Lethal Lapses: 50 botched cases, 53 dead children

They were under the care of a state agency, but that didn't prevent their deaths

- News-Democrat
 May 4, 2008
Fifty-three children died between 1998 and 2005 after state child welfare workers assigned to protect them committed serious errors, made lapses in judgment and ignored their own rules.

Children were beaten, burned, smothered, shaken and starved to death by their parents or other adults, even though the Illinois Department of Children and Family Services was supposed to be protecting them, according to an investigation by the Belleville News-Democrat.

In one case, a full-term baby girl -- posthumously named Vanessa -- died in a ramshackle house in Venice when her mentally ill mother, Jaki Ingram, delivered her into a waste-filled toilet. The DCFS suspended a caseworker and a supervisor for failing to properly assess the case over a five-year period.

In another case, 2-year-old Miracle Moon, of Chicago, died when her mother's boyfriend pushed her head under water because, according to a prosecutor, she was slow at potty training. A medical examiner found more than 50 human bite marks on her buttocks.

State overseers from the DCFS' own Office of the Inspector General investigate child deaths where DCFS worker error or neglect is suspected. The office publishes annual warnings of the consequences of repeated mistakes and offers solutions.

But the newspaper's four-month investigation showed that despite receiving specific warnings regarding the 53 child deaths between September 1998 and January 2005, DCFS caseworkers, child protection investigators, supervisors and contracted private agency workers made repeated errors and failed to properly gauge danger to children.

"No system should tolerate mistakes that can lead to the death of a child," said Bruce Boyer, a law professor at Loyola University in Chicago and director of its Civitas ChildLaw Clinic, which specializes in representing children.

"It makes you wonder what they might be doing wrong in cases where kids don't die."

Bryan Samuels, former director of the DCFS, declined repeated requests for an interview for this series. Samuels resigned Friday.

Investigations of child deaths, which are published one to three years later in inspector general's annual reports, detail department worker errors but do not contain the names of victims, caseworkers or references to where and when a death occurred.

To put a face on these children, the News-Democrat compared these anonymous child death reports to news accounts, police and coroner's reports and other documents.

As a result, the newspaper identified 41 of the 53 children who died and linked errors to actual cases.

The newspaper found that DCFS and private agency workers:

• Repeatedly got suspected abusers' names wrong when making criminal background checks, resulting in false "clean" reports.

• Accepted the word of a suspected child abuser that his son was sleeping and couldn't be disturbed. The caseworker left without seeing the boy, who died an hour later from a beating by his father.

• Failed to fully investigate a scalding case because a state-supplied thermometer did not come with batteries. The child later died of asphyxiation.

• Left a sick, 5-month-old baby boy in the care of a 7-year-old girl. A caseworker said she was in a hurry and didn't have time to wait for the mother to return.

DCFS records are not subject to the state's Freedom of Information Act. This overall confidentiality prevents publicity that could reduce errors by holding DCFS more accountable, said Patrick T. Murphy, a Cook County domestic court judge.

"Kids get tortured and brutalized, and all we ever get is some sanitized report without names, dates or places," said Murphy, who as a public guardian in the 1990s fought to protect children in state care. Murphy said the way to decrease errors is to open the agency's records to public scrutiny.

Kendall Marlowe, deputy chief of communications for the department, said top administrators are aware of worker errors.

"It's a matter of setting up procedures, policies and practices, and monitoring supervision so that if an employee does a bonehead thing, there's somebody right there that catches it before it affects the child," Marlowe said.

Children still die

Despite these procedures, children continued to die during and after botched DCFS child abuse investigations. According to inspector general's reports:

• In Aurora, near Chicago, a child abuse investigator allowed 4-month-old Daniel Bowie's mother to smoke crack cocaine as long as she agreed to first drop the baby off next door. The caseworker accepted this arrangement as a "child safety plan" and allowed Daniel to remain with his mother. A few weeks later, the baby died from a beating in his home. No one was charged.

• In Southern Illinois, 5-month-old Dakota Jean Hedger of Carrier Mills went to the emergency room with "friction burns on her nose, a bruise on her ear, a puncture wound on her foot, a split lip, fingertip bruises on her back and a tear on the underside of her tongue," according to a child death report. A department supervisor sent the baby and her mother to live with a relative, but the two returned to the baby's father without approval. A caseworker could not then locate the family for three days. On the fourth day, a sheriff's deputy called to say the infant was dead. The father is serving 25 years for murder.

