers involved.
For Edward McCann Jr., a former first district attorney in Philadelphia who led the grand jury investigation into the death of Danieal Kelly — who died in 2006 following horrific neglect while under DHS supervision — the Phillips case reveals deep, systemic issues.
"When we did the Danieal Kelly investigation, it was like every person save one or two, almost every one who had a chance, failed this kid. You're looking at the same type of issues here," McCann said. "So that's not just a bad worker or two, that's why it's so alarming to me."
McCann, now a Montgomery County prosecutor, secured convictions of all nine people charged in the Kelly case and sparked the reform efforts still underway at DHS. He said he'd seen significant improvements at DHS since 2008 but called Tahirah's case troubling.
"I've never seen a family with a history like this," McCann said. "I've seen plenty of cases with unsubstantiated reports but none where the agency identifies serious problems and there's still this lack of follow-through."
Tahirah's father pleaded guilty to homicide and 16 related counts this month and is scheduled to be sentenced in January. Tahirah's siblings have been removed from their mother's care and are living with family members.
DHS was not providing services to Sani Holmes, the 4-year-old who accidentally shot herself in North Philadelphia in June 2016. But the agency had received three hotline calls reporting suspected family neglect or abuse in 11 months. The report criticized agency workers for focusing on surface-level issues and not underlying concerns or child safety.
Nearly a decade ago, DHS created a policy to flag cases in which DHS gets three or more concerning calls within a year. The computer system is supposed to highlight these cases for supervisors to more closely scrutinize. But in the report about Sani's death, DHS officials said the policy is impossible to enforce because there are too many cases with three or more reports in a year.
These sorts of early warning signs can be one of the clearest signals a family is in trouble, experts in the field say.
"The best predictor of a fatality or near-fatality is a family that continues to come to DHS's attention for … neglect reports," said Richard Gelles, professor of social work at the University of Pennsylvania. "As a caseworker, your most important job is not to provide services to the parents, it's to make decisions about the safety and well-being of children in the home."
Sani's mother pleaded guilty to third-degree murder and was sentenced to serve two to four years in prison. Her boyfriend, Demetrius Williams, is also charged with third-degree murder and awaits trial.
DHS looks at both cases as terrible but isolated examples of social work practices gone wrong.
"Issues presented in these cases are not systemic," DHS spokeswoman Heather Keafer said. She emphasized that about 10,000 young people receive DHS services, either at home or in a placement such as foster care. "After years of feeling the aftermath of increased reports due to the [Jerry] Sandusky case and new [child-abuse reporting] laws, combined with the city's own reform efforts, we are now seeing signs of stabilization."
In the year and a half since the girls' deaths, DHS has approved the hiring of more caseworkers so each caseworker has no more than 10 families. The agency has also instructed social workers on how to inform families about gun safety in the home.
Next month, DHS will release a scorecard rating the performance of the 10 contracted organizations, known as Community Umbrella Agencies (CUAs), that work with families. The agency will audit a selection of cases to determine how the caseworkers and supervisors on the front line are performing in one of the hardest jobs in the city.
They won't consider child deaths or near-deaths in a CUA's score.
Keafer said that deaths are rare at DHS. Four children died or nearly died in 2015 in homes where DHS was providing services or had open investigations. In 2016, nine children out of 24 who died or nearly died had ongoing contact with DHS. So far in 2017, six children have died or suffered nearly fatal injuries.
Cervone, of the child advocacy center, works with many of the CUA caseworkers and says he thinks that on the whole, they have improved "dramatically" over the last two years.