By Carol Marbin Miller
cmarbin@Miami Herald.com
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In Lake County, a disfigured 2-month-old whose mother did not want
him is left alone in a motel room for 90 minutes, and is later found
smothered. His family had been the subject of 38 prior investigations by
the state’s child welfare agency.
“It is a general consensus,” a report said, “that [the mother] was involved in the death of her child.”
In
Santa Rosa County, child welfare authorities allow a “chronic and
severe” drug addict to bring her newborn home, though her two older
children had been removed from her care for their safety. Eighteen days
later, the mother takes an unprescribed Lortab painkiller and places her
baby next to her in bed. The child is found dead.
And in Polk
County, a mother leaves two toddlers alone in a “kiddie pool” — and
returns to find her 1-year-old daughter face-down in the water. Her
2-year-old son later discloses he pushed his sister down while she was
crying. He now suffers nightmares.
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The children, who all perished last year, are tragically bound by
more than death: Even as the Florida Department of Children &
Families has promised greater openness, the three fatalities, and dozens
of others like them, have never been counted among the state’s victims
of fatal abuse or neglect.
No state can protect every child who is
born to troubled, violent or drug-addicted parents, and even youngsters
for whom child protection administrators make all the right choices can
sometimes fall victim to unforeseen circumstances. To ensure that state
social service agencies learn from mistakes, the federal government
requires that states count and investigate all child fatalities that
result from abuse or neglect.
Regulators don’t, however, strenuously oversee how the counting and investigating occurs.
After the Miami Herald published a
series examining the deaths of
477 children —
and Florida’s failure to protect some of them from abusive or
neglectful parents — the state promised a new era of openness and more
rigor in the way it investigates child deaths.
But except for abiding by a new state law that required DCF to create a
website listing all child fatalities, Florida has continued to undercount the number of children it fails.
“Nothing
has changed,” said former Broward Sheriff’s Office Cmdr. James Harn,
who supervised child abuse investigations before retiring when a new
sheriff was elected last year. “Some day, somebody will say ‘let’s just
stop the political wrangling.’ Here’s what you’ve got to do: Just tell
the truth.”
For several years, BSO, which has investigated child
deaths under contract with DCF, has recorded significantly more
fatalities due to neglect or abuse than other counties, where DCF does
its own investigations. One important reason for the disparity is that
the sheriff’s office long has insisted that drownings and accidental
suffocations — among the leading causes of child fatality — be counted,
while DCF has, in recent years, declined to include the majority of
those in its abuse and neglect tally.
As a result, said Harn, the statewide numbers “are cooked.”
“It’s not going to get fixed as long as they want to hide things,” Harn added.
A
DCF spokeswoman in Tallahassee, Alexis Lambert, said the agency studies
all child fatalities — not just the ones it verifies as resulting from
abuse or neglect — to “improve and strengthen child welfare practice and
services provided to vulnerable children and at-risk families
statewide.”
She added: “The safety and well-being of Florida’s
vulnerable children is DCF’s top priority. Understanding and assessing
child fatalities is one way the department analyzes the issues facing
families and develops strategies to meet the needs of struggling
families and protect vulnerable children.”
Election issue
Child
deaths became an election issue in recent weeks as both Gov. Rick
Scott, a Republican, and his Democratic challenger, former Gov. Charlie
Crist, traded accusations over whose administration better protected
children. In two debates, Scott has stated that child fatalities have
declined dramatically since he took office in 2011. In 2009, he said in
the first debate, 97 children with a DCF history died. “Last year,” he
added, “we were down to 36 deaths.” (The DCF child death website
actually lists 45.) “That’s still way too many,” he said. “We don’t want
to have one death. But it’s a dramatic improvement from when Charlie
was there.”
Scott repeated the assertion in a news release and in the second debate last Wednesday.
A
careful study of thousands of pages of state documents makes clear that
the number Scott cited and the one on the DCF website are both
distortions of reality. They are contorted by years-long delays in
completing investigations — thus keeping deaths off the books — by a
decision to narrow the definition of what constitutes neglect, and by a
determination to “unverify” some child deaths that had previously been
“verified” as abuse or neglect.
Said Pamela Graham, a Florida
State University social work professor who served on a Department of
Health statewide death review committee for five years: “Numbers lie if
you aren’t counting them.”
For many years, state child protection
systems have been evaluated in large part by a standard measure:
“verified” child deaths “with priors” — that is, the number of
youngsters whose families had prior contact with the state. That is the
number that Gov. Scott says is declining. But the decline in
deaths with priors can be traced to the factors cited above.
Drownings
and accidental suffocations differ from, say, beating or shooting
deaths in an important way: “There are human decisions in how you
categorize them,” said Richard Gelles, who is dean of the University of
Pennsylvania’s School of Social Policy & Practice. There is simply
no wiggle room as to whether a beating is a child abuse death. In
contrast, a drowning can be a neglect death, or, as many more of them
are now called, merely tragic accidents.
