Fatal Care: Deadly mistakes doom children
FATAL CARE | A WATCHDOG REPORT
Deadly mistakes doom children
Social service agency fails to heed warning signs as nearly 2 dozen die over 5 years in Milwaukee County
By Gina Barton and Crocker Stephenson of the Journal Sentinel Oct. 4, 2009
In 2004, 18-month-old Jatavius McKillion's mother starved him to death.
At autopsy, he weighed just a pound more than the average newborn.
The home where Jatavius died was infested with cockroaches and flies, public records show. Empty beer cans, trash and partially eaten food littered the floor. The cupboards were virtually bare. But for empty milk jugs and spoiled meat, so was the refrigerator. The toilet was backed up.
Bleach, dirty water and trash filled the clogged tub.
Jatavius' 6-year-old brother sustained himself on a small stash of food hidden in a bedroom closet. The boy told police he did not go to school, could not spell his name, did not know how to make letters, did not own a toothbrush and longed to take a bath.
The family was well known to the state-run Bureau of Milwaukee Child Welfare. Jatavius' mother had been reported three times because of concerns about her children. His aunt, who lived in the same home with her children, had been reported twice.
Jatavius was one of at least 22 Milwaukee County children who died from 2004 to 2008 despite clear warning signs to the bureau they were at risk, a Journal Sentinel investigation found. Also among the 22 children was 13-month-old Christopher Thomas, beaten to death by his aunt last November. In addition to Jatavius and Christopher, the children who could have been saved include:
• At least 11 children, such as 7-month-old Layunnia Lewis, who died even though their families had been in contact with social workers more than once during the child's life, often spanning months. Layunnia died due to neglect in November 2006.
• Three children who died as a result of abuse or neglect in foster homes, relatives' homes or institutions where they were supposed to be protected. One was Angellika Arndt, a 7-year-old who suffocated in 2006 when workers at a day treatment center held her facedown for an hour.
• Two children who died even though their parents were reported to the bureau for suspected abuse or neglect. One of them was Rubi Ochoa-Cervantes, who was reported to the bureau for an unexplained skull fracture a month before her father beat her to death in 2005. She was just 2 months old.
• Four babies who were overlooked by the child welfare system even though their older siblings previously had died or suffered abuse or neglect. Among them was Lamour Caesar-Burnley, who starved to death even as a criminal child neglect charge was pending against his mother.
"That is shocking to me. It is unacceptable," state Sen. Lena Taylor (D-Milwaukee) said of the newspaper's findings. "Clearly we need to figure out what we can do better so that kids don't fall through cracks."
Since Christopher Thomas' death, the bureau implemented many changes intended to better protect children and to hold workers accountable.
But some of those changes have amounted to little more than window dressing.
Workers who make fatal mistakes are reassigned rather than fired. Parents who have mistreated their children for years start with a clean slate virtually every time a new complaint comes in. A culture of secrecy persists despite promises of more transparency.
In response to an open records request, the state refused to release information on any children who died before July 1, 2008, when the Department of Children and Families was created and given oversight of Milwaukee's child welfare system. Officials said public records summarizing the cases of children who died before that date do not exist.
Since 2002, the bureau has been under a federal court order to issue a biannual report of child maltreatment statistics - including incidents that result in death. But those reports contain scant information.
In them, the children are reduced to nameless, faceless statistics.
Further, the reports count only children abused by foster parents or staff members of licensed institutions. For example, Christopher Thomas' death was not counted because he had been placed with relatives by the department. After his death, the reports were expanded to include children staying with relatives.
Children who are abused or killed while in their parents' care with open child welfare cases still are not counted, nor are children whose parents have a prior history with the system.
To determine the true scope of the problem, a team of reporters spent months reviewing thousands of pages of court files, police reports and bureau reports, as well as medical examiners' reports for every child who died in Milwaukee County from 2004 to 2008, the most recent year for which complete records are available. Reporters also interviewed dozens of people involved with the system at every level, from social workers to families with children in foster care.
