Human Services chief admits 'several' kids should have lived
Probe of 13 deaths highlights failings of child welfare system
By Sara Burnett, Rocky Mountain News (Contact)
Published April 15, 2008 at noon
Photo by Linda McConnell / Special To The Rocky
Karen Beye, executive director of the Colorado Department of Human Services, leaves the news conference Tuesday after concluding that several of 13 child deaths in 2007 after visits to their homes by county social services workers could have been avoided.
Zoe
Luz
Neveah
Alize
Chandler
Loreyna
Rosalia
CORRECTION: A previous version of this story should have said that Mary Maes Campos said she had voluntarily given up custody of three of her children to relatives before the death of a fourth child.
At least some of the 13 children who died last year after visits from county social workers might still be alive if social services had done a better job, the executive director of the Colorado Department of Human Services said Tuesday.
In one case, a social worker observed bruises on a 7-year-old girl's body and a mother with a methamphetamine problem. The girl told the case worker her older sister beat her up and the worker closed the case, saying it was "inconclusive for abuse."
In another case, social workers had at least 15 referrals about a Lincoln County boy before he died at age 11.
"I certainly looked at (these cases) in terms of, 'Are there things that could have been done that might have prevented this child's death?' " DHS director Karen Beye said. "In several of those cases, the answer for me was yes."
DHS released a study Tuesday of the 13 fatalities that occurred in 2007 among children who had contact with child welfare agencies in the previous five years.
It included dozens of recommendations for change, including better training for staff - some of whom are assessing cases without having completed the state's basic training program - and better communication between social workers in different counties, so families that move a lot may be tracked.
Not 'any one thing'
But the report did not outline what went wrong in each fatality, and Beye said she didn't think "any one thing" was the cause.
"In some cases, looking back, it was, if we had thought to do X, Y, Z, if we had been more thorough . . . would that have helped?" Beye said. "And the answer was yes."
Beye's office in January ordered an emergency investigation into the fatalities, which spiked in the last few months of 2007.
The goal of the study was to determine if there were common factors in each case.
Among the children who died, there were several common factors: 70 percent were from families with a history of domestic violence, most were born to parents in their early 20s, and more than half were in homes where substance abuse was a problem, the study found.
The review also found that many of the families had moved around a lot. In one case, a family had contact with social workers in five different counties and the state of New Mexico.
But because employees were inconsistent about entering information in the statewide database, caseworkers in one county didn't always know about reports in other counties, so complete patterns of abuse could not be established.
In one case, a caseworker assumed an assessment in another county was ongoing because the worker there had not closed the case online. The case actually had been closed, a review found after the child's death.
"The result of this confusion can mean that . . . an opportunity to intervene on behalf of a child might be missed," the report stated.
The way Colorado's child welfare system is organized also may be problematic, Beye said.
The state is one of 13 nationwide in which counties administer child welfare programs, but are supervised by the state. Yet Beye said she doesn't believe the state has enough authority to take action if a county is not in compliance with state rules.
'Common sense'
One child welfare expert criticized the report as "incomplete," saying it doesn't address the key question in each fatality - what were caseworkers thinking when they made the decisions they did?
"That's what I think we need to know to make the decision of what went wrong," said retired Judge Dana Wakefield, who served in Denver Juvenile Court for 27 years.
Many of the conclusions in the report, he added, seem like common sense.
But Beye noted that in several cases, social workers were in the midst of investigating when the children died. And she said employees don't have the benefit of hindsight, or the ability to predict human behavior.
Today, Beye will join with Gov. Bill Ritter to discuss what the state can do to implement the report's recommendations.
Some will take effect within 90 days, Beye said.
"It is important for us to make sure that when there is a death, we look at the death in terms of what can we do in the future to make sure this doesn't happen again," she said.
burnetts@RockyMountainNews.com or 303-954-5343
Recommendations by state Department of Human Services:
Within 90 days: * Require counties to interview and do background checks on all people in a household being investigated.
* Require counties to check at least the U.S. Department of Justice and Colorado Bureau of Investigation Web sites to determine if registered sex offenders are present in a home where there are allegations of sex abuse.
