The four workers missed other important details as well: Ignorant of the prior abuse conviction, they initially did not speak with the mother's parole officers, who knew she was a crack user who had refused treatment. The workers interviewed Ms. Harden, but never talked to her boyfriends, despite warnings that one of the men was prone to violence and drug dealing. Fatal Burns

It was one of Ms. Harden's boyfriends who later said he had accidentally caused what proved to be fatal burns to the groin, buttocks and legs of her five-month-old son, Jeffrey. The round-faced infant with the soft, fuzzy head of hair died Jan. 17.

The boyfriend, Jeffrey Phillips, told the authorities that he had wiped the baby with a cloth that he had not realized was soaked with cleaning fluid. The medical examiner ruled the death a homicide, saying the burns were caused by immersing the child in scalding water and noting that the child had three broken ribs. Mr. Phillips has not been charged, and the police say the death is still under investigation. Mr. Phillips declined to comment.

Whether the caseworkers in the city's Child Welfare Administration could have prevented the child's death will never be known, but the flaws in the handling of Jeffrey Harden's case illustrate what experts and advocates for children have long called the Achilles' heel of the child protection system in New York and the nation: the frequently poor quality of casework in a fragmented bureaucracy staffed by inexperienced, overburdened workers who do not stay in the job for long.

Over the last three years, the problem has gotten worse as the Dinkins administration has reduced the staff of caseworkers who investigate child abuse by about 25 percent, even as reports of abuse and neglect have continued to surpass 50,000 annually.

Last year, a staggering 77 percent of the workers who investigate child abuse reports resigned, were laid off or moved to jobs in other agencies. Inevitably, caseloads have risen sharply. In January 1990, investigative workers carried an average of 14 cases. None had more than 30. Now, caseloads average 19.5 and commonly top 30.

In the Harden case, high turnover led to a constant stream of changing workers. In a span of only 18 months, the case was passed to four different workers, each of whom would manage only a partial investigation before transferring out of the unit responsible for the case. By the time Jeffrey died, every worker in the unit was gone.

The city's 22-page reconstruction of the case, combined with court records and interviews with the family, caseworkers and parole officers, shows what happens when workers with too many cases and too little experience conduct investigations.

But the problem is not simply one of human error. In the Harden case, the workers had to make extremely difficult decisions with incomplete information. Child protection workers are not entitled to parents' prior criminal records, which are kept confidential under state laws meant to safeguard privacy.

But if their ignorance of Ms. Harden's prior child-abuse conviction was understandable at first, it was less so after she went back to prison for a parole violation. Workers talked to her parole officers, but never found out what crime she had committed.

Usually, the city's handling of child-abuse investigations is shielded from public scrutiny by state confidentiality laws meant to protect family privacy. But records of the city's internal investigation of the Harden case were provided to The New York Times by an official who believes they highlight failings of the system.

In a recent interview, Ms. Harden denied all reports that she was an abusive or neglectful parent, and she denied ever using crack. She said she had never left her children alone in her apartment, and she disputed the hospital's account of how rarely she visited her baby before he died, saying that she had "visited every day." Caseworker No. 1 A Report of Abuse Is Not Followed Up

Ms. Harden, now 28, first got into serious trouble when she was a teenager. She lived at the time with her mother and most of her 11 siblings in a housing project in the South Bronx. She had dropped out of school in the ninth grade, where she had been in a special class for slow learners.

On May 17, 1981, Ms. Harden, then 17, smoked marijuana and angel dust with a 15-year-old friend, Eva Younger, Ms. Harden later said. Then they sexually assaulted a chubby, 7-year-old girl in pigtails. Ms. Younger told the court that she repeatedly forced a toilet plunger into the child while Ms. Harden held the girl down.

Ms. Harden testified that Ms. Younger made her participate in the assault after threatening to hit her with a stick if she did not smoke marijuana. "I felt dizzy and I didn't know what was going on," she told the judge. "Something just come up in my mind and I did it."

