A First Nations child welfare agency (USMA) had placed the girl and her older brother in his home just two weeks before her death, without first conducting a background check into George's violent past. Nor did it remove her brother from the home until five months after Sherry's death.

The NDP is demanding a full public inquiry into the death of 19-month-old Sherry Charlie.

The toddler was beaten to death by her uncle - who had a history of violence - less than a month after being placed in his Port Alberni home in 2002. For weeks, the opposition has been asking why Sherry's three-year-old brother Jamie was left for another five months in the same home.Over the weekend, it was revealed Jamie Charlie remained in the home under a court order sought by a social worker with an aboriginal child protection agency.New Democrat MLA Adrian Dix said Monday that it's the B.C. government that is ultimately responsible. He wants the premier to step in and take authority over the case away from Children's Minister Stan Hagen and Attorney General Wally Oppal.Charlie's grandparents are also calling for a public inquiry, saying they have no confidence that Child Officer Jane Morley can conduct a proper investigation. Morley says a public inquiry isn't necessary.The uncle went to prison last year for manslaughter.

Inquest begins into infant's death

Last Updated: Monday, February 6, 2006 | 10:18 AM PT

Nor did it remove her brother from the home until five months after Sherry's death.

Her uncle was sentenced to 10 years in jail for manslaughter. Because he pleaded guilty, few details about the case were revealed - including why USMA placed the girl in the Ryan home in the first place.

The inquest is expected to focus on the agency, as well as the role played by the Ministry of Children and Family Development.

NDP critic Adrian Dix says he expects the evidence will show that the government was negligent by imposing a "cut-rate social work system, and the consequences of that for these children was disastrous.

"Yet, no one in the system reacted - not the coroner's office which is conducting this inquest, not the police, not the ministry, not the Child and Youth Officer. No one, no one responded."

Social workers, family members and the convicted uncle, Ryan George, are all expected to testify during the one-week inquest in Port Alberni.

Reed never had a chance. -Wilton Manors Florida, April 25 1985, battered

"He had some physical problems and initially mother was told that he would have severe physical and mental deficits, and would probably not live long. But after they had placed him with a woman who was taking care of a son who also had problems, he showed improvement and I wondered what potential he had. Mother already had a 1 year old son and she never bonded with little Reed. When the woman who was keeping him could not continue, father said that a friend of his who sold insurance wanted to place Reed with his family. It was such a mess and I look back and feel so troubled by it. Reed never had a chance. Reed was in the hospital in Fla after having a fall. Mother flew down and called me saying that the police were involved and thought the injuries were from abuse. The caregiver said Reed crawled up on a table and fell, hitting his head. In the hospital xrays showed some old injuries. Reed died, the caregiver was charged (I think), but I believe that he accused his wife and she accused her husband...of hitting him. I'm not really sure that either of them were convicted, though the other night when I sent the email I was thinking that the man did go to jail." xxxxx

Calls for Help Not Enough to Save a Child's Life - Death Spurs Probe of Sacramento CPS

Calls to Child Protective Services about the welfare of 12-year-old Daelynn Foreman were not enough to save her life. The young girl was found dead in her Orangevale home in July 2006.
Foreman had cerebral palsy. According to the Sacramento County Coroner's office, the girl weighed only 23 pounds and died of starvation.

An investigation by the Sacramento Bee found that in the five years before the child's death CPS received seven calls reporting the child was "either severely or generally neglected."

According to report, a CPS worker visited the girl's home where she lived with her mother Brandy Foreman 10 weeks before her death. After that visit, the worker concluded the 12-year-old was indeed neglected, however, no moves were made to remove the child from her mother's custody.

Daelynn was found dead on July 31, 2006. According to Bee, the child was covered in sores so deep her bones could be seen. The coroner determined the child had starved to death. But charges against the child's mother weren't formally filed until February.

Foreman now faces charges of homicide, neglect and the sale of methampheramines.

Officials at CPS say Foreman was very believable when confronted with reports of neglect.

According to Lynn Frank, director of Sacramento's Department of Health and Human Services, an investigation into the Foreman case did follow the child's death and resulted in "personnel actions."

Death Spurs Probe of Sacramento CPS

June 4,2007 - Another life lost on DHS's watch

The agency sent Omega Leach, a troubled 17-year-old, to a Tenn. youth facility in May. A month later, he was dead.

The City of Philadelphia decided a trip south was best for Omega Leach, an angry teenager who got in trouble for stealing a car. In May, the 17-year-old arrived at the Chad Youth Enhancement Center outside Nashville, a mental-health facility for troubled teenagers approved by the city's Department of Human Services.

His stay was brief.

Leach died after a physical confrontation with staff on June 3. He tried to choke one counselor, and another staffer pushed Leach facedown to the floor and pulled his arms behind his back, police said.

Investigators are checking whether the restraint was applied improperly, preventing Leach from breathing. He was pronounced dead the next day in a Nashville hospital, about 15 hours after the confrontation.

"There's no doubt that the kid had an attitude and probably needed to be locked up somewhere," said Sgt. Brian Prentice, of the Montgomery County, Tenn., Sheriff's Office. "It doesn't mean he has to be dead."

Leach's death was one more lost life on DHS's watch. As with other Philadelphia youths committed to such centers, his care was DHS's responsibility. The agency was paying Chad $285 a day for his treatment.

Questions have been raised about the center before. In 2005, a 14-year-old Long Island girl died there of heart failure as she was being escorted by a counselor.

Although Chad staff was not blamed in her death, Tennessee officials quit placing teenagers there. New York did, too.

But not Philadelphia.

On DHS's recommendation, judges and social workers continued to send children to Chad, even though the agency's own reports consistently criticized its performance, an Inquirer review shows.

After the newspaper began asking questions about Chad and the two deaths last week, officials in Philadelphia and Tennessee began to take action:

             Tennessee's child-welfare agency banned new placements at Chad and said it would force the
             facility to improve restraint procedures.

             Philadelphia's DHS also froze admissions to Chad. The department said it was putting into place "a
             contingency plan" for relocating 45 city children still at Chad, pending further investigation. Some
             of the children are delinquents. Others had been neglected or abused.

             A Philadelphia judge criticized DHS harshly for failing to inform the courts of the 2005 death and
             said he would insist on better communication.

"It's disturbing to the point that it's unacceptable," said Kevin Dougherty, administrative judge of Philadelphia Family Court.

Chad one of 110 behavioral-health facilities in 33 states

Chad and its corporate owner, Universal Health Services Inc. of King of Prussia, declined to respond to detailed questions. They did issue a statement defending the facility's record.

UHS owns more than two dozen hospitals and 110 behavioral-health facilities in 33 states. It bought Chad and 29 other facilities the month after the Long Island girl died. The deal was worth $210 million.

Chad's owner - Universal Health Services Inc. Respond

"We have a reputation and history of being a high-quality provider of behavioral health and substance-abuse services to troubled youth and their families," said Duwayne Glaser, Chad's chief executive officer.

He said Chad's training exceeded industry standards.

Chad helps "troubled kids to get better," the statement said. "We take the responsibility of their safety and care very seriously."

Philadelphia's child-welfare agency has been scrambling to remake itself since an Inquirer investigation last fall explored a string of deaths of children under DHS protection.

DHS has undertaken a host of reforms, including new procedures to evaluate the safety of children. Its workers visit the most vulnerable children more often and has hired more nurses to spot medical problems.

In a tough report released four days before Leach's death, an expert panel appointed by Mayor Street said "significant system failures" at DHS had let children die needlessly.

In particular, the report criticized DHS oversight of the private agencies that receive millions of dollars to work with the city's troubled children.

Although Philadelphia has sent scores of teenagers to Chad, paying it $6 million in the last three years, city and state social workers failed to closely monitor how it was treating those children.

For example, in 2006, Pennsylvania child-welfare officials sent out a directive strongly discouraging restraint techniques except as a last resort.

Through a bureaucratic oversight, that directive was never sent to Chad. On Friday, state officials said they would make sure Chad got the message.

In Philadelphia, DHS officials struggled last week to explain why Chad continued to earn their approval, even as DHS's own inspectors filed reports that found the center consistently failed to meet many standards.

For example, one 2005 report said teenagers at the center had complained that staff members had improperly used physical force to restrain them. They also complained that staff members had sex with residents and watched pornography with them.

Before releasing it, the city censored that section of the report, saying it was related to the ongoing investigation and needed to be kept secret. The contents were confirmed by sources familiar with the document.

Throughout last week, DHS released confusing, contradictory and, at times, incorrect information about its dealings with Chad, particularly what it knew about the earlier death.

On Tuesday, Arthur C. Evans Jr., the acting DHS commissioner, said in a statement:

"We were not informed of the previous death. It was the Chad facility's obligation to inform DHS of the 2005 death, but they did not do so."

By Thursday, DHS admitted that was not true.

The agency reversed course after learning that a former Chad executive disputed its account. The executive said in an interview that he had flown to Philadelphia to brief DHS officials about the girl's death.

A source at DHS said on Friday that Evans was initially misinformed by a senior staff member.

Last week, Evans acknowledged failures in DHS's oversight but said a new system would provide "a much more accurate picture" of the quality of outside contractors such as Chad.

Steven Oakman heads the contracting office at DHS. "I'll have to refer you to the commissioner's office," Oakman said on Thursday. "All of the statements are coming out of there."

After Leach died, investigators descended on Tennessee, including teams from from DHS, Family Court, and the Philadelphia public defender's office.

They joined local detectives, child-welfare advocates, and officials from two Tennessee state child-welfare agencies in touring the Chad grounds. The center is a 20-acre complex in Ashland City in rural Montgomery County, northwest of Nashville, with a main classroom building, a gym, and several dorms.

Prentice, who is supervising the criminal investigation, said the Sheriff's Office had fielded a number of allegations over the years that Chad residents had been assaulted, either by staff or by one another.

"There are reports all the time," he said. "There's a lot of runaways, stories [from children] that 'We're being abused out there.' We've had some broken arms, some separated shoulders."

Prentice said victims would stop cooperating with investigators, apparently because they feared retaliation from staff or other youths. No charges have been lodged in any incident, he said.

"They're mostly street kids," he said. "They think they're better off to keep their mouth shut."

Investigators from Philadelphia recently spoke with about 20 city children at Chad and heard allegations that raised "serious concerns," said Robert Listenbee, chief of the juvenile unit at the public defender's office.

"The general feeling is that there are a lot of restraints, daily, weekly and monthly," he said.

Before Leach died, Listenbee said, a child from Philadelphia sustained a broken arm; since the death, another Philadelphia youth has suffered facial injuries during a restraint, he said.

"We're concerned about how frequently they use restraints, the types they use, and the quality of training they have received," he said.

A troubled young man

Outside the Leach family rowhouse in a battered part of Southwest Philadelphia, the walls are adorned with posters with his photo and words of farewell for "Manny," as he was known to friends and relatives.

His mother, Paulette Dolby, cried when asked about her son. She referred reporters to a lawyer, Edith Pearce, who is investigating the death for a possible lawsuit.

Pearce described Leach as an ordinary teenager who loved basketball and video games and doted on his younger sister. He carried a grade point average of 2.7 at Daniel Boone disciplinary school.

"My career goal is to be a lawyer," he wrote recently, in words quoted in his funeral program. "I like helping people, so I plan to be an affordable lawyer, and in that case I will have to go to college."

His father, Omega Leach Jr., 50, has been arrested nine times in two decades and has served time for burglary and drug dealing.

The younger Leach also had a long history of problems. One psychological report called Leach a "deeply troubled and difficult young man."

According to official records, police arrested Leach at age 14 after he allegedly cursed and threatened students and teachers at his school, Tilden Middle. He told one teacher he would "shoot him full of shells," police said.

"His mother is very afraid of him and his behavior," police wrote. The teenager "is out of control."

The city tried to straighten him out. In January 2005, just before Leach turned 15, he was sent to a private facility in Virginia.

By the time he was 16, Leach was back in Southwest Philadelphia. In December, police arrested him for racing through his neighborhood in a stolen Nissan.

Family Court found that Leach was a delinquent, as social workers labeled him with this diagnosis: "conduct disorder."

This time, a judge sent him to Chad. He arrived May 2.

DHS had been placing children from neglectful or abusive homes there since 2001.

In 2006, Family Court judges began using the facility as a destination for a different class of children - those, like Leach, who had committed crimes.

Dougherty said his judges assumed that Chad was a good option because DHS had a long history of using it.

He said it was important that DHS and the courts "develop a protocol" to make sure judges know much more about the places where they are sending children.

Mediocre reviews

Even as the city accelerated its use of Chad, DHS continued to find problems.

Over the past four years, Chad's best evaluation found it met just 46 percent of DHS standards. Even so, DHS ranked the place "average" each year - and kept it on the approved list.

In 2005, Chad met only 34 percent of applicable standards. The reports found that Chad appeared clean, but faulted it for poorly documenting its service and for communicating inadequately with residents' families.

Estelle Richman, Pennsylvania public welfare secretary, said that performance was unacceptable.

"I would say 40 percent out of 100 percent is a problem," she said.

The DHS commissioner at the time of the death, Cheryl Ransom Garner, faulted Chad for not reporting critical incidents to DHS. "We were hearing about them from the kids," she said.

She said the agency checked out some of the reports but could not confirm them. On balance, she said, Chad appeared to be serving children well.

Nowhere in the thick stack of DHS reports on Chad is there a mention of the death of 14-year-old Linda Harris on Sept. 18, 2005.

At the time, Chad officials said she collapsed suddenly while being escorted to a "time-out room" after an emotional outburst.

Harris, who took antipsychotic medicines, had a history of going into rages.

The Nashville medical examiner later ruled she had died of natural causes brought on by a heart problem and asthma, aggravated by "morbid obesity." She was was 5 feet, 7 inches tall and weighed more than 300 pounds.

Michael G. Lindley, one of Chad's former owners, said the staff bore no blame for her death. He said Harris collapsed from a heart attack just moments after a counselor grabbed her arm.

While a Tennessee child-welfare investigation cleared the facility and its staff of any wrongdoing, the state nonetheless decided to stop placing its children there.

"We made a determination it was not worth the risk," said Randall Lea, assistant to the commissioner of the Tennessee Department of Children's Services.

Last week, Lea likened the decision to that of a restaurant inspector who gives a restaurant a 72, when passing is 70 - but then chooses not to eat there with his family.

"There's a gap between minimum acceptable standards and optimum practices, and every agency has to decide what they will settle for within that line," Lea said.

After Linda Harris' death, New York authorities also stopped sending juveniles to Chad and other out-of-state facilities.

"We generally like to have an extremely high confidence level on where we place children," said John Desmond, director of probation in Suffolk County, which had sent Harris to Chad shortly before she died.

"If we have questions about safety, we will not use that facility."

As for Philadelphia, it stopped sending youths to Chad for several months in 2005, but eventually resumed. Ransom Garner, who said she met frequently with Chad officials, said she did not recall discussing Harris' death.

At last count, DHS had 1,554 children in residential centers such as Chad. Of these, 233 were placed outside Pennsylvania.