* Offer more training so all caseworkers on a wait list can complete the state's basic training courses, known as CORE. Within 18 months: * Add six full-time employees in the state office to improve monitoring and oversight of counties.
* Explore using a more thorough, fee-based search to determine if sex offenders are in the home.
* Analyze workloads for caseworkers. Such a review has not been conducted since 1994.
* Investigate how to add a pop-up "alert" in the state database to flag high-risk children and families who move frequently.
The dead children
State officials reviewed 13 child deaths in 2007 before deciding on reforms. Their findings:
Zoe Garcia, 7
Zoe died Dec. 6 in Weld County from blunt force injuries after wrestling with her older sister and the sister's boyfriend in a simulation of the video game Mortal Kombat. The 16-year-old sister, Heather Trujillo, and boyfriend Lamar Roberts, 17, have been charged in the girl's death.
Caseworkers in six counties had received 14 complaints about neglect, drug abuse and homelessness in the family.
The state review cited Weld County for failing to act after a previous report of the girl being harmed by her sister, about her mother's neglect or the mother's use of meth. Allegedly county workers would have found an outstanding warrant for child abuse on the mother from another state if they had checked and caseworkers did not check on a skull fracture in a sibling or check on Lamar Roberts' history, even though he was living in the household.
Weld County authorities dispute the state's findings.
Rosalia Garcia-Quintana, 4
Rosalia died Oct. 30, 2007, in Otero County of bacterial infection due to abuse and/or neglect. She had skin ulcers, bruises, and pneumonia, and was malnourished. Her father, Salvador Quintana, and stepmother, Carmen Guerra, have been charged with child abuse resulting in death.
Caseworkers were cited for failing to check on the child after a report of abuse, because the father said he was in Texas at the time. Neither the child nor her siblings were given medical exams for signs of abuse.
Neveah Gallegos, 3
Neveah died Sept. 24 of unknown causes. Her body was found three days after her mother, Miriam Gallegos, reported her kidnapped. Gallegos and her boyfriend, Angel Montoya, were arrested but released without charges. A homicide investigation continues.
Denver had worked with the mother extensively a year earlier, after the little girl was found to have a vaginal injury after being given a bath by the mother's sex-offender boyfriend. At the time, Montoya refused to be interviewed. Denver closed the case, believing the mother had cut off contact with him.
The state faulted Denver.
Alize Vick, 2
Alize died Oct. 10 in El Paso County of head injuries. Her foster mother, Jules Lynn Cuneo, told authorities she threw the girl against a coffee table. She has been charged with first-degree murder. Cuneo had been investigated four times previously for child abuse.
A caseworker looked into an informant's allegations that Cuneo was unrelenting in her verbal abuse and sat on the child. The caseworker decided the allegation was unfounded, even after listening to a recording picked up by a neighbor's baby monitor of a child screaming for the 300-pound Cuneo to get off.
The state review cited El Paso County because the caseworker did not investigate alleged abuse in a foster-care home within the required 24 hours, and because the report was not submitted for four months, after Alize died. A timely report would have triggered a state review of the caseworker's decision.
El Paso County said it was underfunded to investigate more than 10,000 complaints of child abuse and neglect a year.
The state review does not address statements to the press by the child's grandmother that she complained three times to Kid's Crossing, the private agency supervising Cuneo for the county - once after picking up Alize and finding a fat lip, a black eye and broken tooth. A state spokeswoman said that issue is still being investigated.
Luz Valdez, 3 months
Luz died Dec. 30 in Denver of bleeding inside her skull. Her father, Isidoro Valdez, admitted shaking the child and has been charged with first-degree murder.
Three previous children of the baby's mother, Mary Maes/Campos, had been voluntarily given up to relatives.
The state review cited caseworkers for failing to quickly check on reports that the mother had taken her children back, and that the father repeatedly had dropped the baby. Denver had an outside review done that found problems with a state safety checklist and with a shortage of state funds for training. Denver is adding 40 caseworkers.
Jesse Weaver, 11
Jesse died July 8 in Lincoln County after saying he wanted to kill himself and others, and then overdosing on his mania/depression medication, Seroquel.
Social services found that the parents had emotionally abused the boy by subjecting him to their domestic violence. The agency concluded that the parents' decision to take him off his medications amounted to medical neglect.