"This is not just a list of names. These are real kids in our community with families, neighbors and schools," said Sue Conwell, executive director of Kids Matter Inc., a child welfare advocacy group. "Their deaths leave a hole in the community, and it is important that they are accounted for. That is the only way to take a positive step forward from tragedy."
Reggie Bicha, secretary of the department since its inception, acknowledged things aren't perfect but cited many improvements.
For example, caseworkers have increased their visits from once a month to twice a month for children younger than 6 months old. Doctors have examined more than 500 children ages 5 and younger, checking for medical problems or signs of abuse.
The budget recently passed by the state Legislature provides funding for more improvements, Bicha said. For example, nurses will be added to teams that work with children; and 18 additional social workers will be hired to investigate suspected cases of abuse and neglect.
"We've got a long way to go for our child welfare system to be what this community expects it to be and what I expect it to be," Bicha said.
The bureau's most critical goal is keeping Milwaukee County's children safe.
Social workers are supposed to intervene in cases of abuse, neglect or other threats to kids. Sometimes parents are allowed to keep their children if they agree to close supervision by social workers. In addition to looking out for the kids, workers try to provide parents with help such as child-care training, substance-abuse treatment and mental-health counseling.
In other cases, children are removed from their parents' homes. Some of those children go into foster care. Some are placed with relatives. Some are placed in group homes. Social workers aim to find safe temporary homes where the children can stay until their parents prove they can care for them properly.
"There's a high amount of pressure on the workers to make these judgment calls . . . when it's not easy to understand and reveal what's going on in the home," said Erika Monroe-Kane, spokeswoman for the Department of Children and Families.
When workers make the wrong call, children can die.
That's what happened in the case of Christopher Thomas. Yet those responsible for the decisions have suffered few consequences.
The abuse inflicted on Christopher and his 2-year-old sister by their aunt was described by seasoned investigators as the worst they had ever seen.
Over the months the children were abused, caseworkers had visited his aunt and uncle's home five times, yet missed the seemingly obvious evidence of maltreatment. Christopher died within 11 days of their last visit.
Bicha admitted the system failed Christopher. He publicly demanded those responsible be held accountable.
Under fire, Denise Revels Robinson stepped aside as director of the bureau. After Bicha insisted on changes from La Causa - the private contractor responsible for overseeing the caseworkers who visited the home where Christopher and his sister were placed - the group opted to cancel its $11 million annual contract with the state. Rebecca Hollister, the supervisor on Christopher's case and an earlier case in which 5-month-old Will Johnson died, was demoted.
Since then, Bicha has praised Revels Robinson and La Causa for their service.
Revels Robinson didn't resign - she transferred to another job within the department and maintained her annual salary of $108,919. She worked in the new position for almost nine months before being hired in September by a former Wisconsin child welfare official to a top position in Washington state's Department of Social and Health Services.
La Causa not only remains in business, but continues to provide $2 million in services to Milwaukee County annually - much of it for services to children.
And all but three of the 107 employees who worked under La Causa's case management contract went to work for Integrated Family Services, a nonprofit subsidiary of St. Aemilian-Lakeside, which replaced La Causa. One of them is Hollister. She is now working in an administrative position and has no direct contact with children or families, according to Ann Umhoefer, chief operating officer for St. Aemilian-Lakeside.
Bicha would not answer questions about the implications of keeping on so many former La Causa workers, saying it wasn't appropriate for him to compare the new contractor with the old one.
He did say he was encouraged by Integrated Family Services' plans.
"This is an organization that is committed to finding new ways to do business that will result in safer, healthier children that are touched by the child welfare system in Milwaukee," Bicha said.
State Sen. Alberta Darling (R-River Hills) said she is confident Integrated Family Services is capable of doing a good job because its top managers are different from La Causa's, and their philosophy is more forward-thinking than the previous agency's.