Under agency procedure, DHS first tries to place all youngsters inside the state. Officials say they send them outside Pennsylvania only as a last resort.

A videotaped scuffle

As sheriff's investigators in Tennessee set out to figure out why Leach died, they caught a break: Part of the death struggle was caught on video.

An account of the staff's confrontation came from Prentice, who is supervising the probe.

A counselor confronted Leach about 2 p.m June 2 and told him to leave his dormitory room. Residents are not permitted to stay in their rooms all day.

Leach responded by shoving and trying to choke the counselor. A camera focused on the dorm hallway caught what happened next: "You see them fly out in the hall, with the juvenile actually being the aggressor."

The pair then tumbled back into the same room, out of the camera's view. Another counselor and a nurse run into the room, and the first counselor walks back into the hallway, visibly exhausted.

Inside the room, according to statements from Chad staff, the new counselor applied a restraint technique as the nurse slipped a piece of plastic under Leach's chin so he could breathe.

According to the statements, it appeared that the counselor, though not sitting on Leach, was putting his weight across him, while bowing his arms back, Prentice said.

That may have crushed Leach's diaphragm, he said.

According to a digital timer on the video, the counselor and the nurse stayed in the room with Leach for 20 minutes. Finally, they emerged and frantically began seeking a defibrillator.

Prentice said he could not say how long Leach was under restraint.

According to a 2006 report on restraint techniques issued by Pennsylvania child-welfare officials, "research indicates that most deaths occur within the first six minutes of restraint."

As yet, the medical examiner has not determined the cause of death. Toxicological results are not back.

An autopsy did find that Leach, like Linda Harris, had an enlarged heart. His body bore no bruises or signs of having been choked, Prentice said.

Prentice said he was deeply troubled at the second death of a teenager in the facility. He said he expected a long investigation that would focus in part on the training given the two counselors, both new hires.

"We have a a lot more to do," he said. "We've got to stop this. One is too many. Two is ridiculous."

Read a panel's report on DHS's failures, and recent news coverage, at http://go.philly.com/dhs 

Contact staff writer John Sullivan at 215-854-2473 or johnsullivan@phillynews.com.

Inquirer staff writer Nancy Phillips contributed to this article.

CHILDREN RAISING CHILDREN: 
CITY FAILS TO ADEQUATELY ASSIST PREGNANT AND PARENTING YOUTH IN FOSTER CARE

On 11/29/2004, Cristian Liz, a 3-week old boy died while co-sleeping with his mother.  The mother of two was a teenage foster child who lived at the time of her child's death in a St. Albans, Queens boarding home with her foster mother.  According to the State, a crib was given to the foster home by the foster care agency but unfortunately the danger of improper sleeping position was not effectively conveyed to the mother or the foster parent.  This crib, which could have saved the baby's life, was never assembled.  Immediately after this unfortunate incident, the Public Advocate's Office sought to determine the extent of services provided by the City to foster children with children of their own, like the mother of Cristian Liz, and evaluate whether those services are sufficient. Read more....

Died July 10,2007

-Dead Toddler Had Been Ward Of County

In past, five reports lodged against toddler's family

Died 07-11-2007

Meanwhile Tuesday, officials with the Dane County Human Services Department, which was notified of possible child abuse two weeks before Anastasia's death, said they believed at the time they had an appropriate safety plan in place to protect the child.

July 9, 2005 - Dec. 18, 2005 "He just wanted to live so badly."

David was born two months premature. He weighed less than 3 pounds. His footprint was the size of an adult's thumb.

He spent the first two months of his life in the intensive care unit at St. Luke's Baptist Hospital, undergoing open-heart surgery and myriad other medical procedures to save his life.

"He was a little fighter," said his grandmother, Cheryl Gray. "He just wanted to live so badly."

It wasn't easy. "He was not happy," his mother, Devon Vega, said. "He cried and cried but when I picked him up, he stopped."

David survived only to be beaten to death when he was 5 months old.

"Face full of bruises," the mortician noted.

Undertakers dressed the baby in a white christening outfit with a bow tie and vest and laid his body in a white casket ? the "Loved and Cherished" model.

Police arrested the boy's mother after listening to her admit to dropping David, shaking him, throwing him on the floor and punching him 11 days after CPS had investigated and found no signs of abuse or neglect.

CPS became involved when Gray reported Vega for smoking in David's presence. Doctors had advised her not to do so because the boy had chronic respiratory problems.

The grandmother had other concerns besides the smoking. "(Vega) was detached, not what a mother should be," Gray said. "She would leave David for days. I was frantic when I called CPS."

It wasn't the first time CPS had heard of Vega. Someone reported her in 2001 for neglecting her 5-month-old daughter.

CPS intervened and, in 2003, Vega gave up the baby girl for adoption, agency spokeswoman Mary Walker said. Vega said she felt as though she had no choice. CPS had told her if she wanted to keep the baby she would have to get her own place, a car and a job and meet regularly with CPS caseworkers, Vega said.

The demands in their entirety seemed impossible, she said.

In a recent interview at the Bexar County Jail, Vega said she conceived David to "fill the void."

Soon CPS would get another call about Vega. But when caseworkers went looking for Vega this time, in response to Gray's calls about David, they couldn't find Vega for three months, officials said.

Finally, on Dec. 7, 2005, they made contact but found no signs of abuse or neglect.

Less than two weeks later, David was dead.

At first Vega denied beating the boy, telling police the next day that he had fallen but that she didn't take him to the hospital for fear CPS would take him from her. But when investigators found her trying to check into University Hospital for psychological treatment, they questioned her again. She confessed and was taken to jail.

"For three days I was on suicide watch," she said. "I was given only a smock to wear and no toilet paper, not even a spoon to eat with."

Vega is no stranger to trouble. She struggled in school. After living a while with her father in Puerto Rico, she moved back to San Antonio. At 17, she dropped out of alternative school. She met a man and three months later became pregnant with her first daughter.

That man is not David's father. The identity and whereabouts of David's father are mysteries. Vega named the boy for a man whose paternity DNA tests later disproved him.

Gray, that man's mother, refused to forsake the little boy despite discovering they weren't related. She stayed true to David in life, and she stayed true to him in death. She paid for the funeral. She keeps the blue cap the baby wore in the hospital, some dried flowers and a few sympathy cards.

She keeps an image of David's tiny footprints, too.

Nancy Martinez
Express-News

July 7, 2005 - Sept. 17, 2005

Abigail's life was so short that family albums contain two kinds of photos: those taken after she was born and those taken after she died.

Two months separate the events.

Trouble and heartache are staples in the home that Abigail passed through so briefly, but it is her death that most defines the family.

That family got its start when Abigail's mother, Lynda Bishop, married her first love, John Bishop. Lynda Bishop was 21 and eight months pregnant with her first child. The parents struggled. Living in poverty, they conceived child after child ? four girls, all unplanned, all born and raised on welfare.

Complicating matters, John Bishop had a drinking problem. After a third drunken driving conviction, he went to prison for two years.

While he was doing time, Lynda Bishop lived with her mother. She met David Villa and became pregnant. She gave birth to a boy, her fifth child. When she and Villa had a fight one night, he threatened to leave and take the boy with him. The fight turned physical. Police arrived and saw Villa throw the boy on a bed. CPS was called and Bishop and Villa were ordered to take classes on parenting and drugs and alcohol and to get counseling. An anger-management class was added to the mix after Lynda Bishop rammed her husband's girlfriend's car, totaling it.

In July 2005, Lynda Bishop gave birth to another child, Abigail. John Bishop was the father.

Abigail was 2 months old when Lynda Bishop and Villa decided one night to go to a bar. The mother left her oldest, an 11-year-old girl, in charge of the other five.

Upon returning less than an hour later, Bishop said, she went to the couch to wake her daughter and saw the baby wedged between the couch cushion and the older girl.

Death by suffocation, the medical examiner ruled. An accident, police decided.

Bishop has a wall in her living room on San Dario Street that's covered with photos of her children, oldest to youngest, all with their mother's cherubic face.

At the end is a shrine to Abigail.

There's an album filled with photos of Abigail in her tiny casket.

There's a plaster mold of Abigail's tiny feet, made just before her burial.

Nancy Martinez
Express-News

The fatal bullet Lani Carr fired into her 6-year-old son, Arthur Penn, entered the left side of his forehead and traveled left to right, front to back and slightly upward, shattering his skull and piercing his brain before exiting the right side of his head.

The bullet Carr squeezed off into her 10-year-old, Jamila Butler, who lay in a medical bed with spina bifida, took an almost identical path but moved slightly downward on its deadly path.

If you think that's child abuse, think again. Child Protective Services chose not to put either case on its list of abuse and neglect deaths for fiscal 2006, though CPS previously had investigated Carr for abusing her children physically and verbally.

The exclusion of the siblings and the strained logic CPS uses to explain it is a window on a broken system, child advocates say, one that hinders understanding of the growing problem of child abuse and undermines meaningful reform efforts.

Since confidentiality laws don't allow CPS to release anything more than statistical information about child deaths, and since those statistics are thrown in doubt by the agency's arbitrary inclusion or omission of children from the list of abuse and neglect victims, gauging the problem and prescribing solutions are difficult, child advocates say.

Madeline McClure, founder of Tex Protects, a child advocacy nonprofit in Dallas, said the omission of Carr's children weakens prevention efforts.

State Sen. Carlos Uresti, D-San Antonio, agrees.

"How could they not be on the list?" he said. "(CPS) should be reporting that these children were killed from abuse."

Mary Walker, spokeswoman for the CPS San Antonio region, agrees Carr abused her children. But because Carr killed herself, too, Arthur and Jamila were not added to the list of abuse and neglect deaths ? a list that included cases less clear-cut, such as the accidental drowning of Braden Lackey, whose family had no CPS history.

Lackey, a 4-year-old autistic child, drowned in a pond at his grandparents' home. His family says his death was an accident and not negligent, as CPS classified it. But CPS officials say there were other circumstances that they can't disclose because of confidentiality laws.

Neglect deaths happen for very different reasons than abuse, said Dr. Harry Wilson, a pediatric pathologist and child abuse expert in El Paso.

"We overly attribute things that are due to human error to being an accident," he said. "A true accident is an act of God, something that couldn't be prevented. If a 2-year-old wanders out of the house and gets run over or falls into a pool, that's not an accident. Someone didn't do his or her job. Someone did something wrong."

At opposite ends of the spectrum, the Carr and Lackey deaths illustrate the wide range of cases on which CPS rules as well as the agency's sometimes arbitrary findings.

The agency didn't label as abuse the deaths of Jamila and Arthur even though Carr's own mother had previously reported her for beating the children.

"Although the deaths of (Carr's) children would have been considered abuse," Walker said, "there was no way for us to complete an investigation because of the nature of this being a murder-suicide."

The agency's mission is to protect children, she said. If the abuser is dead, continuing to keep tabs on a family is pointless. And, so, in rare cases, Walker said, the victims are not counted.

Child advocates argue that omitting children like Arthur and Jamila from the CPS list blurs a number that some say serves as the ultimate marker of the success or failure of the agency: the human toll.

Add Arthur and Jamila to the official total for last fiscal year and the number of deaths by abuse or neglect rises to 16, the second-highest total ever in Bexar County.

"To not count them as a child abuse death certainly minimizes the data on how many children are killed by their parents," McClure said. "Data is important to policy, to funding for prevention. We have to know that. How are we going to know how to intervene or prevent it if we don't know the who, what, where, when, why?"

The circumstances of the Carr case add up to a tragedy ? one that occurred on the state's watch.

Carr's mother, Pentora "Penny" Carr Pierce, who lives in Florida, said she called CPS about her daughter in 1996, when Jamila was 6 months old. (Walker says CPS records show the agency's first contact with the family came in August of that year on an allegation of physical abuse. Jamila had a fractured thigh.)

Years later, in 2003, when Pierce took a week's vacation and stayed in Carr's home, she said she witnessed how bad things had become. As Jamila, who had never been able to walk, had grown older and heavier, her care was more taxing on Carr. Pierce said her daughter often complained of back pain.

One day Pierce said she went to the school and talked to the principal and a counselor.

"I thought that was the hardest thing I'd ever done in my life, to call CPS on your own child," Pierce said, remembering she wept as she told CPS about the abuse she witnessed.

Pierce said she saw Carr beat her son every day and hit her daughter in the mouth. Pierce said she also told CPS that Carr refused to take her medication for her anxiety attacks and bipolar disorder.

Pierce recalls one incident vividly. Jamila fell out of her wheelchair, hitting her head on concrete. "Jamila was crying and shaking hysterically, and (Carr) refused to take her to the hospital," Pierce said.

"She flung Jamila over her shoulder and sat her on the toilet, hitting her head on the towel rack. It was a loud, hard hit. Then, she got up in her face and said, 'Stop crying! You're going to school, and when you get to the (expletive) school, don't tell them that you want to come home.'"

Pierce said she told CPS her daughter was troubled.

"She was under so much stress. I knew she needed counseling, and I told them she needed help. But (CPS) didn't even call me or the people whose names I gave."

Walker said the department investigated the allegations of abuse, but in each situation it was unsubstantiated. "Nothing was reported to us that indicated that this woman was going to snap," Walker said.

But on a June day last year, Carr did snap. She shot to death her fiance, Arthur Penn; his body was found outside the house.

She turned the gun on her son and daughter. Arthur died on a mattress on the floor. Jamila died in her medical bed, still connected to a breathing machine.

Then Carr used a fourth bullet on herself.

Last month, on the anniversary of the killings, Pierce and her husband, Willie, drove 14 hours from Florida to San Antonio's Meadowlawn Memorial Park cemetery to visit the graves of Arthur and Jamila.

Under a gray sky, Pierce knelt at the graves.

"Jamila," she said, "I just hope you are having fun walking around in heaven ? you're not in a wheelchair anymore. You all take care of each other up there in heaven. Look for Mom, look for Daddy.

"I'm just praying and hoping that in spirit you all will come and say, 'Hey, Grandma, hey, Papa."

nmartinez@express-news.net

Died July 20,2007 - "He was always smiling."

Kelton died -- March 4 -- at Jackson Memorial Hospital.

He is one of three boys under the watch of the Department of Children & Families to die since February, a statistic that has spurred a public outcry.

"I hit baby so he won't be a 'punk," dad tells cops

Victor Demetrius Robinson wanted his 8-month-old son to be a man.

His infant, Kelton Wright, was being fussy: New teeth were coming in and he wouldn't stop crying.

So, according to child welfare reports released on Thursday, Robinson stuffed a sock in the baby's mouth and told him: ``Be quiet. You're a boy. Don't cry.''

Three weeks later, Kelton was crying once more -- still teething, now sick with diarrhea, vomiting and feverish.

That's when Robinson punched the baby in the back, and ``shook him violently.''

Kelton stopped crying. The force of his father's blow knocked him forward and forced all the air from his lungs.

The infant managed to crawl toward his mother, Ciji Wright, 19, before his eyes rolled back and he stopped breathing.