A State Supreme Court Justice, Walter Schackman, gave Ms. Harden a three-to-nine-year prison sentence. "The acts were the most brutal I have seen in five-and-a-half years of sitting in a felony part," he told her.

Ms. Harden served three years and was released in 1984, when she was 20 years old. For the first two years, she kept appointments with her parole officers, said David Ernst, a spokesman for the state Division of Parole. But by 1986, her attendance had become sporadic. In 1987, she gave birth to her first child, a girl named Genise. An Early Sign of Trouble

Finally, in the spring of 1988, she stopped reporting to her parole officer altogether, and a warrant was issued for her arrest. At the time, she was homeless. She was picked up and admitted that she had started smoking crack, Mr. Ernst said. She was referred to a residential drug-treatment program, but never went.

The first time a report of child abuse was lodged against Ms. Harden came the following fall, records show. A city welfare worker called the state central child abuse registry to say that he had seen Ms. Harden hitting Genise, then 10 months old, on the head and chest in a Bronx welfare office because the baby had put paper in her mouth. When the welfare worker suggested to the mother that she take the paper away from the baby instead of hitting her, Ms. Harden flew into a rage.

"The mother became very angry and slammed the child's tush into the seat, screaming bad language and saying it was her kid and she'll do what she wants," the welfare worker said. "She then took the child and ran out."

Heather Staiman was the child-protection worker assigned to investigate the case. But she quickly discovered that Ms. Harden and her daughter had left their last listed address. "It was an easy case," Ms. Staiman said in a recent interview. "We couldn't find the mother, so we closed it."

Soon after that, Ms. Staiman asked to be transferred to another part of the agency after two years as a child-protection worker. "I felt inept," she said. "My supervisor never sat us down and went over our cases with us. If I had a problem knowing what to do, I tended not to deal with it." Caseworker No. 2 A Case Is Closed After 2 Short Visits

A year later, a second person called the state child abuse registry on Dec. 1, 1989, to allege that Ms. Harden was neglecting her child, and spending her money on crack instead of food.

At the time, Ms. Harden was living in the Bronx, but the case went back to the Manhattan unit that had investigated the first charge. The Manhattan unit objected because the case was in a different borough, but was overruled. This would have a powerful effect on the handling of the case.

Carlos Pages, who had two years' experience as a caseworker and a bachelor's degree from Florida Memorial College, went to the home, which he found well stocked with food. Both Ms. Harden and her boyfriend's grandparents, whom she was living with, denied that she used drugs. The couple said they had thrown Ms. Harden's boyfriend out of the apartment because he was violent and was using and selling drugs, the records said.

"When I was visiting her, everything was going well," Mr. Pages said in a recent interview. "She had broken up with her boyfriend."

Agency policy required the caseworker to make monthly visits to the home, but three months lapsed before he stopped in to talk to Ms. Harden again. Again, he said, she and her baby appeared healthy. Review of Case's Handling

Mr. Pages said he was so overburdened with cases and paperwork that it was difficult to make the minimum monthly visits, much less track down relatives, teachers and parole officers, or spend the time it would take to really get to know the families.

"It's impossible to visit these people within a month," he said. "They're all over New York City."

On the basis of Mr. Pages' two brief visits to the home, the case was closed.

But a month later, Peggy Smith, a high-ranking supervisor, reviewed the case because she was worried about the performance of the unit and wrote a scathing critique of the Harden investigation.

She wrote that Mr. Pages had not gathered the most basic facts about the family: He listed Ms. Harden's boyfriend as her child, and he thought she was living with her own grandparents, rather than her boyfriend's grandparents.

Nor did it appear that Mr. Pages had ever read the prior report of Ms. Harden hitting her infant at a welfare office, much less discussed it with her, the supervisor wrote. Ms. Smith directed the unit to reopen the case.