The report found that caseworkers had dismissed at least 15 referrals about the family alleging physical abuse, neglect, domestic violence, and substance abuse, though they were providing services to the boy. The boy's psychiatrist had recommended hospitalization for disruptive behavior disorder and mood disorder. That did not happen, after Lincoln County social services disagreed with Centennial Mental Health Center about which agency would pay for it.
His mother then took Jesse off his medications and within three weeks, the 11-year-old killed himself.
The review said caseworkers did not respond to new allegations, and did not alert the mental health agency to the family issues.
Loreyna Barea, 7
Loreyna died March 9 in Weld County, weighing just 35 pounds. The medical examiner found she died of starvation, dehydration and blunt force trauma. Legal guardians Genevieve Barea and her common-law husband, Dan Partch, were charged with child abuse resulting in death. Partch was acquitted, and prosecutors are reconsidering their case against Barea.
The state review found that Weld County should have investigated when told two weeks before the girl died that Loreyna and other children were fearful of Barea during a visit to a hospital.
Chandler Grafner, 7
Chandler, who was kept locked in a closet, starved to death. He weighed 34 pounds when he died in Denver on May 6.
He had been taken from his mother after accusations that she abused him, and was placed with the father of his half-brother. That man, Jon Phillips, and his common-law wife, Sarah Berry, await trial on charges of first-degree murder and child abuse.
The review of Chandler's death, released in August, found that three counties had reports on the boy but did not communicate. Denver was criticized for failing to follow up on an injury report after the boy recanted about Phillips hitting him.
Ezra Sprowes, 5 months
Ezra died Dec. 28, suffocating on his own vomit after being put to sleep lying on his stomach amid several stuffed animals and blankets.
His mother, who is reportedly developmentally challenged, tried to resuscitate the child for three hours before someone else came home and called 911.
There was no finding of neglect regarding care of the child. The state review did not cite the agency.
Adrian Ruybal, 1 month
Adrian died Dec. 13 in Phillips County of a non-accidental head injury. His mother, Leticia Ruybal, has been charged with child abuse resulting in death.
Caseworkers had received five referrals on the mother from 2001 to 2003, and one was considered founded. The review did not cite the agency.
Kayla Dutcher, 5
Kayla died Oct. 7 in El Paso County after ingesting the adult painkiller Tramodol.
The review found the parents neglectful but there were no criminal charges. The state cited El Paso County for not documenting the case in a database in a way that could be read by others.
The review said there had been five prior referrals about the family, but the review did not address them because information regarding surviving family members is secret under state law.
Baby boy Campbell, 1 day
The newborn died Dec. 24, 2007, in Teller County after his 16-year-old mother delivered him in her home bathroom. He was later found dead. No criminal charges have been filed, and the agency was not cited.
Rashad Maxey, 8 months
Rashad died in Arapahoe County of a head injury after being shaken. His baby sitter, Yvette Craddock, has been charged with child abuse resulting in death.
Social services had one unrelated contact with the family before the boy's birth. The agency was not cited.
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April 15, 2008
3:29 p.m.
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grandma6 writes:
While I am glad they have looked into these cases, there are kids in the system now that have been subjected to this same inadequate decisions. Someone needs to step in and make changes for them as well. Identify them and address their needs! I'm so sorry for these kids who have been abused and neglected! The victimization continues! Sad to say that it is by the system that is supposed to look out for them. I guess it is a step in the right direction.
April 15, 2008
8:51 p.m.
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Sweetpickle writes:
CHA are such great people doing so much good for our children. It's good that none of them are responsible for this sad event.
April 16, 2008
12:23 a.m.
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mountainguy writes:
Human Services is more like dis services. This organization has needed an oversight committee for years. There needs to be an oversight body that people can report to regarding infractions withing the organization. I'm sure it will be overwhelmed quickly but there needs to be an organization. Human services and its minions are free to say and do what they want when it comes to people in the "System" while they're free to ignore reports about potential abuse regarding children they are also free to lie about foster parents that are doing a good job for kids. I have witnessed this first hand. As long as there is not a oversight committee and only case workers and head-in-the-sand superiors, this system will remain broken for a long time to come. Children will most likely die and loving families can be torn apart at Human Services whims.