Robinson, who is charged with murder, offered this explanation to police: ``I don't want my shorty to grow up to be a punk.''

Kelton died a day later -- March 4 -- at Jackson Memorial Hospital.

He is one of three boys under the watch of the Department of Children & Families to die since February, a statistic that has spurred a public outcry.

The DCF documents released this week reveal more detail about Kelton's short life and the welfare agency's work in the days leading to his death -- casework labeled as ''indefensible'' by Chelly Schembera, then acting head of the DCF's Miami district, in a March 10 e-mail to DCF Secretary Jerry Regier.

Among the details:

? The child abuse investigator assessed the risk to Kelton as ''low'' after responding to the February incident despite Robinson's history of mental illness and molesting a disabled family member. The investigator dated her assessment Feb. 17, but the records show her supervisor did not review the assessment until after Kelton had died.

? Kelton's case was on the table to be reviewed by a DCF attorney Feb. 25 when the attorney postponed his and one other case because ``she had to leave as it was 5 p.m.''

On Thursday, 364 days after DCF reported to police the disappearance of 5-year-old foster child Rilya Wilson, several state lawmakers gathered in Tallahassee to mourn the death of Kelton and the three other children who have died under DCF care since February -- and call on Gov. Jeb Bush to delay the confirmation of Regier as secretary.

''We should not be wringing our hands over more beaten children, more neglected infants, more tiny graves,'' said Sen. Frederica Wilson, D-Miami.

The Miami Herald  | 4-25-2003 | CAROL MARBIN MILLER AND TERE FIGUERAS

CPS involved for five years with family of girl who was beaten to death

MESA - Child Protective Serviceshas launched an internal review of its five-year involvement with the family of a 3-year-old girl who was beaten, stabbed and found dead this week.

The agency announced the review late Friday after the Maricopa County Sheriff's Office released reports detailing several cases where CPS was notified by a school nurse of possible child abuse in the home.

"We know this has raised a lot of questions and we share those concerns and questions," Department of Economic Security spokeswoman Liz Barker said. "We do believe in being accountable and that is going to require careful and thorough review of the cases."

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"We have no easy answers right now but we hope to have some answers soon."

CPS investigated the family of Angeline Plummer eight times from 2000 to 2004, most involving suspected physical abuse of her older brother and sister. All of the incidents were found to be unsubstantiated, according to CPS. The agency had its last contact with the family in April 2004.

Angeline was the subject of abuse in a CPS case investigated in January 2002, the month she was born. The girl's grandmother has said the girl was born with marijuana in her system, but it was unclear whether that was the reason for the investigation.

The girl, who was called Angel by her family, was found dead Tuesday after authorities said she was stabbed, burned and beaten by Christopher Langin, a close friend of her father. An autopsy indicated the girl also was sexually assaulted.

Langin, 30, faces a first-degree murder charge and is being held without bond. He was not named in any of the CPS investigations, Barker said. Attempts to contact the family were unsuccessful Friday.

Angel, who turned 3 on Jan. 26, was living with her father, Michael Plummer, 28, her grandparents, her 5-year-old brother, 8-year-old sister, an aunt, a 3-year-old cousin and Langin in a home and a trailer on the property in the 400 block of North 98th Place in a county island in east Mesa.

According to a Sheriff's report, a school nurse at Taft Elementary in Mesa called CPS three times since January 2004 about possible child abuse at the home.

On Jan. 16, 2004, Angel's brother, then 4, told the nurse that his father threw him into a dresser because he was angry. A few days earlier, Plummer told his son's teacher that the boy was bruised after Plummer accidentally pushed him into the dresser while trying to pick up Angel. The Republic is not publishing the children's names.

"There is no history of physical abuse with his family; however, there is a lifestyle issue," the investigating deputy wrote in a report. "When speaking with (the child) it was clear he needed a bath and clothes that fit."

CPS told the Sheriff's Office investigator they were working with the family on "cleanliness and parenting issues."

In March 2004, CPS was notified again after the boy told the school nurse that his dad grabbed him by the arm and dragged him to the bus stop because he wasn't going fast enough. The boy had a small cut to his head, according to MCSO records. The boy's mother, Corda Morrell, was not living with the family during this time. However, CPS investigated her twice within a month in 2001 when the school nurse from Taft notified them about possible child abuse, Sheriff's records show.

On Oct. 22, 2001, Morrell's daughter, now 8, told the school nurse that her mother hit her in the face. The nurse noted swelling to the girl's face, scratches and bruises on her left shoulder.

Morrell told a Sheriff's Office investigator that the girl was running through the house and hit her face on a bedpost and was bruised when she fell down.

Plummer told the investigator, "the house is such a mess, there's no telling how she got hurt."

On Sept. 10, 2001, the girl's kindergarten teacher sent her to the school nurse because of a small cut on her lip and red marks beneath an eye.

The girl told the nurse she hit her lip on her brother's bed and her mom hit her with her hand. The girl recanted when talking to the Sheriff's investigator.

MCSO arrested Plummer in January 2001 on suspicion of assault after he slammed a door that struck Morrell, causing her nose to bleed. Plummer denied the assault. It was one of 28 times Sheriff's deputies were called to the home.

Outside Angel's home this week, MCSO homicide detectives and identification technicians created a small memorial with flowers.

"This really hit us hard. It has personally impacted them," MCSO Lt. Paul Chagolla said. "They are working very hard to make sure everyone responsible is held responsible."

Senta Scarborough

The Arizona Republic

Feb. 11, 2005 08:12 PM

Zachary Iberg was the first to die. Two years later, his brother Dillan Iberg died.

Zachary Iberg 11-month-old &  Dillan Iberg 4-year-old

The deaths of two little boys remain a mystery

HIGHLAND -Despite a lengthy investigation by some of the nation's top forensic experts and the Illinois State Police, the deaths remain a mystery.

Vincent and Chere Iberg had three sons. Joey, the oldest, is now 12; Dillan, who died on Nov. 18, 2003, when he was 4; and Zachary, who died on Oct. 22, 2001, when he was 11 months old.

Zachary and Dillan died in hospital emergency rooms after becoming unconscious while in the care of their mother, Chere Iberg, according to investigative reports.

The Illinois Department of Children and Family Services assigned a child protective worker to investigate the family about 20 months after Zachary died. An anonymous caller to the state child abuse hot line had alleged that Chere Iberg blackened Joey's eye, according to a DCFS report.

The state investigator found that Chere Iberg had injured Joey, then 9, according to the report.

Despite the finding of child abuse, the state took no action to remove either Joey or Dillan from the family's Bond County home.

Because Chere Iberg already was receiving mental health counseling through the county, the DCFS did not need to become involved, the investigator concluded.

"It's a mysterious case that's been open for a while," Bond County State's Attorney Chris Bauer said of the two boys' deaths. "We all want some answers."

A four-month investigation by the News-Democrat found critical errors by DCFS workers in child death cases between September 1998 and January 2005 that ended in the deaths of 53 children, according to investigations by the Office of the Inspector General.

However, the deaths of the Iberg children are not among them because their cases did not meet the criteria for a full investigation by the inspector general's office. Usually, a full probe is ordered only if caseworker error is suspected.

Instead, the agency conducted a limited investigation and issued a so-called child death summary, which provided some details about what was occurring in the Iberg home.

Chere Iberg referred questions to her attorney, Jim Drazen, of Troy, who did not respond to several requests for comment.

"If they found no medical reason for them to die, they should still be here," Vincent Iberg said of his youngest sons. "I just want justice for my two boys."

The Ibergs divorced in 2004. Vincent Iberg has custody of Joey, but Chere Iberg is fighting to get the boy back.

In court documents, Chere Iberg stated that she is a fit mother for Joey and should have full or joint custody. Currently, she can see him only under DCFS supervision, according to Bond County court documents.

Vincent Iberg wants to retain sole custody. In court papers, he maintains his son is at risk.

In an application for an emergency order of protection for himself and Joey, filed in November 2003, about 48 hours after Dillan died, Vincent Iberg wrote, "She (Chere) has ... put self-inflicting wounds on herself. She heard voices in her head that (told her) they were going to take over her body and kill me and Dillan in our sleep."

A judge quickly granted the order.

Second hotline call

In August 2003, the state child abuse hot line had received another call, this time about Dillan, according to the child death summary.

Because he had been taken to the hospital emergency room three times that month -- including twice in one week -- a suspicious hospital staffer made the call.

The DCFS issued a second finding of child abuse, although the report did not identify the abusers.

By this time in his short life, Dillan's situation had come to resemble what happened to his brother Zachary -- the boy would pass out and end up in the emergency room, only to have doctors find nothing wrong.

The child death summary stated that Zachary and Dillan made a combined seven trips to the emergency room after becoming unconscious, with their mother present each time.

Chere Iberg told investigators the boys had seizures or fell, according to an Illinois State Police report.

But before DCFS could take action to remove the boy from the home as a result of this second finding of child abuse, an ambulance rushed Dillan to the emergency room.

Doctors declared him dead on arrival.

Because two boys in the same family had now died under similar and unexplained circumstances, authorities sent tissue samples from Dillan to experts at the renowned Duke University Autopsy Laboratory in Durham, N.C.

But just as a Madison County medical examiner had been stumped as to what killed Zachary, the university experts failed to come up with a cause of death for Dillan.

Limited intervention

Shortly before Dillan died, the DCFS assigned a domestic helper, called a homemaker, to assist Chere Iberg. Part of the woman's duties were to serve as a nanny and help with any medical problems.

On Nov. 18, 2003, with the homemaker and Chere Iberg present in the home, Dillan had his fourth and final attack.

As with Dillan's three previous attacks, Chere Iberg reported that her son's "... body stiffened and relaxed and he fell asleep."

On the previous occasions when the boy passed out, Chere Iberg called 911 and rode with Dillan to the emergency room, according to the child death summary.

But this time, for reasons that are not contained in any reports or other records obtained by the newspaper, Chere Iberg did not call 911. Instead, she placed Dillan in bed.

Some time later, she noticed her son was not breathing, according to the investigative report. The homemaker attempted CPR. Joey ran next door and called 911. Vincent Iberg was at work at the time.

When paramedics arrived, they found Dillan in cardiac arrest.

Police are still investigating the boys' deaths. No arrests have been made.

Vincent Iberg said that while Joey may be too young to understand everything that has occurred, "He can't help but miss his brothers. What boy wouldn't?"

Born mentally handicapped, she was abandoned
by her parents and then shifted around in foster homes, until she ended up with an adoptive mother
who allegedly abused her and caused her death. She probably cried out for help many times to people,
but nobody care and nobody listened.

Doctors describe diaper rash that killed toddler

JOHNSTOWN, Pa. -- Amy Livingston didn't react when doctors described a rash so bad her son's skin was falling off. She didn't flinch when they testified that had the rash been treated, the boy would not have died.She did shed a few tears every time the prosecution presented photographs of her 15-month-old son taken just minutes after he died. In the digital photos, Harley Livingston's eyes are deeply sunken and discolored, and the diaper rash is clearly evident.

The boy died Dec. 12 from sepsis, as a result of the rash. He was profoundly dehydrated, and when he was taken to the hospital just 40 minutes before he died, he had a heart rate of 350 -- more than three times the norm for a boy his age.

Livingston, 27, is charged with involuntary manslaughter and two counts of endangering the welfare of children. One count relates to Harley; the other is for her older son, Hunter, who also had a severe diaper rash. At a preliminary hearing yesterday before District Judge Michael Musulin, all of the charges were bound over to Cambria County Common Pleas Court.

The prosecution called six witnesses during the lengthy hearing, among them medical personnel who treated Harley.

Amy Lentz, an emergency room nurse at Conemaugh Memorial Hospital, was on triage the afternoon the boy was brought in.

"I saw Harley lying in his mother's arms," Lentz said. "He didn't look alive."

She described him as having deeply sunken eyes, being limp and blue in color.

"How did the baby respond to the pain of treatment?" asked Assistant District Attorney Tammy Bernstein.

"He didn't," Lentz said, adding that the boy never flinched while getting an IV.

The toddler had a severe rash on his genitals. Lentz described red pinprick marks all over his upper thighs.

"I've never seen a rash like that in my life," she said.

Throughout the day's testimony, the pony-tailed Livingston, wearing a red jumpsuit from the Cambria County jail, continually glanced back at her husband, David, who at the time of Harley's death was deployed to Iraq with the Army. Sometimes she just nodded at him, others she'd give him a slight smile. On occasion, he'd return her glance, but he showed no emotion during the four-hour hearing, aside from an outburst at several television reporters covering the event.

According to Jeffrey Lees, the first deputy coroner of Cambria County, Livingston told investigators Harley had seen his regular doctor in November, and everything was fine, When questioned about the boy's symptoms, Livingston told Lees that on Dec. 11 the boy ate well and was playing but the next day he wouldn't eat and was lethargic, he testified.

But Dr. Daniel M. Wehner, the emergency room physician who treated Harley, said the boy had to have been exhibiting signs of illness for days.

Besides an abnormally high heart rate, the boy also had an extremely low respiratory rate, Wehner said. Normally, a 15-month-old breathes up to 28 times per minute. Harley was taking three breaths per minute.

The doctor testified that he had never before seen diaper rash lead to sepsis.

"Had the diaper rash been treated, there would have been no entryway for staph to get into the body," Wehner said.

Typical causes of diaper rash, he added, are not changing dirty diapers often enough and not cleansing the skin properly when changing the diaper.

Dr. Vimal Mittal, the pathologist who performed the child's autopsy, said the diaper rash on the boy was chronic. Some of it had crusted, and was discolored -- from red, to pale brown, black and blue. He described the skin around the boy's penis as black and sloughing off.

Karen Harvey, a group supervisor at the day care center Harley had attended since just before his first birthday, said the boy's diaper rash was "ever present."

As part of the center's protocol, whenever a child had a diaper rash, a note would be sent home to the parents. In Harley's case, if Livingston didn't get the note, Harvey said she'd notify the director of the center, Evelyn Mrsnic, who also was Harley's grandmother. During the week, while the boy was at the center, Harvey said his diaper rash would improve. But then, over the weekends, it would worsen again.

The last time Harvey saw the child was on Dec. 9. That day, she described him as being vibrant and toddling around. During her testimony, she mentioned that the boy was a good eater. At that, Livingston smiled and nodded.

Harvey described Livingston as often being "abrupt, angry and verbally abusive" to her children.

She told the judge Livingston only took Harley to the hospital after her mother told her to.

"She said, 'Oh, my God, Amy, something's wrong with him, you've got to get him to a hospital,' " Harvey recounted.

Mrsnic has been charged with one count of endangering the welfare of children, for failing to report suspected child neglect. She waived her preliminary hearing earlier this week.

Livingston was also charged last week with statutory sexual assault and related charges involving her reported relationship with a 15-year-old boy. Before yesterday's preliminary hearing began, Livingston pleaded not guilty to those counts.