• In Chicago, 6-year-old Alma Manjarrez died after her mother's boyfriend punched the girl in the stomach on Christmas Day and left her outside in the snow. A DCFS investigator failed to check with police about a previous episode involving the boyfriend that could have alerted her to potential danger to Alma. The investigator said it was inconvenient for her to talk to the police officer because he worked nights and she worked days.

• In Blue Island, a department investigator was assigned to determine whether it was safe to allow 3-year-old Kenya Riley to remain at home. But the investigator, who was supposed to contact the family within 24 hours, failed to locate them. He finally got word of Kenya's whereabouts six weeks later when a coroner called to say the little girl died from head trauma.

In September, stories about a young East St. Louis mother whose unborn fetus was cut from her womb and whose three children were killed and stuffed into a washer and dryer emphasized the importance of DCFS' duty to protect at-risk children.

The mother had been involved with DCFS as a child, as were her three children.

The inspector general's office does not investigate most deaths of children involved with the DCFS. During the period examined by the newspaper, 780 children died while wards of the state or while having some involvement with the department. Most of these deaths were due to medical problems or accidents.

The inspector general's investigators conducted full probes into 77 child deaths during this seven-year period. The 53 deaths involved cases where the newspaper found significant caseworker error or neglect. In the other 24, there were few or no serious errors on the part of DCFS workers, even though these cases ended with the death of a child.

In many of the child death reports, the newspaper found a combination of errors, instances of neglect and questionable judgment on the part of DCFS workers.

The newspaper's review showed that state child protection workers who commit serious errors are sometimes disciplined, transferred or counseled, but seldom suspended and almost never fired.

In 50 child death cases (two cases involved more than one child), no department employees or private agency workers were fired. Five employees resigned, 12 were counseled and 14 were disciplined or reprimanded.

In 26 cases, the department took no action against any worker after a child's death.

In one case, 7-month-old Edgardo Martin died in January 2005 in a fire at his family's mobile home in Fairmont City. A DCFS investigator noticed three space heaters hooked up on a single series of extension cords, but failed to warn the family and accepted the word of a Spanish translator that it was OK, according to an investigative report. Three weeks later, Edgardo died in a fire the state fire marshal's office attributed to an electrical overload in the series of cords.

The caseworker received no dicipline, while two supervisors received counseling, the report stated.

Finding solutions

Child welfare advocates say openness, increased staffing and less reluctance by prosecutors to bring child abuse cases to court are the keys to reducing worker error.

"In the private sector, if someone makes an egregious error, you could probably discharge them. In systems where you have a Civil Service setting and personnel rules ... you can't do that," said Jess McDonald, who was director of the DCFS from 1990 to 2003.

McDonald acknowledged that while children die under DCFS' watch, including after worker errors, many are helped.

"Thousands and thousands of children over these same number of years have been protected from abuse," he said, adding that eliminating potentially lethal mistakes is probably a matter of increasing supervision and vigilance.

"You know what they say when you walk along the beach," said McDonald. "Don't turn your back to the ocean because that one in a million rogue wave may get you. It's the same with worker error."

Most current and former department workers contacted for this series did not want to be identified or talk on the record. They described the work as stressful and said the department, especially in the East St. Louis office, does not have enough workers.

Gary Guadagano, a former DCFS child abuse investigator, said the department pays caseworkers to make "very chancy decisions."

"I found the job excruciating," he said. The state of constant worry about whether he made the right decision led him to leave his DCFS job.

"It's the worst thing. You worry that something might happen to a kid you saw," said Guadagano, who works as a court liaison for the department in St. Clair County Court.

A study released earlier this year by Council 31 of the American Federation of State, County and Municipal Employees, which represents DCFS workers, found that despite an 11 percent increase in child abuse investigations from 2001-05, the department lost 23 percent, or 747, of its "frontline" staff statewide.

Murphy, the Cook County judge, said the agency's strict emphasis on confidentiality leads to a lack of accountability and increased caseworker error. He favors making all details in child death reports public except for the names of people reporting the abuse and psychiatric records, unless a judge reviews them.

"They want to keep the whole thing secret, like this investigator who let the mom smoke crack. That stuff goes on across the board. I've seen it repeatedly," Murphy said.