April 16, 2008
7:42 a.m.
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grandma6 writes:
We were in the system. You are held to the threat of loosing your child (grandchild for us) if you make waves! Yes we know that during DNN hearings we can speak but if you do........... An oversight board would need to guarntee that there are no repurcusions. There needs to be immediate action for these kids. It was only when we had her protected with guardianship that we have said anything! Yes there are some good workers but we happened to have the worst all the way around. We have an older brother who is another Chandler! Where is the system that has let that happen AGAIN?
April 16, 2008
7:49 a.m.
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holekeeper writes:
um.....Dems help me think of w was we can balme bush....oh,ho, I know it was Gov. Owens Fault, and He may have talked with Bush once or twice, so Its his fault
April 16, 2008
8:49 a.m.
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kathyM writes:
One referral might be a fluke. Two should be enough for an investigation. But FIFTEEN referrals is EVIDENCE.
April 16, 2008
9:17 a.m.
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vudumom writes:
I think it's time to start charging case workers with negligence resulting in death if they had clear evidence of a child being abused and failed to do nothing. If we start holding the social workers responsible for there clear negligence then maybe they would step up and do there jobs. Many of these cases were clear and undeniably child abuse. Yet the case workers failed to protect these children. That is there job! If they do not protect the children then what the hell are they there for? I'm sick of hearing they are overworked with caseloads. If you have a 2 year old with vaginal injuries what part of this is not normal do they not understand? Why would they even let this little girl go home with a mother who is living with a child sex offender?
These cases are glaring abuses by the case workers. Yet they will spend more time on a case of alleged abuse that shows no sign of injuries or abuse. This is sickening. Even a person who is not a so called qualified social worker could see right away that these children needed to be removed immediately. If they are really that blind than they need to be fired. I sick and tired of there excuses for not doing their jobs. Get the hell out of social work if you can't tell a child with bruises all over their body and tells you someone has been beating them , needs to be protected.
April 16, 2008
10:38 a.m.
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T1anda writes:
The only time social service workers show any competence is when they pick up there un-earned paychecks! They are really good at that!!!! An un-biased and HONEST over-sight committee should be selected and put to work immediately!!!
April 16, 2008
11:51 a.m.
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coloradoaspengirl writes:
This is the nightmare I am in with my 6 year old son. They just keep letting him get hurt over and over, but it is always an "accident" and the abuser is always the truthful one, not the 6 year old wearing the bruises... They simply don't care and I am afraid for my son
April 16, 2008
12:53 p.m.
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ROCKIESBB writes:
I find it very interesting how many people are quick to accuse the Department of Social Services of not doing their jobs. Let me point out .... it's deranged people who sometime call themselves parents who are responsible for abusing and murdering their children. The responsibility of the Social Worker is a burden most of us would never subject ourselves to. On one hand they have to make a decision whether the removal of the child is appropriate and when that decision is made it must be upheld by the courts of the county where the child resides. I would guess that decision is not done lightly and is based on all the information collected during an investigative period. I can also guess the family members involved aren't eager to have a child placed in foster care and on atleast some occassions could and do lie to the Social Worker about the events which necessitated the involvement of the Social Worker. If the People of Colorado want the entire responsibility for the nurturing and protection of the children to be placed into the hands of Social Services and removed from the families of the child, the solution is obvious. Each report of child abuse, regardless of it's basis, should immediately result in the childs placement in foster care until it can be confirmed by the county, the state and the courts that the child is safe to return to it's mother and father.
April 20, 2008
12:25 a.m.
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annie143 writes:
This is very hard to read. It is going on all across the country.
I agree with the Judge that said some of this stuff is common sense. But, when the officer wanted to temporarily remove Chandler and his brother from their home, there was no place for them to go.
So Chandler died.
I wonder if Chandler has ever had a marker put on his gravesite.
Sweet little fellow.
Another thing, I do not understand how in the recent trial of the little girl, Loreyna, I think, the common law husband was acquited and they are thinking of dropping the charges against the aunt ? That little girl was murdered, as sure as the sun is coming up tomorrow. The verdict was unbelievable.