Thursday, April 07, 2005   By Paula Reed Ward, Pittsburgh Post-Gazette
Paula Reed Ward can be reached at pward@post-gazette.com or 412-263-1601

Couple killed child with salt, court told

A couple convicted of killing their three-year-old foster son by poisoning him with salt are facing a retrial.

Ian Gay, 39, and his 40-year-old wife Angela, from Halesowen, won an appeal court hearing against a conviction for the manslaughter of Christian Blewitt.

The couple, who planned to adopt the boy, were jailed for five years in 2005. They have been released on bail.

Christian died in hospital four days after staying at their home. High levels of salt were found in his body.

The Gays have served 15 months of their five-year jail terms. The retrial will be heard later this year.

In a BBC interview Ian Gay said: "Prison has changed us. This whole experience has changed us a great deal. I hope that one day we'll regain our trust in the human race but right now we're just trying to get our feet back on the ground and our lives back in order.

"We've had an experience over the last 15 months which has certainly changed our lives and will continue to do so for the rest of our lives."

Speaking outside court, Angela Gay said she was pleased the convictions had been quashed.

"However we must now face the fresh agony of a retrial," she said.

"We now know for certain what we believed all along. That Christian died of natural causes.

"We are now looking forward to going home."

After thanking family and friends, she added: "Yet again we protest our innocence and hope that one day soon justice will finally be done."

Appeal lawyers argued Christian had a rare condition, a sort of salt diabetes, which led to the high salt levels.

Prison abuse

The court held that if the jury at the original trial had heard fresh evidence suggesting Christian could have died of natural causes the verdict might have been different.

Mrs Gay told the BBC she had been the target for abuse from other prisoners while on a segregation unit.

"I had threats of being beaten up, being cut up, having water thrown at me and I had salt put into my clothes," she said.

Christian died after being found unconscious at the couple's house in Bromsgrove, Worcestershire, in December 2002.

Lord Justice Richards, sitting with Mr Justice Penry-Davey and Judge Ann Goddard, said the appeal court had not lost sight of the fact that the medical evidence, though important, formed only part of the evidence in the case.

The couple, having recently taken on three children with a view to adoption, were "in a position of considerable stress", he said.

Difficulties experienced with Christian added to that stress but did not alter the possibility that the fresh evidence could have influenced the outcome of the trial.

Arguing against a retrial Michael Mansfield QC said the scientific dilemma facing medical experts could not be solved by asking a fresh jury to grapple with it.

Prosecutors at the original trial argued the couple either murdered him by brute force or were guilty of manslaughter by feeding him salt as a punishment for naughtiness.

The couple have always insisted they loved Christian and his younger brother and sister, who have since been successfully adopted elsewhere.

That, apparently, is what Ian and Angela Gay did to three-year-old Christian Blewitt, the little boy they had taken into their home and planned to adopt.

He'd been behaving badly, so they force-fed him the salt to teach him a lesson. He went into a coma and, four days later, he died.

Aug. 29, 2005 - Feb. 1, 2006

Ericka had been sick for a month with a cold, cough and conjunctivitis, or pinkeye.

The night she died, the 5-month-old had been crying a lot.

"I thought she finally fell asleep because I didn't hear her anymore," her mother, Maria Lopez, said.

Lopez and her husband, Eric Lopez, surmised that Ericka died of sudden infant death syndrome. Police agreed and closed the case.

But because the medical examiner ruled the cause of death undetermined, citing bruises and abrasions on the baby's scalp, CPS classified the death as abuse or neglect and tried to take temporary custody of Maria Lopez's 5-year-old son.

According to a court hearing, CPS was concerned about a boyfriend Lopez had taken up with after separating from Eric. The boyfriend has a criminal history. Ericka and her brother and their mother were staying at the boyfriend's house the night Ericka died. At the hearing, Sheri Bryce, an assistant district attorney, called Lopez's boyfriend "extremely violent in nature."

July 6, 1993 - May 30, 2006 -"Grandma, take me with you."

Sometimes when children are removed from homes where they are thought to be at risk, they end up in a more dangerous place. Such was Lenny's case.

He and six siblings were removed from the home of parents Angelica and Larry Ortega in 2004 after CPS determined the kids were being abused.

The Ortegas' attorney, Dennis Moreno, said the couple did not abuse their children. The Ortegas were guilty only of being poor and having an apartment that was too small for their large family, he said.

But Lenny was placed in a religious-themed residential treatment center in Ingram, Star Ranch, for children and teens with emotional problems. Lenny, who had a mild form of retardation, lived there for 19 months. Then his parents successfully petitioned to get him back.

Before that could happen, however, Lenny and four other boys were riding their bikes on the grounds of Star Ranch with a female staff member after a heavy rain and Lenny got off his bike to try to pluck something out of the fast moving Johnson Creek. The water swept him 75 feet into a drainage culvert, where he became lodged.

That happened May 6. Lenny died on May 30 after his parents authorized a do-not-resuscitate order. He was 12.

Police ruled the death an accident, but CPS concluded negligence was a factor. (The Ortega incident prompted CPS to cancel its residential treatment contract with Star Ranch and relocate the 18 other boys who lived there. Lenny's was the second death in six months at Star Ranch.)

CPS paid for Lenny's funeral. It cost $2,700. His grave is a short walk from that of Jovonie Ochoa, whose starvation death on Christmas Day 2003 also brought CPS under scrutiny.

Lenny's grandmother Nora Ortega said it is difficult to fathom how the agency took him away, ostensibly to save him, and put him in greater jeopardy.

"I don't know why things happened this way," she said.

When she looks at pictures of Lenny as a toddler, she remembers how happy he was then.

Then she thinks of her visits with him at Star Ranch.

"Before I left he would tell me, "Grandma, take me with you."

"It seems like the department looked the other way just to close the investigation and say the child was not at risk,"

In his death, little Zach helped save the life of another child by donating a vital organ.

BELLINGHAM, Wash. - The pain is unbearable for Christina Kuoppala. Her little nephew, Zachary Commissaris, was apparently beaten to death, four months shy of his second birthday.

"I actually slept with his clothes last night so I could smell him . that's how much I loved him," she said.

The family said doctors told them Zachary was likely beaten, strangled, dragged on the ground, shaken and ultimately killed by a massive blow to the back of his head.

"He had cuts from head to toe on his ears, eyes, nose. He had a cut on his hand that looked like he was protecting himself," said Kuoppala.

Police say a 29-year-old friend of the boy's family brought the boy, unconscious, to the emergency room of Bellingham's St. Joseph Hospital Friday afternoon. Doctors called police but the man disappeared before they arrived.

The man had been watching Zachary for four days because the boy's parents had been evicted from their home. Exactly what happened over the course of those four days is still unclear, but the results are brutally obvious.

"He barely had begun to live and somebody took his life away. It's not fair, it's you know, a monster," said Kuoppala.

In his death, little Zach helped save the life of another child by donating a vital organ.

Police are refusing to name the man who dropped Zach off at the hospital in Bellingham. They are calling him a "person of interest" and hope to talk to him soon.

Deputies served a search warrant at the man's home, and questioned several people, including his girlfriend, the boy's parents and other family members.

A second child belonging to the man and his girlfriend was placed with Child Protective Services.


The Associated Press contributed to this report.

Fire Was Set To Cover-up Boy's Neglect Death - Caseworker Pleads Guilty Of Falsifying Records In Norris Case

ELWOOD, INDIANA--On January 21,2003, firefighters responding to a house fire in Elwood found the burned body of 8-year-old Mark Adrian Norris II.

Officials believed at first that the boy, who had cerebral palsy and epilepsy and used a wheelchair, died in the blaze that consumed his family's single-story home.

But autopsy results tell a different story: The county coroner confirmed Friday that Mark died of pneumonia at least one day before the fire.

During a press conference Madison County Coroner Marian Dunnichay said there was no smoke in Mark's breathing passages, indicating that he was not breathing at the time of the fire. The autopsy also showed signs of malnourishment, extensive muscle deterioration and several bedsores. Additionally, toxicology tests found no traces of the medication Mark should have received to control his seizures.

Prosecutor Rodney Cummings said Jennifer Norris, Mark's mother, is suspected of letting her son die and then setting the fire to conceal the real cause of his death.

"The child died, and at some point -- probably a day or two before the fire was set -- the mother discovered her child had died, and the fire occurred as a mechanism to cover up the death -- that's what I suspect probably happened," Cummings explained.

Mark's mother, his 1-year-old sister and 5-year-old brother all escaped from the fire unharmed.

Cummings said he is considering filing neglect and reckless homicide charges against Jennifer Norris.

Caseworker Pleads Guilty Of Falsifying Records In Norris Case
By Dave Reynolds, Inclusion Daily Express
November 8, 2004

ANDERSON, INDIANA--A former Indiana Division of Family and Children social worker pleaded guilty Monday to tampering with computer records in connection with the death of 8-year-old Mark A. Norris II.

Under a plea agreement, a felony neglect charge was dropped against Mike Warrum, who had worked as a Child Protective Services caseworker.

Warrum was sentenced to one-year probation with no jail time. He had faced up to 20 years in prison if convicted of felony neglect.

Mark Norris' body was found by firefighters on January 21, 2003 after the family's home in Elwood had been destroyed by fire. Autopsy results confirmed that Mark, who had cerebral palsy and epilepsy, died of pneumonia at least one day before the fire. Toxicology tests found evidence that he was malnourished and had not been given prescription medications he needed to treat his seizures.

His mother, Jennifer L. Norris, was sentenced in March of this year to nine years in prison after pleading guilty to neglecting to seek medical treatment or properly care for her son.

Investigators had suspected that the fire was set deliberately to cover up Mark's death, but no evidence was found for them to charge Ms. Norris with arson.

Warrum was supposed to supervise Mark and his siblings under an earlier court order. Prosecutors claimed that he only visited the family once, but falsified entries in the state's computer system after Mark died.

Judge Asked to Dismiss Case Against Anderson Social Worker

Anderson - AP) -- A defense attorney is asking a judge to dismiss a neglect charge against a social worker indicted in an eight-year-old central Indiana boy's death.

Attorney James Bell says caseworker Mike Warrum was not directly responsible for the child's well-being. A grand jury indicted Warrum on felony neglect charges that he failed to adequately protect Mark Adrian Norris the Second.

The boy had cerebral palsy and was confined to a wheelchair. He was found dead after a January fire at his home in elwood, about 45 miles north of Indianapolis. An autopsy found he had died of pneumonia a day before the fire, and tests found evidence that he was malnourished and had not been given medicine to treat seizures.

Prosecutors said Warrum visited the Norris home only once despite a court order to supervise the care of the boy and his siblings. The judge gave both sides until Monday to file additional arguments.

Authorities admit failings over baby's death

Swindon Social Services

May 9th, 2007

"Health visitor grave concerns to social services ignored"

A review into how an 11-month-old baby was left to starve to death reveals a health visitor expressed grave concerns about the family to Social Services.

Neil and Alison Baker, of Hunsdon Close, Walcot, were jailed for five years in March after admitting the manslaughter of their baby Kimberley.

As reported at the time Kimberley was described as looking like a famine-ravished Third World child in court.

A report out today from the Swindon Local Safeguarding Children Board shows that although many of the indicators of neglect were apparent, the main input of Health and Social Services seemed to focus on the mother's health and general family support' rather than the well being of Kimberley.

It continues: "It is possible that the focus was on the mother's and children's health rather than identifying child protection concerns."

The 16-page review outlines 20 recommendations to the agencies who encountered the family, including Social Services and Swindon and Marlborough NHS Trust.

It says there were a number of missed opportunities for Social Services to intervene and assess the situation.

Kimberley was last seen alive by health workers in September 2004 when she was doing well. She died in April 2005.

The report, chaired by Julie Downey, head of Safeguarding for Children Services, said: "It is of significant concern that such a young child, with a family background of feeding problems, maternal depression and domestic violence incidents, was not seen by any professionals between then and the time she died."

The report also shows how concerns of the health visitor, probation officer, GPs and hospital doctors were noted, reported, passed on to each other informally but not followed up.

Had they been, the report says, it would have had the effect of highlighting the collected concerns of the professionals, and raising the profile of the case.

The review shows there was also uncertainty on who should take the lead in coordinating the concerns when they arose.

There were occasions in 2001 and 2002 when neighbours reported worries about the children to the police and health professionals.

It was in April 2002 that a health visitor expressed grave concerns about the family to Social Services.

But it was six months before the first and only visit from a social worker and no interventions were made beyond support for a housing application and help for the mother to get more rest, the review said.

The report shows that other health professionals made a number of visits to the family home but were unable to make contact.

Yet these failed visits were not flagged up with the relevant line manager.

In April 2005, the month of Kimberley's death, a health visitor found the home was dark, smelly and sparsely furnished.

Kimberley died before discussions with the family about a referral to the Local Preventative Group were due to take place.

The 11-month-old baby weighed just 4.6kg when she died- the average weight of a six-week-old baby.

Sentencing the couple to five years each, Mr Justice John Royce described Kimberley as a "pitiful, seriously emaciated mite" and said photographs of her dead body were "truly shocking".

"Her chance of a decent life or any life in this world had been snuffed out by the appalling negligence of you two," he told the couple.

"Had you gone to seek expert advice it may very well be that Kimberley lived. Instead you decided to save your own skins."

Dr Hugh White, who carried out the post mortem examination, said the cause of death was starvation, dehydration and neglect.

The couple claimed Kimberley had not been eating for two weeks but Dr White said his findings were not consistent with this claim and it looked a significantly longer period of neglect and inadequate nourishment.

Neil, 29, and Alison, 25, had four other children who have all been taken into care.

The case file shows that for the first five years, while he was in his mother's care Trevor Nolan was a physically stable, happy, and active little boy.

On March 20, 1997, five year-old Trevor Nolan was removed from his mother's care based on an assumption of the possibility of Munchausen Syndrome by Proxy (MSBP).

On March 21st, he had his first medical crisis. Dale had been told that he was fine and would be sent home in two days and that she was not to hold a vigil over his hospital bed, as she had done in the past.

Dale complied, hoping not to further fit the MSBP profile.

After spending a week in the hospital, on March 29, he was placed in an unlicensed foster home.

He was not taken to his specialist, was fed "normal kid food" instead of his special diet. His blood sugar was not monitored and he did not receive the necessary corn starch feeding through the nasogastric tube.

CPS ignored Dale's pleas as she saw her son deteriorating and running a fever.

Twelve Days after CPS took Trevor from his mother, five year old Trevor Nolan died after suffering a cardiac arrest.

The autopsy showed that his body was overwhelmed by infection caused by improper care and feeding.

----------------------------------------------

Trevor Nolan was born with a metabolic disorder, Glycogen Storage Disease, Type 1D. Trevor was fortunate, his mother was an emergency medical technician and Trevor was doing well.

During Dale's divorce from Trevor's father, a custody battle that ensued and the court appointed a family counselor, Cynthia Stout of Glendale, California.

An accusation of Munchausen Syndrome by Proxy (MSBP) was made against Dale. Mono County, Child Protective Services took Trevor and his older brother, Wade, into protective custody.