But Mr. Pages said he was never given Ms. Smith's report. He left the unit two months later after he was injured in a car accident. Caseworker No. 3 A Criminal Record Gets Little Notice

Finally, five months after Ms. Smith ordered the case reopened, a new worker, Rose Rivera, was sent to check on Ms. Harden. Ms. Rivera would never lay eyes on Ms. Harden. Her efforts to talk to Ms. Harden were sporadic and unsuccessful.

Ms. Rivera, who has a sociology degree from Brooklyn College, had been hired just six months earlier. She had 14 cases of her own, but because other workers in the unit were often absent, she had to deal with many additional cases.

When Ms. Rivera finally went to visit Ms. Harden in October 1989, she learned that Ms. Harden was in prison for a parole violation and that her children were living with their grandmother. (Ms. Harden had given birth to a second baby, Shaquan, earlier that year.)

In January 1990, Ms. Harden was released, again on the condition that she participate in drug treatment.

The next month, Ms. Rivera talked to the mother's parole officer, but apparently never asked what crime Ms. Harden had committed. The worker reached Ms. Harden by telephone at her mother's Bronx home. They agreed to meet at the agency's office in Manhattan, but Ms. Harden did not show up, the records said.

Ms. Rivera and her supervisor, Susan Kynor, recently declined to comment on the case. Ms. Rivera told city investigators that she had little memory of Ms. Harden, whom she never met. She thought Ms. Harden had been imprisoned on a drug-related charge. Ms. Kynor was under the impression Ms. Harden's crime was robbery.

Almost as soon as Ms. Rivera arrived in the unit, she left, burned out by the demands of the job. "She found herself working six days a week plus evenings," the internal city report said. Caseworker No. 4 Report of Progress, And Then a Death

So once again, in March 1990, a new worker was assigned to the case. Cecilia Parris had only been on the job for four months. She had a bachelor's degree in criminal justice from John Jay College.

She caught up with Ms. Harden at her mother's apartment in the South Bronx. The children looked healthy, but their doctor said that Ms. Harden had not brought them in for regular checkups or immunizations.

Ms. Parris also talked with Ms. Harden's parole officer, Wallace Webb, and asked him to have Ms. Harden take the children for immunizations. In an interview, Mr. Webb said he did not recall talking to Ms. Parris, but did remember that Ms. Harden was attending drug treatment. "She was stabilized and happy to have an apartment of her own," he said.

There is, again, no indication that the caseworker asked about Ms. Harden's criminal history. Ms. Parris declined to comment on the case recently, but city records say she decided to close the case since the mother was in contact with the parole officer. Move to Manhattan

Ms. Kynor later conceded that the case might have been kept open if the mother had not lived in the Bronx, inconveniently distant from the unit, based in lower Manhattan, the city's internal report said.

Later in 1990, Ms. Harden and her children moved into a crumbling, drug-infested building in Harlem, where young men peddled crack and most of the tenants were, like herself, formerly homeless families from city shelters. It is there that her son would be fatally burned.

Ms. Harden became pregnant in 1991. But before she gave birth in August, her boyfriend went to jail for selling crack. Ms. Harden said she was lonely and quickly started seeing her neighbor's cousin, Jeffrey Phillips, 19.

At that time, because the investigation was closed, no caseworkers were visiting the home. But relatives say there were many signs of trouble. In the fall, Shaquan had a nasty bruise on his face. Ms. Harden said Mr. Phillips hit the toddler and sometimes her, too. But Mr. Phillip's sister, Glenda Phillips, who lived in the same apartment with Ms. Harden, suspected Ms. Harden. Shaquan's face looked as if someone with a woman's long, slender fingers had squeezed hard enough to leave a hand imprint, Ms. Phillips said. Children Often Left Alone

Jenna Fleming, who lived across the hall from Ms. Harden and was Mr. Phillips's cousin, said that Ms. Harden sometimes left her two toddlers and infant alone at home when she went to the store or to the laundry. She said she sometimes found 3-year old Genise trying to play mother, rocking the infant and holding an empty bottle to his lips.