‘Verified deaths’
Verified
child deaths did spike during the Crist administration, whose term
ended in January 2011. And the numbers on DCF’s newly minted website
show that overall child deaths — whether from abuse or illness or
something else — have receded somewhat. But the more striking decline
has been in the percentage of child deaths that are “verified” as
neglect or abuse.
In 2009, 43 percent, or 206, of DCF’s 474
reported child deaths were verified. The percentage dropped to 34
percent in 2010, 31 percent in 2011 and 2012, and then to 10 percent in
2013. So far this year, 13 percent of DCF’s 348 reported deaths have
been verified, the records show.
Changes in the standard for
verification of child deaths have led to some unusual variations. For
instance, Broward County — where BSO investigates child deaths under
contract, independent of DCF — tallied 21 “verified” child deaths from
abuse or neglect in 2013 out of 30 total fatalities, or more than
two-thirds. In Miami-Dade, as of Thursday night, DCF had not verified a
single 2013 death as being from abuse or neglect out of the 39 overall
fatalities for that county listed on the agency’s website.
On Thursday, the June 21, 2013, killing of
Ezra Raphael remained unclassified
, though the boyfriend of Ezra’s mother,
Claude Alexis,
is in jail awaiting trial on a murder charge. Alexis told North Miami
Beach police he whipped the child with a belt for spilling bathwater.
After the Herald asked about the 39 Miami cases Friday morning, Ezra’s
case was switched that same day to “verified.”
The July 20, 2013, death of
Jayden Villegas-Morales remains unverified, though his father,
Angel Villegas, is charged with manslaughter. Of
Jayden’s death, DCF says only that the “2-year-old child was found unresponsive by his father.”
Lambert,
DCF’s spokeswoman, said 15 of the 39 Miami-Dade child fatalities from
last year remain under investigation by the department.
Aftermath of reforms
Following the Herald’s series on child deaths, Innocents Lost, lawmakers passed a
sweeping reform bill.
One of its provisions required DCF to maintain the website with details
on every child death that is reported. The website depicts a dramatic
decline in the verification of deaths in categories that are susceptible
to manipulation: the drownings and accidental smotherings. In 2009,
before the new neglect guidelines took effect, 76 drownings were
recorded. Of those, 58 — or 76 percent — were verified as resulting from
neglect, and, among those, 26, or 45 percent, came from families with a
prior agency history.
So far this year, DCF has tallied 66
drowning deaths. Only nine of the 66 cases were “verified” as resulting
from neglect — or 13 percent — and only one of those nine involved a
child whose family had any DCF involvement in the prior five years.
Over
five years, then, the share of drowning deaths that were verified as
neglect dropped from 76 percent to 13 percent. And in the category that
is used to judge Florida’s child-protective efforts against other states
— deaths with priors — only one of the 66 drownings from this year is
on course to make the list.
The percentage of unsafe sleep deaths
verified by DCF also declined, though far less sharply. In 2009, DCF
reported 97 such fatalities; among them, 31, or 30 percent, were
verified. Of those, 21, or 68 percent were children with a prior family
history within the previous five years. In 2013, DCF reported 103 unsafe
sleep deaths, and 26 of them, or 25 percent, were verified, DCF’s
records show. Among the 26 that were verified, fewer than half involved
children with a prior agency history.
Lambert said investigating
drowning or unsafe sleep deaths is particularly challenging. “Deaths
resulting from drowning and co-sleeping require the most extensive
analysis and investigation as these deaths can sometimes be tragic
accidents,” she said.
Gelles, the social work dean, said the total
number of drowning and unsafe sleep deaths is generally not susceptible
to manipulation — but the precipitous decline in cases that are
verified suggests that those numbers are “fudged.”
“They are no less dead,” he added.
The death of Nyla Hardy was counted. And then it wasn’t.
Nyla
was born on April 17, 2013, to 22-year-old Alysha Rivers and
24-year-old Kendrick Hardy, two longtime drug abusers. Rivers, according
to state records, “admitted to smoking two blunts [of marijuana] a day,
and the father admitted to smoking five blunts a day.” A former foster
child herself, Rivers had lost custody of an older child in 2007 due to
marijuana abuse.
Two months before Nyla was born, DCF received a
report of physical abuse, burns and environmental hazards involving
older siblings, including one who was previously removed but later
reunited with the parents. The allegations were ruled unfounded, and the
agency closed its case when the mother agreed to accept help from the
state.
When Nyla was 3 weeks old, her parents smoked marijuana and
then went to bed. Hardy had rolled over onto the newborn once before,
the mother said, but the couple continued to co-sleep with the child
anyway. That night, “the mother stated she placed the baby in the middle
of the bed, with her arm around her,” a report said. When she woke up
the next morning, Nyla “was all blue; she was cold and hard.” She also
had suffered “multiple hemorrhages...two contusions,” and was drenched
in her own blood — so much so, a report said, that the local medical
examiner initially said the death most likely “will turn into a
homicide.”
In the end, the cause of death was ruled undetermined.
In November 2013, the Herald obtained records on 40 child death
investigations DCF submitted to a consultant, Casey Family Programs, for
the consultant to
analyze.
At the time, Nyla Hardy’s death had been “verified” as a neglect death.