Trevor's physicians, who had known the mother and child throughout Trevor's life, disagreed with the diagnosis of MSBP.

Trevor's metabolic disorder required continuous feeds during the night through a tube that was threaded through his nose and into his stomach and small frequent meals throughout the day to keep his blood sugar stabilized. His body could not metabolize the usual "kid" food.

After being put into an unlicensed foster home, based on the assumption that Trevor was being made ill by his mother, CPS authorized the removal of his nasogastric tube for daytime feeds. The nasogastric tube would be reinserted each night. Trevor was neutropenic and nightly replacement of the nasogastric tube can cause serious infections.

Dale was told that Trevor was doing fine and would be returning home in two days. Later, she received a call that she needed to get to the hospital, QUICKLY.

Ten days after the removal of the nasogastric tube, Trevor went into hypoglycemic shock and coma. He was airlifted to a hospital in Reno, Nevada.

When his mother arrived at the hospital, Trevor was dead.

____________________________

Update:

Wade was permanently returned to Dale's care. She and Wade adopted a little girl several years later and have tried to pick up the pieces of their lives and move forward.

Died November 19 2006

Police probe death of girl, 4, in foster care; medical examiner rules death was a homicide

OCEANSIDE -- Detectives are investigating the death of a 4-year-old girl who died while in the care of a foster family Sunday, Sgt. Leonard Mata said.

An autopsy on Angelina Espalin determined that the death was a homicide, a medical examiner's investigator said Tuesday.

Officers were called at 8:30 a.m. Sunday to Tri-City Medical Center regarding a suspicious injury to a child, Mata said. Angelina was unconscious when her foster parents brought her to the hospital seeking treatment, he said.

Angelina was taken by air ambulance to Children's Hospital in San Diego, where she died later that day, Mata said.

Police released few details about the case, including where the injury occurred. Mata said he did not believe the girl was related to her foster care parents.

San Diego County's Health and Human Services Agency spokeswoman Cathi Palatella said she could not comment on this specific case, but generally, the majority of children who have died while in the foster care system passed away of natural causes.

"Many of our children have special needs and are medically fragile," Palatella said. "Just because they died in foster care doesn't mean it was suspicious."

Generally, there are 6,000 children in San Diego's foster care system every year, she said.

It was unclear how many children had died in the San Diego foster care system this year, but last year there were three deaths, four deaths in 2004 and 2003, six deaths in 2002, two deaths in 2001, and eight deaths in 2000, she said.

Palatella said she could not elaborate on instances where the deaths were not natural, but that some were accidental. She said she could not comment on whether any foster care parents had been prosecuted for any of the deaths since 2000.

She added the county orders a criminal and child welfare background check on a prospective foster care parent. The background checks are conducted by the FBI and the state, which includes fingerprints for every adult living in the home. Additionally, the county does home evaluations to make sure the home is appropriate for the child, Palatella said.

-- North County Times wire services contributed to this report.
By: YVETTE URREA - Staff Writer
Contact staff writer Yvette Urrea at (760) 901-4076 or yurrea@nctimes.com.

Boy dies knowing the love of his mother

Amarion McDaniel, 2, died peacefully Saturday after being held and cuddled by his mother, who fought the court system last year for the right to remain the parent of her terminally ill child.

Hours before he died at a Wauwatosa hospice, Amarion's mother, Anastasia Schoenfield, 28, took him outside so he could feel the sun and wind on his face once last time, Barb Tanis, the boy's grandmother, said Monday.

"He was very peaceful and calm," Tanis said. "It was a beautiful day."

Schoenfield's plight was the subject of several stories in the Journal Sentinel last year, after the Milwaukee County district attorney's office petitioned to terminate her parental rights because of her limited mental abilities and complicated decisions that would have to be made on her son's behalf.

The boy was in foster care since birth. He died of a rare genetic disease.

"This was not an everyday situation," Tanis said. "My daughter is a person that did 100% of her best job, and it wasn't enough to have the child in her care. But she could give 100% to love her child, and the system isn't set up to accommodate that."

Schoenfield, who is known as "Annie," acknowledged she could not care for her son's physical needs. She told judges at Milwaukee County Children's Court last year that she just wanted to be Amarion's mother until he died and to love him to the best of her ability.

"In five volumes of Wisconsin statutes, there has to be a way to continue to let her be a mother to this child and prepare for what ultimately is going to happen," Judge Dennis Cimpl said at a hearing last June.

Last September, the petition to terminate Schoenfield's parental rights was dismissed. Since then, she had regular visits with her son and participated in decisions about his care, said Suzette Schigur, the boy's foster mother since birth.

On April 17, Amarion was moved to a hospice, where Schoenfield could stay overnight and care for him as much as possible, Tanis said. She added that all five of the Bureau of Milwaukee Child Welfare case managers who had been involved with the case visited the hospice before Amarion died.

"He had the biggest, brightest blue eyes - just like the ocean - and a smile that lit up the entire room," Schigur said. "His whole face smiled."

Visitation will be from 4 to 6 p.m. Friday at Krause Funeral Home, 7001 W. Brown Deer Road, with services to follow. Burial will be private.

By MARY ZAHN
mzahn@journalsentinel.com

Posted: April 23, 2007

Even after her death, the system continued to fail Michelle: "The Department of Social Services, which had custody of Michelle, has turned to the 16 other foster children that have died in its care since."

FROM MASSACHUSETTS: A FOSTER CARE "WHODUNIT"

She loved to sing Whitney Houston's "I Want to Dance with Somebody," and she would tell jokes and stories to her three brothers, Joseph, Timothy and Jonathan.

The director of the Horizons for Youth camp recalled: "Michelle was not a quick child to laugh, but once she got past the barriers that serious little face would break into an incredible smile. It was almost like the sun breaking through."

But the sun she radiated into the lives of those who knew her would forever set on October 6, 1994.

The Emergency workers struggled feverishly to revive the slender body of Michelle Walton. Clad in black pants and black-and-white turtleneck, she was found in a littered hallway of her Mattapan foster home under 380 pounds of sheetrock.

THE INQUEST

Doctors at Carney Hospital examined her body finding that not only had she been sexually abused vaginally and anally, but the abuse had been chronic. The largeness of her vaginal opening, as well as the scarring on the outside of her vagina, suggested the abuse "was repeated and took place over a period of time," according to Dr. Margaret Gutierrez of the Carney Hospital.

Judge Arthur Sherman, chief judge of Cambridge District Court, determined after an inquest that Michelle had been "chronically abused at some point during her three-year stay" in foster care. He did not say by whom.

During the inquest, her foster parents, along with their children, gave conflicting accounts of how the death occurred. When questioned about whether they had sexually abused Michelle, both the foster father, Charlie Johnson, and his teenaged son Saleen each claimed the Fifth Amendment right against self-incrimination, refusing to answer the question.

Michelle's foster parents claimed Michelle had been crushed by nearly 400 pounds of Sheetrock. Yet she had not a single broken bone and only a few mild bruises, several of them around her neck. There was not so much as a speck of dust on her body.

The autopsy determined that her death was due to asphyxiation, yet it remained unclear exactly how she died. Medical Examiner Leonard Atkins testified at the inquest that covering her mouth and nose, or placing a weight on her chest could have caused her death.

Said judge Sherman in a subsequent interview: "In my judgment she was smothered, smothered with a pillow or a towel or some celluloid plastic thing. The Sheetrock was placed on top of her to make it appear that was how she died."

The jury had been unable to determine who was responsible for her death. Said judge Sherman: "You can't charge anybody because there's nobody to point a finger at. There're no clues. No witnesses. No circumstantial. All we have is a result to look at. A body."

HER MOTHER

Barbara Ruffin learned about her daughter's death on the 10 p.m. television news. The newscaster did not identify the girl by name, but Ruffin recognized the blue house surrounded by metal fencing as it flashed on the TV screen. She had walked by it countless times. "I never went inside, but I been past that house so many times. I mean, my babies were in there," she told reporters.

During much of the previous year Ruffin had stayed clean of the drugs that led to her four children's placement, and she participated in a score of programs in an effort to reclaim her children, who had been placed in foster care in 1991.

In August 1993, Ruffin returned to her old habits, and stopped showing up for her weekly meetings with her children. The Department of Social Services, which had temporary custody of her four children, abandoned hope of reuniting the family in September of 1993, moving to put the children up for adoption.

Michelle's mother carries a knapsack with her daughter's autopsy report along with other assorted documents that chronicle Michelle's death. Says Ruffin: "I carry 'em because it makes it easier for my sanity. It helps me from going insane. Or maybe it just keeps her alive a little bit longer."

THE DEPARTMENT

Incredibly, during the proceedings, with the possibilities of sexual abuse and murder in the case still looming, the Department of Social Services placed Michelle's surviving brothers back into the same foster home. It was only after a report in the Boston Globe that the children were again removed.

Writing in the December 10, 1995, edition of the Boston Globe reporter Sally Jacobs notes that even after her death, the system continued to fail Michelle: "The Department of Social Services, which had custody of Michelle, has turned to the 16 other foster children that have died in its care since."

Copyright © 1996 Rick Thoma

Doctor crusades to exonerate imprisoned mother -Evidence points to guilt

A retired Seattle doctor has spent nearly a decade on a daunting mission: to prove that a woman serving 40 years in prison didn't kill her little girl.

Investigators were sure Noreen Erlandson did it, and so was a 1992 Snohomish County jury. The adopted 2-year-old Korean girl was covered with bruises, and her brain bled inside her skull from some kind of swift blow.

One doctor still recalls Kayla Erlandson's tiny body as suffering "one of the most severe beatings I've seen."

But Carl Nugent, a veteran physician in family practice, is certain Kayla suffered from a little-known medical disorder. The rare form of epilepsy strikes young children, leading to injuries that can be severe -- and mistaken for abuse.

An expert in childhood epilepsy agrees that some seizures can leave children seriously hurt, and a circle of Erlandson's fiercely supportive friends and neighbors agree that it would explain what they couldn't: Why Kayla was always falling down. Why she was slow to learn things.

And why her mother, a nurse-practitioner who cradled the girl most of the way home from a foster shelter in South Korea, was blamed for something so unthinkable.

Erlandson, 48, who lives at Gig Harbor inside the razor-wired fence of the state's only prison for women, says she is more convinced each day that Kayla suffered from Lennox-Gastaut Syndrome. She hopes to prove she is innocent.

"The more information I get, the more I believe this is what she had," she said. "There's nothing else I can think of that could have happened."

Tragedy spans a decade

Erlandson picked up Kayla from the baby sitter April 24, 1991, and took her to the family's two-story home in the woodsy outskirts of Bothell. The toddler dozed in the car, her mother said later, picked lethargically at her dinner and began throwing up.

Erlandson said she carried Kayla into the bathroom and stood her next to the toilet when the phone rang. She left Kayla alone for a minute or two to talk to her husband, who was headed home from a business trip.

She said she then heard a "bonk" and found the little girl whimpering on the bathroom floor. She said she thought Kayla slipped and hit her head on the rim of the toilet, but she seemed to be OK.

Later, after she had tucked Kayla into bed, she said she found her struggling to breathe. She was trying to awaken the little girl when her husband came home.

They called the family doctor, then 911.

Medics could tell Kayla had suffered a severe head injury. Seizures racked her small body, her pupils were uneven, and her brain was swelling.

She also had a small tear in her liver, a burn near her elbow and what appeared to be a bite mark on her scalp.

Doctors at Harborview Medical Center tried surgery to relieve the pressure in her skull, a last-resort effort to save her.

She died two days later.

By then, police had arrested her mother.

Always covered with bruises

When Erlandson's world fell apart that spring, Carl Nugent didn't know her. His wife, Alice, had met her through a shared interest in folk dancing.

Curious, Nugent sat through parts of her trial. Testimony about Kayla's injuries made him skeptical, so he began looking into the toddler's death himself.

He stumbled onto something called Lennox-Gastaut Syndrome as he read about seizures caused by head injuries. He'd never heard of the disorder, he said, but its classic symptoms described Kayla perfectly.

Many people recalled the toddler as being inexplicably klutzy, and some noticed that she rarely put her hands out to protect herself when she fell.

The disorder not only slows a child's learning ability, but its different kinds of seizures can prompt unexpected falls.

The seizures can be fleeting, ending in a few seconds. Children often bounce back up so quickly that their parents miss what happened -- and their claims that the bruised child "just suddenly fell" may raise eyebrows, Nugent said.

Kayla took a scary tumble two weeks before she died, leaving her face cut and swollen. Her mother was nowhere near her when it happened.

A baby sitter heard a loud crash and found Kayla on the floor, crying and bleeding amid the broken glass of a heavy water-cooler bottle. Somehow the tiny 2-year-old had hit it hard enough to break it.

Nugent believes only a myoclonic seizure -- when muscles contract suddenly and intensely -- could cause her to fall so forcefully. And he doesn't think it was a fluke.

The little girl was always covered with bruises, once prompting a grocery clerk to call Child Protective Services. But the caseworker didn't find evidence of abuse, Nugent said. She suggested Kayla wear a helmet.

Nugent is convinced a quick, violent seizure also led to Kayla's death. He believes it made her fall hard in the bathroom, striking her head against the porcelain rim of the toilet.

But the key was what he found in Kayla's medical records: Paramedics gave the toddler two 1.2-milligram doses of intravenous Valium.

The drug is often used successfully to calm seizures, a symptom of severe head injuries. But literature about Lennox-Gastaut warns that the drug can worsen or prolong seizures in children who have it.

Before Kayla was given the Valium, according to the testimony of one firefighter, she was "conscious with her eyes open and breathing on her own." Afterward, Nugent said, Kayla's left pupil became much larger than her right, and neither would respond to light.

Medics told the Erlandsons to meet them at Children's Hospital, then abruptly decided to go to the region's top trauma center instead. Nugent suspects it was because Kayla's condition took an alarming dive after she was given the Valium.

"There's such an obvious cause for what happened," Nugent said, emphasizing that medics couldn't have known and weren't to blame.

Textbooks and research papers clutter several rooms of Nugent's Ravenna home, where the feisty 74-year-old works on or thinks about Erlandson's case every day.

He travels to national seminars on child abuse, forensic science and epilepsy, and he has studied every word of a trial transcript nearly 3,000 pages long.

Yet he knows that his quest to exonerate the woman may be impossible.

"The law loves final conclusions," he said.

Evidence points to guilt

There was no mention of seizures or Valium during Erlandson's 1992 trial.

Prosecutors told jurors that Erlandson was frustrated that Kayla wasn't as good as her adopted Korean son, who was 4. She was klutzy, slow to learn and threw tantrums.

The evidence was vast and damning. There were horrifying photographs of Kayla, and testimony that the severity of her head injury was on par with tumbling several stories from a building.

Paramedics testified that Erlandson tried to keep them from cutting off Kayla's pajamas as if she didn't want them to see bruises. They recalled the panicked gibberish she told them, something about a water bottle and a too-hot bath.

A dental expert, though disputed, testified that the bite mark behind Kayla's ear seemed to match Erlandson's teeth.