On Dec. 15, 1991, Ms. Fleming agreed to watch the children while Ms. Harden went Christmas shopping.

That afternoon, Mr. Phillips dropped by to see Ms. Harden and agreed to watch the children while Ms. Fleming stepped across the hall to her apartment. When she came back, the baby was crying inconsolably. She lifted the sheet and saw that the baby was badly burned. Mr. Phillips later said that while changing Jeffrey's diaper, he wiped the baby with a cloth he did not know was soaked with cleaning fluid.

"Being a little high, he probably wasn't conscious of what was on the rag," said his sister, Ms. Phillips. "He told me he was smoking reefer before he came in the house."

Doctors at New York Hospital found the baby had second- and third-degree burns over one fifth of his body, and that three ribs had been broken sometime before he was burned. Memories of a Short Life

On Jan. 6, three weeks after the baby was admitted to the hospital, a social worker on the burn unit, Joyce Scheinberg, called the city caseworker to report that Ms. Harden was not visiting the infant. Jeffrey needed a skin-graft operation, but his mother was needed to sign consent forms first.

A day later, Ms. Harden signed the consent forms, but then disappeared from her baby's side for another 10 days, Ms. Scheinberg reported. On Jan. 17, he died of a massive infection caused by the burns.

Ms. Harden's surviving children, Genise and Shaquan, were placed in foster care with their grandmother after the death.

Mr. Phillips, who says he hurt the baby by accident, is now in the Union County jail in New Jersey, awaiting sentencing on drug and gun charges.

Ms. Harden is still living in the same dingy Harlem apartment where her son was fatally burned. Four disposable diapers and a single white baby shoe are tacked to the wall to remind her of Jeffrey.

Died August 12, 1998

Report Faults Child Agency In Death Of 6-Year-Old

 

 The boy, Matthew Eli Creekmore, was kicked to death by his father, Darren Creekmore, more than a year ago. But the case is just beginning to have national repercussions as legislatures around the country study a sweeping overhaul of the child welfare laws in the State of Washington that came about as a result of the clamor over the child's death.

The rumblings of change come in the aftermath of a 200 percent increase nationally in reported cases of child abuse in the last decade, and they follow public outrage over cases like the Creekmore killing here and the fatal beating of 6-year-old Elizabeth Steinberg in Manhattan last November. An Issue of Top Priorityt

National experts monitoring the growing problem say that reform of child abuse laws is shaping up as a top priority for state legislatures in the coming year.

After a long trend toward keeping troubled families together, sometimes at the expense of an abused child, states like Washington are reversing previous laws and making protection of the child the paramount concern. In another change, social workers here do not have to wait for substantiated harm before removing a child from the home but can intervene on the basis of the potential risk of abuse.

This state also recently passed a pioneering law that makes child abuse resulting in death the equivalent of first-degree murder. Under this ''homicide by abuse'' law, prosecutors no longer have to prove premeditation or intent to kill to win a conviction. Instead, they must show that the abusive parent displayed ''extreme indifference to human life.''

''Premeditation in child abuse cases is almost impossible to prove,'' said State Senator Stuart Halson, who drafted the law. ''This gets us around that oft-heard defense: 'I didn't mean to kill the boy; I just wanted to discipline him.' '' Other States Study Law

The new law is being studied by a number of states, including New York, where about 100 children a year die from child abuse, according to a spokesman for the Department of Social Services. Experts estimate that nationwide from 2,000 to 5,000 children die each year as a result of abuse. Officially, there was a 23 percent increase in child abuse deaths from 1985 to 1986.

Nationally, ''there is a real crisis going on now in every state,'' said Susan Robison of the National Conference of State Legislatures, which is based in Denver. Reflecting concern about the 2.2 million abuse and neglect cases reported nationally in 1986, many states have recently enacted tightened child welfare laws. But at the same time there is a countertrend toward more legal rights for parents who are accused of abusing children.