However, she thinks there should have been a more thorough review of La Causa's caseworkers and supervisors before they were hired by the new contractor.
Darling also is troubled that Bicha did not take more responsibility for the bureau's role in Christopher's death.
"I think they just passed the buck," she said.
Operating in secret
Milwaukee's child welfare system operates largely in secret. State law strictly limits the information that can be made public, even when children die. Those confidentiality laws, designed to preserve children's privacy, end up shielding those responsible for their deaths.
For example, Hollister was the supervisor on the case of Will Johnson, a 5-month-old whose mentally unstable mother drowned him during an unsupervised visit in October 2007. But Hollister's role in Will's case didn't come to light until the Journal Sentinel began investigating the death of Christopher Thomas the following year.
A bipartisan bill on the fast track to becoming law is being touted as the solution. But the proposal still would allow the bureau to avoid releasing key information. And it continues to protect child abusers and workers who make fatal mistakes by keeping their names confidential.
Under current law, the state Department of Children and Families may voluntarily release a written statement when a child dies as the result of neglect or abuse. It includes basic information about the circumstances of the death and short summaries of each time the child's family has come to the bureau's attention. It contains no names, except the first name of the dead child. It contains no context about other children who might have died under similar circumstances.
As a result, the public doesn't know who made the decisions that may have cost a child's life or why those decisions were made. And no one outside the system can identify troubling trends or push for meaningful change.
The bill requires broader disclosure and allows the public to identify trends.
Bicha, who has repeatedly pledged more openness since he took over as head of the department, supports the bill.
"We have tried to be more transparent in how the bureau operates and the work we do without exposing or adversely impacting or harming the children we serve," he said.
But the bill allows the department to avoid releasing any information at all if the disclosure is not "in the best interests of the child," or if it would jeopardize a potential criminal investigation or civil lawsuit.
Child welfare officials who withhold information must justify their actions to a district attorney, a judge or the agency that reported the incident - most commonly a police department.
There is no objective way to decide which cases must be disclosed, which means some inevitably will be left out, said Dave Kopplin, president of the labor union that represents social workers.
"From my experiences and from the reactions of the . . . social workers, this bill doesn't help children one bit and may actually have the opposite effect," he said. "Frankly, if this becomes law, BMCW management will radically increase the pressure on an already horribly overwhelmed staff."
Questions remain in death
Although Jatavius McKillion died five years ago and his mother, Decha Caston, was convicted of a felony in connection with his death, critical questions about his case remain unanswered.
Caston was reported to child welfare officials in 2002 for leaving her children unsupervised, according to an interview Revels Robinson did with the Journal Sentinel shortly after Jatavius' death. Services were provided, she said, but Caston and the children moved several times, and caseworkers could no longer locate them.
Bureau officials would not say what kind of services the family received, nor would they detail what efforts were made to find the family.
In early 2003, the bureau got another complaint and investigated allegations that Caston did not keep a medical appointment for one of her children and that she had left them with relatives for extended periods. Investigators found no evidence of abuse or neglect, officials said.
The bureau would not provide any information about whether Jatavius had missed medical appointments or what kind of treatment he got for his many conditions, which included high blood pressure, sleep apnea, swelling to his eyes and feet, and chronic lung disease. The extent of his medical problems is known only because they were detailed in a medical examiner's report.
In spring of 2003, Caston and three of her children moved in with her sister, Tamar Sullivan, who also was criminally charged in connection with Jatavius' death, court records indicate.
In 2001, the bureau had investigated an allegation that Sullivan had given birth to a child who tested positive for marijuana. The allegation was ruled unsubstantiated.
There is no indication of whether the child was tested for marijuana exposure.
In 2002, social workers investigated an allegation Sullivan's children were living in filth. A social worker not named in the report said Sullivan's house was clean and well cared for. Public records do not indicate how much time passed between the complaint and the inspection.
When police were called to Caston and Sullivan's home on Feb. 6, 2004, less than a year after they moved in, it was a cesspool.