The mother had written in her journal that Kayla adored one of her playmates, then added that the boy was always biting her. Prosecutors called the added phrase an effort to shift blame.

The jury took two days to find Erlandson guilty of second-degree murder. The verdict hit her Seattle attorney, David Allen, hard.

"This is a woman who has an exemplary background with no suspicion of any wrongdoing in the past," he said at the time. "This is not like one of those cases of ongoing abuse. That didn't happen here."

The typical sentence ranges from 10 to 13 years in prison, but Snohomish County Superior Court Judge Joseph Thibodeau said Kayla was a vulnerable child who had endured "extreme cruelty." He gave Erlandson 40 years.

Holding up a stack of letters from Erlandson's supporters, he said he was struck by how many people refused to see the truth.

Debate over syndrome

Even today, Dr. Abraham Bergman doesn't have any doubt that justice was served. A witness for the prosecution in 1992, he recalls Kayla's injuries as "textbook abuse."

"This was one of the most severe beatings I've seen in my 40 years of pediatrics," said Bergman, chief of that department at Harborview. "Falls from short distances do not cause such trauma."

Another witness for the prosecution, Dr. Ellsworth Alvord, is familiar with Nugent's theory.

"It's not impossible, but each point I think he is stretching to the limit," the University of Washington neuropathology specialist said.

But Dr. Gregory Holmes, director of the Division of Epilepsy and Clinical Neurophysiology at Children's Hospital Boston, has seen seizures cause serious injuries, including a "subdural hematoma" brain injury like the one Kayla had.

Holmes believes a seizure could cause a toddler to fall against a toilet rim with enough force to cause a serious head injury -- and that a mother may have no idea it was a seizure.

"It might be tough, initially, for a parent to tell," said Holmes, who is also a professor of neurology at Harvard Medical School. "They're quick. The parent could be standing right next to the child, and all of a sudden, the child is on the ground."

Holmes thinks it's more likely that the head injury killed Kayla than the Valium, though her other injuries make him more circumspect.

He has seen burns on children who have fallen against something hot, and he speculated that a fall against something angular -- like a coffee table -- could cause a liver laceration.

But he pointed to the obvious. There is no way that Lennox-Gastaut Syndrome can cause a bite mark.

"Proud to be her mother"

Erlandson has maintained her innocence for 10 years, and she still contends that another child must have bitten Kayla. She said the toddler had come home from a baby-sitter co-op once before with teeth marks on her leg.

"I'm not a biter," Erlandson said. "Timeouts were my way of discipline."

In prison, she keeps photographs of her daughter, who liked to sleep with a stuffed bunny and thought every white-bearded man was Santa Claus. The toddler's learning and coordination problems didn't make her love the girl any less, she said.

"I can't even fathom that theory as a parent," she said, shaking her head. "I didn't commit a crime. I was the best mother that I could be."

She said she always tried to let Kayla know that being adopted meant that she had been specially chosen. In the seven months that she had her, she dressed her in pink and tied bows in her hair.

"I was proud to be her mother," she said. "I took a gazillion pictures of her, bruises and all."

She remembers panicking the night Kayla wouldn't wake up. She said she didn't know what was wrong, so she rambled frantically about Kayla's accident with the water bottle.

She said when the medics started cutting off Kayla's pajamas, she reached over to unsnap them because "the mom in 'me felt like, 'Wait, wait. Don't treat her like an object.'"

Facing prison time until 2022, Erlandson has high hopes for Nugent's research. So do her friends, many of whom pitched in thousands of dollars for her legal costs.

"Noreen is innocent," said Paddy Cottrell, a longtime friend who also adopted children from Korea. "Once the steam roller of county prosecution takes after you, all reason is gone."

The last of Erlandson's court appeals, arguing juror misconduct, was rejected in 1997. After standing by her for six years, her husband filed for divorce.

"It still hasn't been proven to me what happened to Kayla," Doug Erlandson said, but "I do believe there was a miscarriage of justice."

Seattle defense attorney David Marshall recently agreed to look over her case for free and found Nugent's theory plausible.

"Some of the literature he's shown me about the syndrome is quite remarkable," Marshall said.

Showing Kayla had it, however, would be a challenge. Ideally, he said, he could convince the state Court of Appeals that today's medical technology would have changed the outcome of Erlandson's trial.

"You have a higher hurdle the second time," Marshall said. "We would have to get quite a case together before we try to persuade the courts."

P-I reporter Tracy Johnson can be reached at 206-467-5942 or tracyjohnson@seattle-pi.com

Toddler's death at center of lawsuit over R.I. foster care

PROVIDENCE, R.I. --Thomas "T.J." Wright was smacked in the face and head, dragged on the ground, flipped backwards on the stairs and even doused with a quart of milk, court records say

After the 3-year-old died of brain injuries in 2004, his guardians -- aunt Katherine Bunnell and her live-in boyfriend Gilbert Delestre -- were charged with murder and accused of beating him to death. Their cases have not yet gone to trial. But T.J.'s death has returned to the spotlight as the center of a federal lawsuit alleging that children in state custody are being sexually abused, assaulted, returned to unsafe homes and left to languish in foster care.

"T.J. Wright almost in itself, by itself, typifies everything that goes wrong within the system," said state child advocate Jametta Alston, who filed the lawsuit late last month against the governor and the Department of Children, Youth and Families.

The lawsuit alleges that systemic problems revealed by T.J.'s death remain unfixed and, citing federal data, says Rhode Island is routinely among the nation's worst in the rate of abuse and neglect of foster care children.

DCYF director Patricia Martinez, who took over in 2005, said the department has improved since T.J.'s death. Gov. Don Carcieri has said some of the allegations in the suit were found to be unsubstantiated and expressed confidence that DCYF is following up on abuse complaints.

Still, T.J.'s case forms the backdrop of the lawsuit.

Terese Curtin, executive director of Connecting For Children and Families, a Woonsocket nonprofit focused on improving family life, said T.J's case has similarities to those of other foster children, even if most instances of abuse don't usually end with a child dead.

"Things end up falling through the cracks, and that's because we don't have enough front-line workers out there in the community," she said.

T.J. and his two brothers went to live with Bunnell, then 20 years old, after their mother was arrested on drug trafficking charges in Illinois. Bunnell and Delestre, both unemployed, lived in a one-bedroom apartment in Woonsocket

A report issued by a panel a year after T.J.'s death said while the state prefers placing foster children with relatives, it should never have permitted T.J. to live with Bunnell and Delestre, who each had juvenile records and were already raising two children of their own.

According to a statement Delestre gave police, he and Bunnell returned home early on Oct. 30, 2004 from a night of drinking to find their home "trashed." They blamed T.J.

Delestre acknowledged hitting the child, causing him to flip backward down the stairs, but said he did not mean to injure him. A baby sitter testified at a hearing that she saw Bunnell smack T.J.

"I was so mad. I just tapped him, and he just fell back," Delestre said in the statement. "He's clumsy a little, you know?"

Bunnell and Delestre have pleaded not guilty to murder and conspiracy. Bunnell's attorney did not return phone messages. Delestre's lawyer declined to comment.

The panel report identified at least five missed opportunities to protect T.J. It also offered 15 recommendations, such as reducing caseworkers' workloads and conducting thorough background checks before foster children are placed with relatives.

The suit describes a system in which caseworkers are too busy to meet with all the children assigned to them, siblings are unnecessarily split up and kids spend too long in emergency shelters.

Martinez said the department's improvements include providing more training for caseworkers and their supervisors. In addition, the department has its own fingerprinting machine to allow for swifter background checks, and ten additional caseworkers are being hired.

The lawsuit cites 10 children who it says have been cycled from home-to-home and either sexually assaulted, attacked or returned to parents who had previously abused them. Carcieri said it did not appear that DCYF knowingly endangered any child.

Alston said the children cited in her case are simply examples of all that can go wrong and that her goal is to force sweeping change of a system she believes is badly broken.

"T.J. is the worst that can happen in terms of a child dying," she said. "But there are still little horrors happening.

By Eric Tucker, Associated Press Writer  |  July 7, 2007

"The death of Diamond Alexander was one of the pivotal cases that sparked an investigation and review of Child Protective Services and the creation of a Blue Ribbon Task Force to recommend changes in the way the agency handles its cases. "

Accused Baby Killer Pregnant, Lost Rights To 4 Children -Alexander Has Criminal History

SAN ANTONIO -- A 24-year-old San Antonio woman charged with capital murder in connection with the beating death of her 2-year-old daughter lost her parental rights to four other children while living in another state, is pregnant and has a criminal past, KSAT 12 News reported.Kimberly Alexander, who remains in the Bexar County Jail, was questioned two years ago about one of her children, who was believed to be missing while she was living in Michigan, KSAT 12 News reported."I believe it was a little boy," said State Rep. Carlos Uresti, of San Antonio. "But it hasn't been confirmed, and I pray that that's not the case."

Texas Child Protective Services officials told KSAT 12 News they talked with Michigan authorities about the mystery child and concluded the child doesn't exist.Uresti is also calling for an investigation into the custody case and death of Diamond Alexander-Washington, who died over the weekend from severe head trauma. He wants to know how why the child was returned to her mother.

Bexar County Associate Judge Peter Sakai, who awarded custody of the baby to Washington, wouldn't comment on the case, but said the news of the baby's death hurts him.

"It breaks my heart," Sakai said. "It's devastating. It really does affect myself as a judge."

KSAT 12 News also learned that Alexander was on probation for theft when her daughter was returned to her in April. The infant had been living with a foster family after Alexander tested positive for drugs when she gave birth. Alexander ended up fulfilling CPS requirements to regain custody of her child.

Alexander also spent some time in jail in May when the child was in her custody, KSAT 12 News learned. Child Protective Services officials said since the baby's father, Tarri Washington, was the primary caregiver, the theft charges weren't considered threatening to the baby.

"I'm so angry," Washington said Tuesday about his daughter's death in an interview with KSAT 12 News. "I don't know what I should do. My head is confused and I'm real angry. I would never thought she would hurt a child to the point where she (would) kill (her). I would (have) thought she would discipline a child, but not to kill one."

According to an arrest warrant affidavit, a woman staying with Alexander witnessed the alleged beating of the infant. The woman told police the little girl was allegedly beaten because she wet her pants. She alleges Alexander struck the child in the head.

___________

CAPITAL MURDER CONVICTION UPHELD IN DEATH OF DIAMOND ALEXANDER

San Antonio , Texas ; May 03, 2007: 

Bexar County District Attorney Susan D. Reed announced that yesterday the Fourth Court of Appeals affirmed Kimberly Alexander's capital murder conviction and life sentence. Kimberly Alexander was the mother of the two year old victim, Diamond Alexander. The evidence at trial showed that Diamond had been struck at least twenty six times, with at least three instruments. The Court of Appeals rejected allegations that the evidence was insufficient to convict. The Court also rejected the arguments concerning the trial court's refusal to charge venue for the trial due to pre-trial publicity.

A jury in the 144th District Court convicted Kimberly Alexander, then age 25, on December 13, 2005. Because the charge was Capital Murder she received an automatic life sentence.

The death of Diamond Alexander was one of the pivotal cases that sparked an investigation and review of Child Protective Services and the creation of a Blue Ribbon Task Force to recommend changes in the way the agency handles its cases.

For more information, contact District Attorney Susan D. Reed at 335-2342.

Bexar County Justice Center -300 Dolorosa, Fifth Floor -San Antonio,Texsas 78205-3030

05-30-2001 - 10-09-2003

Dying in silence

A Juvenile Court judge sent 2-year-old Miranda Davila back to parents with a history of drug use who said they weren't ready for her. Critics say what happened next wasn't a surprise.

Miranda Davila's parents faced a painful choice.

The recovering drug addicts were told in early 2003 they needed to take their 22-month-old daughter back to their cramped motel room or risk losing the girl to the child welfare system forever.

Tonia Fernandez and Salvador Davila decided to take their little girl home, despite concerns that the toddler - who'd been in foster care since birth - would add new stress when they were already struggling to care for four other children in one small room.

They did so even though their social worker told the Orange County Juvenile Court that the child would be at risk if returned to a family not ready for her.

Commissioner Gary Vincent said Miranda could go home.

Seven months later paramedics found her bruised and unconscious, her skull shattered, in a motel room fouled with mold and infested with maggots. She died a few hours later.

Fernandez told police she accidentally hurt Miranda, then changed her story and blamed her longtime boyfriend. Davila was convicted of second-degree murder and is now serving a 25-year-to life sentence. The couple's remaining children were taken by Social Services. Davila didn't respond to a letter sent to him in prison. Fernandez could not be found.

But the little girl's story - detailed in hundreds of pages of confidential records obtained by The Orange County Register - shows how the system meant to protect abused and neglected children failed this little girl.

The family's story also opens a window into the growing toll of methamphetamine on local families. Miranda was part of a spike in such births. The number of families in the child welfare system with substance abuse problems jumped from 329 in 2000 to 498 in 2005. Orange County social workers intervened in 181 cases where babies tested positive for drugs last year.

The Register first learned about Miranda's case during an investigation of 23 abused and neglected children who died since 2000 while under protection of the court. The Register litigated for two years to force the Superior Court to release Miranda's records.

Miranda's foster mother and paternal grandmother said they tried to get help but were ignored.

"They never should have given that baby back," said foster mother Nancy Perez, who cared for Miranda since infancy and testified in defense of the father, Davila. "Even when I told (the social worker) the baby had signs of abuse, nothing was done."

Commissioner Vincent was the same judge who presided over the case of Darian Robinson, a 10-month-old foster child who was murdered in 2001 after being returned to his mother. In Darian's case, Vincent also dismissed a social worker's recommendations.

Vincent cut back his hours in March, after 17 years on the bench, and now works only part time as a judge. He declined to be interviewed for this story.

In an interview last fall, Vincent said social workers often make incorrect recommendations because they don't know the law. He said he can't keep families apart unless there is convincing evidence of substantial risk of harm.

"We can't take children away because we don't like their parenting style, their cleanliness, or (that) they are poor,'' he said. "It has to be foreseeable there is a problem."

Judge Robert Hutson, presiding judge of the Juvenile Court, also defended Vincent's decision to return Miranda to the family, saying children need the stability of a permanent home. "We can't let a child stay in limbo forever," Hutson said in an interview last year. "The child had been in foster care for two years."

Social services officials said once the judge ordered Miranda's return, there wasn't enough evidence to prove she was at serious risk of danger to remove her again.

But records show clearly that the situation had deteriorated. Senior social worker Daniel Whitehurst wrote in a report he signed Oct. 9, the day Miranda died, that Miranda's affect was flat and she lacked energy. The father had lost his job, the motel room was frequently littered with trash and crumbs and the children were often holed up in the room, Whitehurst wrote.

Whitehurst did not respond to requests for comment. Social services officials said he is on leave and not available. But the agency defended him, saying he was honored in 2005 by a nonprofit that fights child abuse. He was devastated, an agency spokesperson said, when he heard about the little girl's death.