For example, while Washington State, in its sweeping 1987 overhaul of child protection laws, gave social workers the right to interview children without notifying their parents beforehand, several members of the Colorado Legislature introduced a bill to allow parents greater legal representation in abuse investigations. That bill was voted down, but its supporters are planning to re-introduce it.

Every state now has some sort of mandatory reporting law, requiring doctors, health or day care workers who come in contact with an abused child to tell the authorities about it, but ''there is still a tremendous amount of under-reporting of abuse going on,'' said Patricia Toth, director of the National Center for the Prosecution of Child Abuse, in Alexandria, Va. Rise in Abuse Cases

Ms. Toth attributes the 200 percent increase in reported child abuse to ''a combination of increased awareness, mandatory reporting laws and perhaps a general rise in parental abuse.''

Ms. Toth said cases such as the Steinberg and Creekmore deaths ''are the catalysts for more change.''

''The country will go along, basically unaware, and then something very awful happens to grab everybody's attention,'' she said.

Deborah Daro, research director of the National Committee for the Prevention of Child Abuse, which is based in Chicago, said that after the news of Elizabeth Steinberg's death, ''There was a response like we'd never seen before, an outpouring of outrage, our phones ringing off the hook with people asking 'why,' ''

In the Washington case, social workers from the state Child Protective Services had removed the 3-year-old boy from his home in Everett three times in the 10 months before he died. But each time they returned him, despite reports from his grandmother, doctors and day-care teachers that he was being abused. His father had twice been charged with beating the boy.

At the time of the boy's death, state officials had determined that the family was making an effort to improve the situation. But on Sept. 27, 1986, the boy was kicked repeatedly in the stomach and then left to die in his bedroom. Mr. Creekmore was convicted of second-degree murder and sentenced to 60 years in prison, one of the most severe sentences in recent memory for such a crime. The boy's mother, Mary Creekmore, testified for the state and was allowed to plead guilty to a gross misdemeanor charge of failing to get medical attention for the child.

When the case first came to light last year, hundreds of parents demonstrated outside the social service headquarters in Everett and Olympia, the state capital, demanding that the system be overhauled. They were soon joined by Child Protective Service workers, who said inadequate financing and understaffing had contributed to what the state social service director admitted was ''a breakdown of the system.''

The case, while not unique by national standards, was an example of problems facing overburdened child welfare workers around the country. Nationally, while reported cases of child abuse rose 156 percent from 1981 to 1986, state financing to attack the problem rose a mere 2 percent, according to a recent Congressional study.

''In probably every state in the country, you've got child protection workers not going out on a lot of cases except the high priority ones, and that in itself is very dangerous,'' said Patricia Schene, director of the American Association for the Protection of Children, based in Denver.

''What's clear is that there are bad decisions being made because the system is overloaded, and that means we'll see a lot more foment in the next year or two,'' she said. A lurking problem, she said, is the dearth of foster homes. While the public and state officials are calling for more abused children to be removed from their homes, they have yet to provide adequate money to attract foster parents for those children.

In Washington, because of the fallout from the Creekmore case, more than 5,000 children were removed from their homes in the last year, but officials could only find 3,800 foster homes in which to place those children.

But increased public concern has also led to more private charity. Following the furor over young Eli's death, a new $1.3 million private center for abused children, the Eli Creekmore Memorial Center, was opened near Seattle last month.

In dedicating the center, its director, Patrick Gogerty said, ''In death, his voice became a mighty shout that stirred the conscience of all the people in the state of Washington.''

Confession not enough

Some Washington prosecutors complain that a state law is hindering their ability to bring child-killers to justice.

Nine days after her birth, Amber Pineda died while sleeping in bed with her mother and 2-year-old brother in their Bremerton home. A March 1998 autopsy found no sign of foul play.

But police were suspicious from the start. The mother, Kelly Pineda, 31, was fully dressed when her husband found her in bed with the baby. She showed no emotion at the hospital. And she laughed while telling an officer "maybe I can have another one," according to police records.