Court involvement

DCFS Inspector General Denise Kane said one of her top concerns is the practice of allowing children to remain in the home in the face of obvious or repeated abuse.

She warned that accepting a parent's word without verification and giving too much consideration to their promises to do better is "fraught with difficulties."

"If a parent is using (drugs) and keeps getting high, there's a risk to those children," she said.

DCFS often tries to steer family drug cases into court, but many state's attorneys won't take them, Kane said.

"Our office says that's not correct. You should take them, even if it's only for an order of supervision," she said.

An order of supervision allows a judge to force a mother into court, where she can be ordered to accept drug treatment or lose custody of her children and forfeit state benefits.

In order to remove a child from the home, a judge must find "an immediate and emergent need." That's a problem, Kane said.

"If a mother smokes crack on Monday, but word doesn't get to the judge until Thursday, he will probably decline to place the children in protective custody because the immediate need was when the DCFS worker actually saw the mother taking drugs," Kane said.

But Guadagano, who makes recommendations to judges about whether a child should be removed, said most judges are willing to put a child into foster care if there's any chance that leaving them at home will lead to injury.

"Most people will err on the side of caution," Guadagano said. "Who wants to take a chance like that?"

When to intervene and get a court order to remove someone's children is the most difficult part of the job, said Michael Davis, a member of the Illinois Child Welfare Ethics Advisory Board. The investigative office turns to this board for broad answers about why children die in DCFS' care.

"When somebody actually dies, a lot has to go wrong," he said, "because DCFS has ... a number of back-up systems in place.

"There are egregious errors," he said, "which is why they ended up in the reports. Our view is that (child deaths) indicate problems ... and we try to figure out what the underlying cause is."

But in some cases, the DCFS allowed children who were obviously being abused to remain in dangerous situations.

In Harvey, Ill., 9-year-old Shanecia McClellan, who suffered from cerebral palsy, starved to death, despite 33 visits to the home by DCFS caseworkers, according to a child death report.

The girl's mother, a cocaine user who refused free drug counseling, told police that Shanecia had died three days earlier, but she hadn't called authorities because she was "too busy to deal with that."

Waiting too long

William Adams didn't survive childhood, though there were many warning signs that he was in danger.

In April 2002, 3-year-old William died in a Centreville house fire. His mother had a long history of drug use and neglect during years of involvement with DCFS, yet her children were allowed to remain in her care, according to a child death report.

The mother, Rosie Rainey, gave birth to three children before William was born. Two tested positive for cocaine at birth, according to the state report. Three weeks after the birth of her second child, Rainey took her 3-year-old daughter to a hospital emergency room where the infant was found to be suffering from gonorrhea.

Authorities never charged anyone with sexual assault of the toddler.

William also tested positive for cocaine at birth. The DCFS referred the mother to a drug treatment program, but she attended only sporadically and was kicked out, the report stated.

In August 2000, Centreville Police Officer Pat Reliford found Rainey's four children home alone. He found the oldest child, a 6-year-old girl, cooking for her younger siblings. Police charged Rainey with child endangerment.

As required by state law, Reliford called the state child abuse hot line. DCFS took the children into protective custody but later returned them and assigned a second caseworker to the family.

The state investigative report on Williams' death stated that the 14-month tenure of the second caseworker "was characterized by ineffective assessments and lapses in critical judgment."

According to the state report, the caseworker was not concerned about the threat of fire from the use of space heaters and general disarray of the house "... because the mother did not smoke cigarettes."

But Rainey did use drugs, and one afternoon, while she slept, William's older brother found a lighter and accidentally set some blankets on fire, according to a police report.

The older boy tried to awaken his mother to help William escape the smoky and burning bedroom, but Rainey, who admitted to using crack a few days earlier and smoking marijuana the night before, slept on.

Finally, she awoke and tried to rescue the trapped boy, but it was too late.

"I heard William screaming in the room," she told police, "and I kept calling to him to 'come to Momma, come to Momma.'"

Contact reporters George Pawlaczyk at gpawlaczyk@bnd.com or 239-2625 and Beth Hundsdorfer at bhundsdorfer@bnd.com or 239-2570.