"The threshold of the law is good enough care. It is not the ideal home, it is good enough," said Social Services spokeswoman Terry Lynn Fisher. "There was no legal basis to remove the child. (Whitehurst) went above and beyond."

Miranda's death while under the protection of the Juvenile Court ignites passionate debate among child advocates. They disagree whether government did enough, or too much, to reunite a family struggling with poverty and drug addiction.

Robert Fellmeth, executive director of the Children's Advocacy Institute in San Diego, said the government leans too far on the side of reuniting fragile families.

"If you've got someone you attempted reunification and they relapse, you don't have to wait for the third time," Fellmeth said. "Methamphetamines destroy maternal and paternal instinct. It's a parental disqualifying feature."

DRUG BABY

Tonia Fernandez rushed into Western Medical Center on May 2001, ready to give birth. There was no record that the 26-year-old mother had any prenatal care, prompting immediate suspicion among nurses. Salvador Davila, her 28-year-old boyfriend, appeared drunk, nurses said.

Tests were ordered and Miranda was found positive for amphetamines, becoming one of 1,008 drug babies since 2000 referred to the Orange County Social Services Agency.

Fernandez, already the mother of three young boys, admitted she'd smoked methamphetamine, a highly addictive stimulant that can create developmental delays in children. Davila, a high school dropout who worked as a roofer, admitted to a five-year history of drug use.

Yet the couple's other young children showed no signs of abuse and neglect, social workers said. The parents said they wanted to take Miranda home and would do what was necessary to get her back.

First they had to prove they were fit parents.

Miranda was made a dependent of the court and transferred to the three-bedroom home of a Cypress foster parent, Nancy Perez, who specializes in babies born addicted to drugs. Social workers deemed the three older brothers safe at their family's home.

The couple agreed to weekly parenting classes, counseling, and twice-weekly drug tests.

They struggled to stay sober. A week after Miranda was born, Davila showed up at a drug test looking dirty and intoxicated, reports show. Within six months of her birth, both parents failed three tests in a row, according to social services reports.

Recovering from a meth addiction is difficult. Less than a quarter of meth abusers complete their treatment, according to a 2000 study published in the Journal of Psychoactive Drugs. Relapses are common. But many family advocates argue that children do better with their parents, even not-so-perfect ones.

"Children want to have a connection to their birth parents and they deserve to have a connection to their birth parents," said Nancy Young, director of the National Center on Substance Abuse and Child Welfare. "Just because they have a drug dependency doesn't mean they don't love their child."

During that first year, Davila was arrested and jailed for resisting an officer. He lost his job. The family was evicted from their mobile home and had to move in with relatives. The mother got pregnant again.

The couple also showed strengths. They continued to attend drug counseling classes and faithfully visited Miranda, social services reports said. The child reacted well to her parents and Perez grew especially fond of the father, who never missed a visit.

FINDING A HOME

In a county where the median cost of a home is $645,000, finding adequate housing can be daunting for even the affluent. For the working poor, with an eviction on their record, it can be nearly impossible.

In June of 2002 - when Miranda was a little more than 1 year old - the couple told Whitehurst, the social worker, they wanted to postpone her return until they found a better place to live than the home they shared with relatives.

By the time Miranda turned 18 months, the family was living in a small room in the Grand Inn in Fullerton with their three sons and baby daughter. The room had two queen-size beds, a refrigerator and an electric wok.

Whitehurst urged the family to take Miranda but Davila continued to resist, citing their living situation. He told the judge Miranda would be at risk if returned.

"It is preferable to allow the child to return to her parents' care when the parents feel comfortable with the idea," he said in his report.

Commissioner Vincent postponed a decision four times in nine months, waiting for the family to find better housing.

Whitehurst tried to help. But Fisher noted that social workers can't provide housing for their clients. Social workers like Whitehurst average 18 cases, with some carrying as many as 38. "It was up to them to follow through," she said.

When Miranda was nearly 2 years old, the parents were told by their attorneys they couldn't put off Miranda's return any longer, Perez said.

"He told me that the lawyer said either you take her now or they are going to put her up for adoption," Perez said.

Yana Kennedy, the attorney appointed by the court to represent Miranda, defended Vincent's decision. She said she would have opposed any plan to put Miranda into long-term foster care.

"This is just a social worker's recommendation. They don't know the law," she said. "They wanted to get a better place. That doesn't mean someone is going to kill their child."

Richard Wexler, executive director of the National Coalition for Child Protection Reform, said the judge should have listened to the parents' concern. 

"When parents say we are not ready you have to listen to that. It was a remarkably responsible of them,'' Wexler said. "What judges are hearing is (they need to create) permanence. in a situation like this I would have waited another 18 years."

Bill Grimm, a senior attorney for the National Center for Youth Law, examined Miranda's case records for The Register. Grimm said he didn't see any changes that showed Miranda would be safe at home.

"To me it (was) a powder keg ready to explode," he said. "Nothing changed to make it reasonable to believe it was a safe environment."

'PLEASE TAKE THE BABY'

On March 14, 2003, Perez carried Miranda up the stairs to the Grand Inn. The little girl ran into her father's arms, she said.

At first, the family seemed able to care for Miranda, Whitehurst reported.

But as spring turned to summer, the family seemed to be slipping. The parents had lost the will to improve their housing situation, Whitehurst found. Neither could show proof they were attending 12-step meetings.

In August and September, Whitehurst found Miranda with multiple bruises. The mother said the girl had fallen from her playpen. He wrote that Miranda appeared "marginally cared for."

Davila's mother, Angela, visited later that month and found her granddaughter weak and lacking patches of hair. The motel was filthy.

She begged the couple to let her take Miranda with her, she said. She called Whitehurst and left a message.

"I said I visited them and the baby looks sick, looks terrible, please take the baby away from them. I need to talk to you," the grandmother said. "He never called me back."

On Sept. 25, Whitehurst took Davila to visit an apartment complex in Anaheim. Whitehurst realized, after months of working with the family, that the father hadn't completed any of the apartment applications at all.

What happened on Miranda's last night remains unclear. The couple's stories changed over time. Davila told police he was frustrated and had a painful toothache. He pushed his 3-year-old son, he said, the boy collided with Miranda and she "cracked herself."

Later, he testified that Miranda tripped after he pulled her away from Fernandez, who was biting the little girl on the cheek.

Whatever the scenario, paramedics arrived late Oct. 8 to find Miranda lying on the ground unconscious. She had a 4-inch fracture running down the back of her skull - a serious injury that couldn't have come from an accident, a pathologist later explained.

She had bruises or abrasions on her forehead, the bridge of her nose, both cheeks, the right side of her mouth, her back and on both legs, according to court documents. She had scarring from earlier injuries.

The bathtub was filled with shrimp and covered with ants and bugs, police reported. Raw pork was found by the dresser. The refrigerator was filled with maggot-covered food.

The next morning, Whitehurst was called at home. Miranda was in the hospital with a fractured skull. Her siblings had been taken to Orangewood Children's home.

Whitehurst went to his office and signed a report detailing the deteriorating situation over the previous months. His recommendation: Miranda should remain with her parents.

He did not mention she was already dead.

Kennedy received the document a few days later. She wishes she'd been made aware of the problems. But she said that knowledge might not have changed anything.

"Social workers will often pick up the phone and call us. He didn't. Maybe he didn't think it was bad enough," she said. "There are a lot of situations like this where conditions will go downhill in a home. It is extremely unusual to have a child killed."

Perez, the foster mother, still is haunted by the death of the brown-haired girl who danced in her home like a princess.

"Why didn't (the social worker) see what was going on?" she said. "Why didn't they see the baby was so skinny, she looked like a skeleton? . Her death could have been prevented."

Child protective services agencies were created to remove minors from unsafe homes. In the 1980s, the federal government began to focus efforts on helping at-risk families stay together.

The debate over the balance between protecting children and keeping unstable families together continues today.

Tragic deaths like Miranda Davila's can swing the pendulum toward pulling children out of unsafe homes. But a recent study by the Massachusetts Institute of Technology found that children who aren't obvious candidates for removal do better in life when they remain at home.

Richard Wexler, executive director of the National Coalition for Child Protection Reform, said social workers need to limit the number of children they remove so they can concentrate on the families with bigger problems.

"They do leave children in dangerous homes even as they take more children from homes that are safe or could be made safe with the right kinds of help." Wexler said. "The two problems are directly linked."

According to a CPS case file, three children were removed from the home last year.

DENISON, Tex. - A Denison family is dealing with the pain of losing a 14-month old child. Now Child Protective Services are stepping in. Zachary Ellis Duncan died on Sunday after being hit by a car while playing in puddles in front of his home. His mother was also hurt in that accident after trying to save her child.

Family members tell us Child Protective Services is looking into what happened. It's not the first time mother Victoria Neasbitt and her children have been involved with CPS.

Ruby O'Neal says Zachary's mother and her sister-in-law, Victoria Neasbitt "is not a bad mother" and that "she did what she could to take care of her children."

Neasbitt's family is grieving for the loss of Zachary, but they're also defending the actions of his mother.

"She's in the hospital with injuries sustained from trying to save her son's life."

Denison police are still investigating details surrounding Sunday's accident and have already charged the driver, Terri Perdew, with manslaughter.

As for Zachary's mother, the family says the single mom had just gotten back on her feet after losing her job, regaining custody of her children weeks prior to the accident.

According to a CPS case file, three children were removed from the home last year. Court documents state living conditions were inadequate for the children.

All three children were placed in foster care at that time.

Ruby O'Neal says it's normal for kids to play outside in puddles and people need to refocus their attention on praying for the women who hit Zachary and not the CPS investigation.

"Everybody that's making negative comments on my family, you need to take and refocus your energy and pray for this woman," O'Neal said of her sister-in-law.

Family members say they have forgiven the woman who hit Zachary, and it was an unfortunate accident.

CPS officials won't comment on the case, but Denison police confirm that an investigation is underway.

