Kentucky officials knew that many of the children who died from abuse might be at risk

By Deborah Yetter • dyetter@courier-journal.com

Nearly 270 Kentucky children died of abuse or neglect during the past decade — more than half of them in cases where state officials already knew of or suspected problems.

During one recent 12-month period, 41 children died — the highest rate of any state, according to a recent report by the Every Child Matters Education Fund, a Washington child-advocacy group.

In a six-month review of the problem, The Courier-Journal found that:

-- Child-protection officials, day-care workers, and parents, friends and relatives missed signs of abuse such as suspicious bruising and evidence of previous injury, or were hesitant to act.

During one recent 12-month period, 41 children died — the highest rate of any state, according to a recent report by the Every Child Matters Education Fund, a Washington child-advocacy group.

In a six-month review of the problem, The Courier-Journal found that:

-- Child-protection officials, day-care workers, and parents, friends and relatives missed signs of abuse such as suspicious bruising and evidence of previous injury, or were hesitant to act.

Related

-- While reports of abuse have soared, the rate at which social workers substantiated child abuse and neglect has declined . Nine years ago, problems were substantiated in 27 percent of the reports received compared with 12.5 percent this year, according to reports by the Cabinet for Health and Family Services.

-- Since 2008, the state has cut $51 million from human-service programs, including child protection. Social workers say that they don't have time to fully investigate cases or to follow up with families. Nor do they have money to provide the in-home assistance, drug testing and treatment that some families need.

Secrecy within the child-protection system protects it from scrutiny rather than protecting children, many judges and critics believe.

Most troubling is that many child deaths could have been prevented had state social workers, physicians, day-care workers, friends and relatives responded sooner and more aggressively to signs of abuse or neglect.

“It would be rare for a child to have never been abused and then be abused to the point of death,” said Dr. Gerard Rabalais, chairman of the University of Louisville pediatrics department. “Much more typically, it's violence that escalates over time.

“There's time to find the perpetrators and stop it and intervene on the child's behalf.”

In its investigation, the newspaper examined hundreds of pages of court records and outside studies and interviewed more than 50 judges, state officials, medical experts, children's advocates, prosecutors, lawmakers and others including family members who suffered the loss of a child.

It found that since 2000, Kentucky Child Protective Services officials have investigated reports of problems in cases of 149 of the 267 Kentucky children who subsequently died from abuse or neglect, according to the annual report on such deaths produced by the cabinet.

“That's pretty alarming,” said David Richart, a consultant and longtime child advocate in Louisville. “Those are dangerous, ominous signs when you are already involved with the family or with the home.”

Patricia Wilson, commissioner of social services for the cabinet, said she believes that the state's nearly 1,520 “front-line” social workers who handle child protection are hard-working and do a good job helping protect children.

But she said she is disturbed by the 41 deaths highlighted in the Every Child Matters report — which covered 12 months that ended Sept. 30, 2007 — and acknowledged it's not an area where the state wants to be No. 1.

“We really wish there weren't any fatalities,” Wilson said. “Every fatality is a tragedy.”

MULTIPLE REPORTS

21 cases involved 10 or more notices

State officials had received two or more reports of suspected mistreatment in 60 percent of the 304 cases in which a child died or suffered life-threatening injuries during the past 10 years, according the state's annual report on child-abuse deaths.

And in 21 of those cases, the cabinet had received 10 or more reports of suspected mistreatment, according to the annual report.

Wilson said the state's policy about confidentiality prevents her from commenting on specific cases or whether the cabinet was involved at the time of a child's death. But she acknowledged that multiple reports about suspected mistreatment would be potentially serious, depending on how recent they were and their nature.

“It makes a difference whether it's three times this year or three times three years ago,” Wilson said.

Though the details of state child abuse cases are secret — even after a child dies — court records of adults charged with murder in some recent cases show state officials were well aware of suspected problems. For example:

Two-year-old Christopher Allen of Louisville died Aug. 28, 2008, from a severe battering three days after a social worker removed him from his mother and placed him with an aunt.

Social service and other officials had repeatedly investigated allegations that he had been mistreated. The aunt and her boyfriend are facing murder charges; the case is scheduled for trial next year.

Kayden Branham, 20 months, of Monticello, died May 31 after drinking drain cleaner that his 14-year-old mother and 19-year-old father allegedly were using to make methamphetamine in a Wayne County mobile home. Both Kayden and his mother were under the supervision of state child-protection authorities and were supposed to be in another home.

Seven-month-old Gaige Pyles, of Elsmere, died Aug. 15 after being shaken to death. His father, Matthew Pyles, 27, was indicted Oct. 22 and charged with murder. State child-protection officials had been involved with the infant before his death, according to the Kenton County prosecutor.

Each death is devastating to family and friends, survivors say.