Related Material from "Lethal Lapses Investigative Series": 

Lethal Lapses:  DCFS files reveal how child agencies failed a Southern Illinois boy

Caseworkers altered files after deaths of children

The girl who never had a chance; the forgotten boy 

Child victims: their stories

Cases are reviewed, results are questioned

LETHAL LAPSES: Child deaths referred to as 'heater cases'

Can you help identify any more victims?

Duties of a DCFS worker

Series prompts DCFS to review agency policy

DCFS offers few answers about deaths

Hold DCFS accountable

Child victims: their stories

LETHAL LAPSES: Is there a better way to protect children?


Gary Guadagano, a former

Gary Guadagano, a former DCFS child abuse investigator, said the department pays caseworkers to make "very chancy decisions."

"I found the job excruciating," he said. The state of constant worry about whether he made the right decision led him to leave his DCFS job.

"It's the worst thing. You worry that something might happen to a kid you saw," said Guadagano, who works as a court liaison for the department in St. Clair County Court.

Interesting article.  But I know one thing...    I wouldn't want Gary's old job.

It's not that I don't respect him or his former profession, but it has to be an excruciating decision to remove (or not to remove) children from abusive homes - especially so in those not-so-obvious borderline cases.  After all, foster care ain't no picnic neither.

Remove or reprimand the bad caseworker who shows poor judgement, or who doesn't follow established guidelines or protocol.  I'm all for accountability.  But even for those good caseworkers, this job has to be something close to hell on earth.

I also found it interesting that almost all of the cases cited were of children who were abused (or worse) after the decision was made not to remove them, perhaps in the name of family preservation.  It seems every well-meaning cause has its collateral damage.


The duty within

Whether a person is dedicated to family preservation or adoption practices, criminal neglect and falsified records should NEVER be ignored, dismissed or given a pardon.  How successful can any program be if there is caseworker error and neglect?

 The 53 deaths involved cases where the newspaper found significant caseworker error or neglect.

It's very easy to blame and criticize abusive parents, but who's paying attention to the closed case records that prove CYA (Cover Your Ass) protection is given to the workers, not the children?

A News-Democrat investigation into children who died while under the watch of the DCFS found at least three examples where state workers altered records in an apparent attempt to cover up mistakes or minimize department blame.  [From:  "Caseworkers altered files after deaths of children", May 4, 2008, http://www.bnd.com/lethal_lapses/story/4972.html]

In another article, about another case, the newspaper investigation reveals the problems seen within a closed-confidentiality system:


The story of the Lay twins is important because it illustrates how Illinois' child protection system failed the children -- a failure made public through an Indiana open records law.

The twins' confidential history both in Indiana and with Illinois DCFS was released by an Indiana judge. These records provide a rare and troubling look at how years of effort by scores of child welfare professionals failed to protect Kalab and Kayla.

The Indiana law provides that in cases where children under state care die or are seriously injured and a parent or guardian is criminally charged, confidential case files become public.

A similar law took effect in Illinois in June. It stemmed from a News-Democrat series in 2006 called "Lethal Lapses" that revealed how caseworker and supervisor error and carelessness were involved in the deaths of 53 children under the care of the DCFS.

The Illinois law, which also depends on children being killed or seriously injured and charges being filed, has yet to be tested. Nevertheless, it has the potential to give the public unprecedented insight into one of the state's largest and most secretive agencies.  [From:  "Lethal lapses: DCFS files reveal how child agencies failed a Southern Illinois boy", October 12, 2008, http://www.bnd.com/179/story/500096.html]


The problem is not "family preservation practices", the problem is far more simple:  Protection is not given to those who need it most. 

Does anyone dare to investigate the collateral damage caused by that?

Just a few facts

  • In 2000 New Jersey placed 33 children in unlicenced foster care homes
  • In 2001 Hawaii placed 17 children in foster care homes without criminal background checks
  • In 2002 Maryland placed 36 children in foster care without making a reasonable reunification attempt
  • In 2003 New Jersey placed 27 children in unlicenced foster care homes
  • In 2003 New Jersey placed 36 children in foster care without making a reasonable reunification attempt
  • In 2003 the District of Columbia placed 39 children in unlicenced foster care homes
  • In 2003 the District of Columbia placed 24 children in foster care homes without criminal background checks
  • In 2003 Puerto Rico placed 98 children in foster care without making a reasonable reunification attempt
  • In 2003 Montana placed 28 children in foster care without making a reasonable reunification attempt

as found on: aspe.hhs.gov

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