Reporter: Ruth Baker
Email Address: ruth.baker@kxii.com

A Child-Suicide in Foster Care-Four days before Valentine's Day 2001

LOS ANGELES - The garden at the house on Stockwell Street overflows with collard
greens, lacy baby tears and pink flowers; inside the five-bedroom home, the family room's walls
are covered with photographs of two generations of African-American foster children cared for by
Mercenia Tucker, a retired aerospace worker who, at 78, uses a cane but paints her toenails
emerald green.
Appearances of tranquility, however, can be deceptive.
Last year, on the morning of Feb. 10, tragedy struck inside the Compton home - and nothing
has been quite right since.
Four days before Valentine's Day 2001, 9-year-old Kerry Brooks, a precocious kid with an
impish smile, apparently hung himself with a shoelace inside a closet in his bedroom. In so doing,
Kerry became what is said to be the youngest child suicide in the history of Los Angeles County,
according to county officials.
The day before he died, Kerry reportedly told a younger foster sister that he was planning to
kill himself. She didn't believe him - and professionals who knew Kerry well said they didn't see it
coming.
A case in point was Victor Ross, program manager for Compton System of Care where
Kerry, a special education student, attended school.
"[Kerry was] the last person in our program that my staff and I think would commit suicide.
He was our highest functioning student both academically and behaviorally," Ross said.
Ross' letter was among 459 pages of Los Angeles Juvenile Court documents examined by
the Daily Journal following the child's suicide. In re: Kerry Brooks AKA Kcerry Cardenas,
JCK24829 (L.A. Juv. Ct., Sept. 1996).
"Kerry went on a field trip with the class the day before his death and was described as
energetic and happy," Ross wrote a few days after Kerry's death. "This child never appeared
depressed. He was in our program because he would become enraged at times and he fought
with other children. Depression was never an issue."
The court documents also contained conflicting reports of Kerry's disposition.
In May 1998, a social worker reported that Kerry was a "healthy [and] handsome and
friendly little boy who loves to play on his scooter and go rollerblading. He is a sweet child who
needs a lot of love and attention."
That same month, a different social worker reported that Kerry said he'd never met his
social worker and wanted to go to "court and kill everyone."
Even with the benefit of hindsight, Kerry's death remains a mystery.
The Los Angeles Department of Children and Family Services assigned blame to the foster
mother 15 months after Kerry's death. On May 9, 2002, the department sent Tucker a letter
informing her that her foster home - in operation since 1978 - had been placed on "endangerment
'do not use' status" because she left a child with a "history of depression" alone with an
unauthorized baby sitter.
"As a result of our investigation, we have substantiated [l]ack of [s]upervision and [s]evere
[n]eglect. You have acknowledged that you were not home at the time of the foster child's death
and that you left him in the care of the 17-year-old. However, neither licensing nor DCFS
approved the 17-year-old as a temporary baby sitter."
Tucker was heartbroken by the accusation.
"They said I didn't do right for Kerry," she said. Tucker also denied the department's
allegations.
The social worker told Tucker she could leave Kerry in the care of Marcus, the older child,
for brief periods, Tucker said. The day of Kerry's death, Tucker had expected to be gone only an
hour.
The department also claimed that Tucker failed to give Kerry the full dosage of a
psychotropic medication he had recently been prescribed. After Kerry's death, DCFS
investigators counted the pills in his prescription bottles and claimed there were too many. "What
they conveniently 'forgot' was that when the medication was first prescribed, Kerry was receiving
half the dose," Tucker said.
Mercenia Tucker, a widow, raised six children of her own before becoming a state-licensed
foster care provider. When she met Kerry shortly after he entered the child protective system in
September 1996, she was smitten. She considered him street-smart and adorable.
"He walked in and said, 'Well, hello there Ms. Tucker,' and gave me a high five. From the
day we met, we hit it off. I had a bond with him," she said. "When he first came, he couldn't sleep.
He had nightmares."
Kerry had been abandoned by his parents, lived at MacLaren Children's Center and was
rejected by a previous foster mother because he threw a temper tantrum after she told him to
take a nap. Though it would have changed nothing, Tucker said she was not informed until
shortly before Kerry's death that he had been diagnosed by a court-appointed psychiatrist as
suffering from post-traumatic stress disorder.
Tucker, whose husband died in 1988, was soon calling Kerry "the little man of the house."
They watched television together, and the boy checked all the doors in the house each night to
make sure they were locked.
"He was a sweet child, but he had his moods," the foster mother said. "He got an allowance
for taking out the trash and working in the yard. He was an all-around kid. He was an usher in
church and sang in the choir. He was on the drill team, and he won awards. I miss all that."
Kerry's final day at the house on Stockwell Street began in the simplest of ways.
Dressed in a nightshirt, Kerry got up early that Saturday morning to cook a surprise
scrambled-egg breakfast for the woman he called "Mom." Although the fourth grader was
supposed to go with Tucker and his 8-year-old foster sister to a friend's funeral that morning, he
wanted to stay home with his teen-age foster brother, Marcus.
After softening Tucker up with the scrambled eggs, Kerry promised to clean his room and do
his chores while the old woman was gone.
"I said, 'Kerry, you don't want to go?'' she said. "And he said, 'No, I don't.'"
When Tucker walked out the front door, Kerry gave her a kiss and told her he loved her.
"When I left, he was fine and as happy as he could be," she recalled. "He loved me very
much, and I loved him very much. ... I was the only one that had his confidence."
Soon after, one of Marcus' friends arrived. The boys watched television and listened to
music. Then Marcus reminded Kerry that he'd promised to clean his room.
The 9-year-old, still clad in his nightshirt, marched off to his bedroom and closed the door.
What happened next is inexplicable.
The 81-pound boy allegedly took an 18-inch white shoelace out of his tennis shoe, created
a noose, and then tied the shoelace to the wooden rod running the length of a white, child-size
portable closet. At 4-foot, 6-inches, Kerry was taller than the closet rod. So, he leaned his head
into the small closet to get the shoelace around his neck before dropping knees-first into the
closet, police and coroner's investigators concluded.
Around 11: 30 a.m., Marcus went in to check on Kerry. When he opened the door, he saw
Kerry's feet. According to police reports, the older boy cut the shoelace with a butter knife, lifted
Kerry down, and called 911 and Tucker's adult son, who lived nearby. Paramedics arrived
minutes later to find the 9-year-old barely alive.
Kerry was rushed to Martin Luther King-Drew Medical Center where he was pronounced
dead a little after noon. Meanwhile, Tucker, who said her car had been blocked in by the funeral
procession, arrived home at noon.
"I came home and saw all these police cars and I said, 'What in the world are they doing?' I
saw Marc standing by a car. They said Kerry tried to kill himself and they wouldn't let me go to the
hospital - and they wouldn't let me in the house," she recalled.
Today, another child uses the portable white closet, that still is in the same room on
Stockwell Street.
When asked about Kerry earlier this year, Department of Children and Family Services
Director Anita Bock said that whatever was troubling the boy happened during the first four years
of his life, not during the nearly five years he spent in foster care. When Kerry entered the
system, Bock said, he was diagnosed as suffering from post-traumatic stress disorder.
"He'd had a traumatic life. There was substance abuse in the home. He'd witnessed his
mother being beaten," Bock said. "We saw a child who was struggling, always, with anger and
pain."
Kerry Brooks was born Kcerry Kashif Di-Shiek Cardenas at St. Mary Medical Center in Long
Beach on March 16, 1991. His parents were Luis Fernando Cardenas, an 18-year-old native of
Columbia, and Mikko Shauni Brooks, a 15-year-old who grew up in Long Beach.
Kerry never knew his father, whose whereabouts remain unknown.
For the last three years, Mikko Brooks, in trouble with the law much of her adult life, has
been incarcerated in a federal prison in Northern California. She was convicted in 1999 of
possessing 24 pounds of marijuana with intent to distribute across state lines. At the time she
was arrested, Brooks said her infant daughter (Kerry's younger sister), was with her. That child
was placed in foster care, she said, and has since been adopted. Brooks is scheduled for release
from prison next year.
Through an exchange of letters with a Daily Journal reporter, Brooks - who insisted her son
be called by his birth name, Kcerry Cardenas - shared details about her life and how she has felt
since learning of her son's death.
Kcerry was my best friend. I've never done anything intentionally to hurt him. I hurt every
day, and this is something I have to live with. I pray that this doesn't happen to anyone else while
their child is in the system," Brooks wrote.
Like Kerry, the young mother said she too grew up as "a child of the system." Brooks
believes her life was, and continues to be, dysfunctional. Although she's hoping to have a
successful future when she gets out of prison, she acknowledged having to tie up a lot of "loose
ends in my past" before that can happen.
When prison officials told her of Kerry's death, Brooks said she was unable to show her
pain.
"I was brought up to show little emotion. When you're hurting, people tend to use your pain
against you," she wrote. "I've been having a lot of bad dreams lately pertaining to Kcerry. This
might sound crazy, but he always gets murdered in my dreams."
Brooks said that no one may ever know what really happened with Kerry, but she is still
thankful that Tucker loved and cared for her son. "Kcerry knew how to touch anyone's heart that
he came across," she said.
Records from the Department of Children and Family Service indicate that Mikko Brooks
had been accused of child abuse before Kerry entered foster care.
The mother denied having ever abused her son and, according to court documents, none of
these allegations were substantiated.
Brooks said that when Kerry was 4, she needed some time to get on her feet following the
crib death of an infant daughter. She left Kerry in the care of a female cousin.
Two months later, when the cousin attempted to enroll the boy in kindergarten but didn't
have proper documentation, Kerry was picked up and placed in foster care at MacLaren Hall on
Sept. 20, 1996.
At the time, Kerry was 5-years old.
"I know I could have dragged Kcerry out of Mrs. Tucker's home. I just wasn't stable, and I
felt he was in a stable environment. I was coming for him, please believe that. A lot of Kcerry's
emotional problems came from his being so close [to me]. We [did] everything together. He
always told me to never leave him and I did. I have to live with that for the rest of my life. I've
never physically abused [any] of my children. I guess I've done the ultimate: abandonment,"
Brooks wrote.
Kerry last heard from his mother on Oct. 15, 1997, when she called him at Tucker's house
after being released from Los Angeles County jail, where she was being held for an alleged
assault. All Kerry ever wanted, Tucker said, was to see his mother and the rest of his biological
family.
Not long after his mother called, a mental health professional diagnosed Kerry as suffering
from attention deficit disorder and oppositional defiant disorder.
By the next February, Kerry had been declared a "special needs minor." Brooks' parental
rights were terminated that month, and her whereabouts were listed as unknown. Los Angeles
Juvenile Court Referee Guillermina Byrne noted that the mother did not provide the necessities of
life for her son and failed to participate in court-ordered programs that included counseling, drug
testing and parenting classes.
"Kerry has been acting up again since his mother Mikko called," a social worker noted in a
court report dated Feb. 26, 1998. "Kerry broke down and cried."
Though Tucker said nearly everyone who met Kerry "fell in love," a part of him remained
elusive. "No matter what would happen, he would go back to those first four years," she said. "He
was always tying something around his wrist, waist and neck - and I would have to take these
things off. He was putting things in his mouth and I had to take them out. One time he put a ring
in his mouth at church and he was gagging."
"I'm the unfit parent and that's all people is gonna see when it comes to me. I know I'm at
fault and that's something I have to live with," Brooks wrote.
By August 1998, Kerry was in second grade and receiving counseling. He was considered
available for adoption. Members of Mikko Brooks' extended family said they wanted to adopt
Kerry, according to court documents.
But Kerry now thought of Tucker as his mother and her family as his family. But Tucker
wasn't prepared to adopt the boy. At that time, Tucker was trying to adopt Marcus, who had been
with her since he was found abandoned in his stroller at a shopping center when he was 2.
Tucker also hoped, according to court documents, that one of Kerry's parents would come
for him.
"I wanted to give them a chance," she said.
Meanwhile, Tucker was willing to become Kerry's legal guardian.
To facilitate that, Juvenile Court Judge Byrne declared Kerry "not adoptable." Guardianship
was granted to Tucker on Aug. 27, 1998. The action was taken against the recommendation of
the Department of Children and Family Services, which contended the boy was too mentally
fragile for Tucker to handle. The court terminated its jurisdiction, but the department continued to
supervise and monitor Kerry's care.
Things did not improve. In third grade, Kerry was expelled from Caldwell Elementary School
for threatening teachers with a pair of scissors.
"I said, 'Why did you do that?'" Tucker recalled. "He said they took something from him.
Anything would set him off."
Eventually Kerry was sent to Compton System of Care, a school for special-needs kids
where he could go to school and receive outpatient therapy. By all accounts, he was doing well,
though he became depressed when another child in the Tucker home was reunited with his
mother.
Then, barely two months before he died, Kerry began taking a psychotropic medication that
had been prescribed by Todd Bollinger, a psychiatrist. The doctor had been recommended by
Kerry's DCFS social worker, according to Tucker.
The psychotropic medication Kerry took was called Wellbutrin. It is commonly used to treat
depression and, sometimes, attention deficit disorder. It's also given to smokers to help them curb
their habit. While one of the side effects listed for Wellbutrin is suicidal ideation, it is unclear
whether Kerry was affected.
After Kerry's death, according to court documents, Bollinger told DCFS investigators that he
prescribed the drug for the boy because he was "exhibiting symptoms of irritability, oppositional
defiant disorder and ADHD." The psychiatrist also said he couldn't rule out "depressive disorder."
At 78, Tucker said that she can live with not being able to take in any new foster children.
But, she does want back her good reputation.
"I just wish I could keep the name of my house clear," she said.
Tucker finds it ironic that the child welfare system seems to be blaming her for Kerry's death
when the system paid scant attention to the boy's needs when he was alive.
"You're just lost in the system," she said.
Kerry's Department of Children and Family Services social worker last visited and spoke to
him "in private" April 27, 2000, according to court documents, nearly a year before he died.
However, the social worker noted in court documents that she called Tucker once a month to ask
how the boy was doing.
Kerry's funeral was held at the Ajalon Temple of Truth Baptist Church he regularly attended
in Los Angeles. Members of Mikko Brooks' family attended the services. But his mother said
authorities at the prison would not let her attend. The child is buried in an unmarked grave at
Angeles Abbey Memorial Park in Compton.
Tucker said the county paid for the mortuary but waited nearly a year before reimbursing her
for Kerry's burial costs. "I paid it out of my pocket," she said.
The old woman's biggest regret is that they didn't send her enough money to buy a
headstone for the little man of the house on Stockwell Street.
DAILY JOURNAL ARTICLE
© The Daily Journal Corporation. All rights reserved.
-------------------
Despite Law, Paper Maze Slows Access to Dependency Records
By Cheryl Romo
Daily Journal Staff Writer
LOS ANGELES - Twelve days after being informed of Kerry Brooks' death by a confidential
source, the Daily Journal petitioned the Los Angeles Juvenile Court for access to his dependency
court file. Initially, court officials said the file was lost. After five months, however, it was
discovered and then-Presiding Judge Terry Friedman granted access to the file.
The Daily Journal was allowed to view part of Kerry's records. What was held back is not
known or disclosed to those seeking access, but in this case is believed to include psychiatric and
medical records.
To paint a more complete picture of Kerry's life, the Daily Journal contacted those who had
cared for him.
Two court-appointed attorneys who initially handled Kerry's dependency court case said
they couldn't remember Kerry or his mother. Nathan Hoffman, who represented Kerry's mother,
said he handles "hundreds of cases" and didn't recall the family.
Jo Franklin of Dependency Court Legal Services represented Kerry. She said she met her
client just once and hadn't been his attorney for years.
The child's autopsy report was released eight months after his death. It indicated that Kerry
was in good physical health, although he was reported to have a history of emotional problems.
Although originally investigated by law enforcement as a homicide, the coroner concluded the
cause of death was suicide by hanging.
The 17-month search for an explanation why a 9-year-old child killed himself in Los Angeles
County illustrates the difficulties faced by child advocates in a system wracked with secrecy.
Three years ago, the state Legislature enacted the Lance Helms Sunshine Act to shed light
on the plight of youths in the dependency system. Named in the memory of a Los Angeles
County toddler who was murdered by his father, the legislation was introduced by state Senator
Richard Polanco, D-L.A.
The Lance Helms Sunshine Act was designed to give greater access to information when a
child in the system dies. The law was revised in 2001 and came about because of concerns
about a lack of candor, specifically on the part of Los Angeles County officials, in the wake of a
plethora of foster care deaths in the late 1990s.
Recently, some child advocates have begun to question whether the Lance Helms Sunshine
Act is working as intended.
Virginia G. Weisz, directing attorney for children's rights at Public Counsel, said all of a
child's records ought to be open, whether the child died or was injured.
"I'm not a fence-sitter on that one," Weisz said. "And if the child died, I don't think you need
anyone's permission to see the file. With the court's permission, you definitely need to have a little
sunshine in there."
Children's tort attorney Linda Wallace Pate said child deaths must be viewed as a warning
that something is drastically wrong and that the situation cannot be remedied without access to
information.
"If information is being withheld behind a shield of confidentiality, this is insane. Obviously,
the Helms Act is not working," Pate said. "The legislative intent was to provide some
transparency regarding the issue of children who died in foster care so that we can prevent and
end this tragedy. It's barbaric when children die in foster care and we can't proceed to prevent it if
we don't have the information."
However, Anne Fragasso, who heads one of three Dependency Court Legal Services firms
representing children at the Juvenile Court, said that because of the potential for harm to siblings
of the dead child, she doesn't feel confidential information about child deaths "should be spread
about" in public.
"We can't control the information after it's out there," she said. "We want to see what people
are looking at and why."
Fragasso also feels attorneys who represented the deceased child may have a continuing
responsibility to protect their client's confidentiality.
"My guess would be that we still have a responsibility," she said. "There's nothing in the law
that says confidentiality evaporates when a child dies."
In addition to petitioning the Juvenile Court for access to Kerry Brooks' file, the Daily Journal
since December has filed eight petitions with the Los Angeles Juvenile Court seeking access to
information about children who were murdered or committed suicide. The children all had
dependency court cases, and some were were under the supervision of the Los Angeles
Department of Children and Family Services, according to sources with knowledge of the various
situations. In each situation, the Daily Journal asked that the Juvenile Court's decisions on the
Sunshine Act petitions be expedited.
To date, the court has permitted no access, and seven of the petitions are pending.
The only case for which a response has been received involved Christopher, an 11-year-old
boy who committed suicide with a gun in his home May 23, 2001. In re: Christopher W., DCS
Case No. 9532468.
In response to the Daily Journal's petition for information about Christopher, Deputy County
Counsel Richard D. Bloom, the attorney for the Department of Children and Family Services, sent
a letter, dated Jan. 22, 2002, to the court.
Bloom stated his office had "no objection to the inspection of the juvenile case file" for
Christopher, but requested that "privileged or confidential information contained within the
juvenile case file not be disseminated."
On Feb. 26, Juvenile Court Presiding Judge Michael Nash denied the Daily Journal's petition
without explanation. The court then denied access to its minute order in an April 5 letter, saying
"there is no authority that requires the Court to provide its reason for the denial of a WIC 827
petition."
Terry Francke, general counsel of the California First Amendment Coalition, said that while a
juvenile court presiding judge can restrict access to confidential files, he can do so only on
"particular findings."
The law itself states that access rights are statutory and that the presiding judge "may issue
an order prohibiting or limiting access to the juvenile case file, or any portion thereof, of a
deceased child only upon a showing that release of the juvenile case file or any portion thereof is
detrimental to the safety, protection, or physical, or emotional well-being of another child who is
directly or indirectly connected to the juvenile case that is the subject of the petition."
In May, Nash issued a clarification order stating the dead boy's court records would not be
released "because the child was not a dependent of the Court."
The order also explained that the presiding judge had made a determination that release of
the requested records would be "detrimental to the physical or emotional well-being of another
child who is directly connected to the child that is the subject of the petition."

The following articles were published in the Los Angeles Daily Journal on July 8, 2002.
This submission tied for 2nd Place in the 2003 Price Child Health and Welfare Journalism Awards.
DAILY JOURNAL ARTICLE
http://www.dailyjournal.com