“It really sickens me, how the baby suffered so much,” Samantha Chapman said of grandson Robert Ross Jr., a 3-month-old Covington baby who died in 2008 from a skull fracture and suffered multiple broken bones. “That just tears my heart apart.”

SIGNS UNRECOGNIZED

More vigilance is needed by all

Child-abuse experts say the true picture may be even worse because as many as half of all child-abuse or neglect deaths may not be recognized and reported, being classified instead as accidental or from natural causes.

“I think some people are too nice to allow themselves to imagine what some people are capable of doing,” said Dr. Melissa Currie, director of the University of Louisville's pediatric forensic division.

The Every Child Matters report said national research shows that officials may be missing as many as 50 percent of child-abuse deaths.

In Kentucky, the leading cause of death of abused children is head trauma, and 70 percent are under age 3. Other causes include shootings, strangulation and poisoning, according to the state's 2009 annual report. Neglect deaths were most often caused by drowning, failure of adults to seek medical treatment, exposure to drugs and suffocation, the report said.

State law requires anyone who knows of abuse or neglect to report it to police, prosecutors or the Cabinet for Health and Family Services. But those involved in child-abuse detection and prevention say even the most obvious signs of abuse — bruising, especially in infants — often go unrecognized and thus unreported.

“Bruises on babies are not normal — period,” Currie said. “If you see them, you should do something.”

A 2007 study led by UofL researchers examined the abuse deaths or near deaths of 20 Kentucky children under age 3 and found that in most cases, evidence of prior abuse, such as suspicious bruising, had been previously documented by someone, such as a social worker, nurse or doctor, but not acted on.

Officials say that many more children could be saved, even with Kentucky's risk factors for child abuse, such as high rates of poverty and drug abuse and low educational attainment. But that would require more vigilance on the part of everyone who encounters such children — not just state child-protection officials.

“There is only a certain percentage of cases CPS has an opportunity to intervene in,” Currie said. “All the rest need to be caught by the rest of us.”

Some advocates believe opening confidential state records of abuse deaths or near-deaths would shed more light on the system and help improve it. Though such disclosure is allowed under federal law, many states including Kentucky, choose not to do so.

“Information about these tragic events ... is withheld by many jurisdictions,” said a national report released last year by the Children's Advocacy Institute at the University of San Diego law school and First Star, a Washington child advocacy group. “This is unacceptable.”

LACK OF FUNDS

Social workers face enormous pressure

The state's annual report shows a sharp decline in the rate of cases where social workers substantiate abuse or neglect, despite an increase in reports of abuse or neglect since 2000, a trend advocates and some social workers blame on a shortage or workers and resources.

Wilson, the social service commissioner, credits a better system of screening out complaints that don't appear to involve abuse or neglect — such as families without utilities or food. But child advocates are skeptical.

“That just doesn't compute,” Richart said of the decline in substantiation rates. “There's no logical reason why that would be so.”

Critics note that the underfunded state social-service system has undergone three rounds of budget cuts in the past two years and likely faces more.

“The state leads the nation in child abuse deaths,” Sheila Patrick, a 15-year social worker from Eastern Kentucky, told a legislative panel in October. “That's as high a price as you can pay.”

udges also lament the shortage of services for families — such as counseling, drug treatment or parenting classes — all reduced sharply by state budget cuts.

“Typically, parenting classes are one of the things we order,” said Jefferson Family Court Judge Stephen George. But now poor parents must wait several months to get into a class while the children linger in foster care, he said.

Also cited is a culture within the state social-service system that gives regional supervisors broad power to put enormous pressure on social workers to meet paperwork deadlines or face discipline. That sometimes forces them to skimp on investigations or take short cuts, a group of social workers told lawmakers this fall.

“We are just putting out fires,” Barbara Cowan, a Kenton County social worker, said at the October meeting of the House-Senate Health and Welfare Committee. “Corners are definitely being cut.”

Compounding the problem is that social workers are afraid to speak out, say officials of their union and others.

“Workers are scared to say anything,” said Shane Sidebottom, a Covington lawyer who has represented seven state social workers in “whistleblower” lawsuits alleging that they suffered retaliation for trying to point out problems. “This is a culture of fear.”

In failing to adequately deal with signs of abuse, Kentucky is hardly alone among the states. The Every Child Matters report found that child-welfare authorities nationwide generally have had prior involvement in about half of the cases of children who die each year from abuse or neglect.

Michael Petit, president of Every Child Matters, said his organization is calling on the federal government — which provides about half the money states spend on child welfare — to step forward with national standards and stricter oversight of state child protection programs.

“This problem isn't going to go away,” he said. “I don't think any state can wrestle this to the ground. You've got to have federal involvement.”

Reporter Deborah Yetter can be reached at (502) 582-4228.