On the day Jatavius died, Caston told police the boy hadn't eaten in four days. Strapped into his car seat, alone in a bedroom, he had not moved in 24 hours. Paramedics didn't attempt CPR.
Rigor mortis already had set in.
When calls come in
When calls come into Milwaukee County's child-abuse hotline, department policy directs investigators to consider the family's history, looking for patterns that could signal danger.
Records show they often don't.
Seven-week-old Lamour Caesar-Burnley starved to death even as a criminal neglect charge was pending against his mother. At the time of his death in July 2008, Lamour - a preemie who spent the first three weeks of his life in the hospital - had been home less than a month.
A summary released by the bureau doesn't name the social workers involved with Lamour's case or indicate how many there were. The records also don't explain why no one seemed to connect the dots in time to save him.
Abusive mothers such as Lamour's often get another chance each time they give birth.
If social workers are working with the family at the time a new baby is born, the infant's safety must be evaluated, according to Monroe-Kane, the department spokeswoman. If the family currently isn't receiving services, no state law or bureau policy requires notification that a new baby exists - no matter how many times the parents have been reported to child welfare authorities.
While Lamour's mother, Vera Morehouse, was pregnant with him, she was arrested on a felony charge for trying to run over her boyfriend, Damone Burnley.
According to the criminal complaint, it started with an argument over who would watch their older children. Morehouse was trying to drop off the children with Burnley. When she took them out of the car, Burnley put them back in, then punched Morehouse and walked away. She took them out again, and when Burnley started running back toward her, she drove over the curb, chasing him down the sidewalk. Burnley was thrown onto the hood of the car, smashing the windshield.
When Lamour was born, a misdemeanor child neglect charge was pending against Morehouse for leaving her 6-year-old son home alone. The little boy had been found sleeping on a park bench across the street from his mother's apartment.
The bureau was notified. It was the sixth call child welfare officials had received about Morehouse in less than three years - and the second call that month.
She was first reported in November 2005 because her 18-month-old child had a broken arm - from falling down five stairs, the mother said. The complaint wasn't substantiated because a physician assistant said it was possible the child broke his arm from falling.
Five days later, the bureau received a report that Morehouse's boyfriend was physically abusing the toddler. The abuse was substantiated, but child welfare investigators weren't able to figure out who had inflicted it. The case was closed at the end of January - no explanation is given in the public record.
The third call reporting Morehouse - for neglect - came in February 2007. The allegation was unsubstantiated, and the case was closed the following month with no further explanation.
Six months later, the bureau got yet another neglect call about Morehouse, who was accused of failing to pick up her child from an after-school program. The complaint was ruled unsubstantiated after investigators determined she had made arrangements for someone else to pick the boy up.
The fifth call came in April 2008, four days before Morehouse's 6-year-old son was found in the park. The bureau investigated a complaint that he had been left alone while she was in jail. An investigator responded immediately due to concerns of "immediate danger" but discovered Morehouse had left the boy in the care of a family member.
At the same time, the investigator offered Morehouse parenting help. She declined, saying she already was receiving assistance from Milwaukee Healthy Beginnings Outreach Service, a community agency. The investigator confirmed she was.
Shortly after the 6-year-old was found in the park, the same investigator - not named in public records - visited Morehouse, who was then six months pregnant, and her children. After neglect charges were issued later that month, the social worker made three more attempts to visit the home. No one answered the door, and the worker left.
"Baby Lamar (sic) was not born at the time of the investigations in April and was never assessed by (the Bureau of Milwaukee Child Welfare)," according to a statement released by the agency shortly after his death. "No services were provided to the family by the Bureau prior to the death of Baby Lamar (sic)."
In an interview at that time, Department of Children and Families administrator Cyrus Behroozi said the social worker, whose name was not released, was demoted. The worker should not have given up on the family just because Morehouse wouldn't come to the door, he said.
"The failure to act is inexcusable," Behroozi said