But months later, when a formal death review was attached to DCF’s
fatality website, the classification had been switched to unverified. It
now will never be counted among the 2013 neglect-related deaths.
Even
as it deemed the case an unverified death, the final death review
noted: “Due to the extensive use of drugs by the parents, a child died
while in their care.”
‘Verified’ to ‘unverified’
Charlize
Terrell’s name has vanished from the 2013 count, as well. Her death also
was among the 40 cases reviewed last year by the consultant, and a
five-page “casework analysis” provided to the Herald noted an
investigation of her May 4, 2013, death was “closed” and “verified.”
Charlize was born addicted to her mother’s opiate drugs, and spent several weeks in a hospital detoxifying from them.
Charlize
died 10 weeks after birth. Both of her parents “admitted to being under
the influence of methadone and alcohol the night Charlize died,” a
report said. And though the details of her death remained undetermined,
“investigators believe that the mother likely rolled over on top of the
infant after falling asleep under the influence.”
In a final death review, the “verified” finding was changed to unverified. Charlize’s death will not be counted.
The
“casework analysis” of the May 31, 2013, death of Brooklyn Stewart
prepared for the DCF consultant concluded that the 1-year-old girl’s
drowning “should be” verified, records obtained by the Herald showed.
Brooklyn
was the toddler left unsupervised in a kiddie pool with her slightly
older brother. “Neighbors reported that the children were often seen
outside unattended,” the initial review said. It added that Brooklyn’s
mother offered differing accounts of the drowning.
Brooklyn’s parents had been the subject of 11 DCF complaints, the most recent four months before Brooklyn’s death.
A bruise on Brooklyn’s head supported her older brother’s claim that he had pushed her in the pool, the report said.
Despite
what was written initially, DCF still closed the case as unverified,
without offering any explanation in the formal death review for the
switch. And despite the formal finding that abuse or neglect did not
cause Brooklyn’s death, her siblings were removed from their parents’
care. Brooklyn’s death did not count.
In another of the Casey
Family Programs reviews obtained by the Herald, an unnamed DCF
administrator wrote that the March 17, 2013, drowning of a 1-year-old
Polk County boy should be verified, as the agency had faulted the family
for failing to supervise the toddler — a lapse that led to the boy’s
death. Yet that case, too, was never counted.
An unnamed DCF
administrator in another case reviewed by the consultant chided death
investigators for failing to verify the Feb. 28, 2013, smothering death
of a 4-month-old Manatee County girl. The infant’s mom had been the
subject of four prior child abuse hotline reports from 2011 through
2013, including two reports of violence between the parents.
“The
child’s father,” the administrator wrote, “admitted he had been
educated on co-sleeping dangers by the paternal grandmother, who works
with infants and children, yet despite this knowledge, he chose to place
his infant daughter face down on a blanket in his bed.”
Still,
Tampa Bay’s child death supervisor at the time, Lisa Rivera, suggested —
in clear conflict with the administrator cited in the Casey Families
report — that the father may not have been aware of the dangers of
co-sleeping. Though the infant’s mother had been warned in a prior DCF
probe, Rivera wrote, “the mother admitted that she later failed to share
that information with him.”
Rivera now is the top child death
administrator statewide. She wrote a recent email in which she asked
that a death in Broward from unsafe sleeping be changed from verified.
“Increased risk factors, yes,” Rivera wrote, “verifiable maltreatment,
no.” It is unclear whether the death was later discarded from the
state’s tally.
And in a particularly unusual case, the agency
chose not to verify a suffocation death only because investigators were
unsure which parent smothered the 35-day-old baby in bed with them.
“Case is being closed with not-substantiated findings of death, due to
not being able to determine which caregiver was responsible for the
rollover onto the child,” the report said.
Lambert said the
department has limited options when a medical examiner’s findings are
undetermined and police conclude there is insufficient evidence to make
an arrest. In such cases, Lambert said, “DCF also does not have enough
evidence to verify. However, we do have authority to remove surviving
siblings” when evidence suggests they remain in danger.
Graham,
the FSU professor who spent five years on the Department of Health’s
statewide fatality committee, which attempts to glean patterns from
child deaths, said she was struck by how often the same agency missteps
repeated themselves. “You see the same issues over and over and over —
and they are all correctable,” Graham said.
“The thing that disturbs me the most is that the energy that is put toward keeping the [“verified abuse”]
numbers
at a minimum could be better spent looking at the real issues, and
preventing future deaths,” Graham said. “To me, that is the biggest
crime: We are spending so much energy not looking at cases to make
ourselves look good. We should be figuring out how to do this better.”
Florida child deaths by year
2009
Total deaths: 474
Verified: 206
Percentage verified: 43
2010
Total deaths: 469
Verified: 164
Percentage verified: 35
2011
Total deaths: 428
Verified: 136
Percentage verified: 32
2012
Total deaths: 408
Verified: 129
Percentage varified: 32
2013
Total deaths: 432
Verified: 45
Percentage verified: 10
2014 to date
Total deaths: 358
Verified: 45
Percentage varified: 13
Source: DCF child death website
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