Detectives also knew state Child Protective Services caseworkers had previously intervened because Pineda's son showed signs of neglect.

Police questioned Pineda intensively and accused her of smothering the infant.

At first she denied it. But as the hours wore on, Pineda admitted she'd been "tipsy" from drinking four beers and had placed her right side on top of the infant with the mother's hand over its face, police records show.

She was charged with second-degree manslaughter.

"She was not describing an accident to the officers," said Kitsap County Deputy Prosecutor Kevin Anderson.

Pineda's attorney, David Rovang, said police manipulated Pineda during a five-hour interrogation.

"It was a horrible, horrible case," Rovang said. "She is kind of an odd person. But to take those characteristics of her personality and say she must therefore be guilty is not reasonable."

Rovang asked the court to dismiss the charges based on the "corpus delecti" law that requires confessions to be corroborated with physical evidence. The purpose of the law is to protect vulnerable people from confessing to something they didn't do, he said.

In Amber's case, the autopsy didn't independently prove suffocation because the findings were the same as a SIDS death, he said.

Kitsap County Superior Court Judge Leonard Costello reluctantly agreed that Pineda's incriminating statements could not be used without other evidence of a homicide, especially given a previous Supreme Court ruling on a similar case. He dismissed the charges in August 1998.

Pineda did not want to comment when she was contacted recently.

Prosecutors appealed Costello's decision, but the Washington Court of Appeals upheld it in January 2000.

"What this means is not only can you get away with smothering an infant, you can get away with admitting you did," Anderson said in a recent interview.

The court failed to recognize that an infant death can only be classified as SIDS if no other cause is found. That was not true in Pineda's case, he said.

"I don't know if a jury would have convicted Mrs. Pineda," Anderson said. "But I think that baby deserved to have this heard."

The Washington Association of Prosecuting Attorneys is also concerned, and has lobbied legislators over the last year to change the law so that confessions can be introduced in infant homicide cases. "We believe juries should hear the evidence in these cases," said Tom McBride, executive secretary of the prosecutors association. "I'd argue you should make more of an accommodation because it's the death of a child."

The court's position has had a "chilling effect" across the state, McBride said: "There are cases that are not being pursued."

By RUTH TEICHROEB
SEATTLE POST-INTELLIGENCER REPORTER

Social Services Department did not know when or how the boy contracted AIDS because there was no requirement for a child placed in foster care to have a medical examination.

 

 

LEAD: A caseworker for the South Carolina Social Services Department has been indicted on charges of failing to investigate or report a suspected case of sexual abuse of an 8-year-old foster child, who later died of AIDS.

A caseworker for the South Carolina Social Services Department has been indicted on charges of failing to investigate or report a suspected case of sexual abuse of an 8-year-old foster child, who later died of AIDS.

The indictment Thursday by a Richland County grand jury charged the caseworker, Frank Edson, with two counts of obstruction of justice and two counts of failure to report child abuse in the case of the Columbia boy, Brett Hall.

The boy's foster mother told Mr. Edson in October 1987 that the boy had been sexually abused, but Mr. Edson waited eight months before beginning his investigation, the indictment charged. By that time Brett was dying of acquired immune deficiency syndrome. He was 9 years old when he died in November.

Julaan Prince, an assistant prosecutor, said the investigation of Brett's death had turned toward the boy's caseworker because there had been was no way to prosecute the person responsible. She said the prosecutor's office did not know how the boy contracted AIDS and was not trying to find out.

She said that there had been no evidence of sexual abuse of Brett and that the statements of the foster mother could not be used in court because they were hearsay. ''If you've got a child that is alive and can talk, 9 out of 10 times you have a case and can be successful,'' Ms. Prince said. ''But at the least you've got to have a live witness.''

A 1977 state law requires child protection agencies to follow through on any suspected case of child abuse or neglect within 24 hours. Each count of obstruction of justice carries a maximum 10-year prison term. Each count of failure to report child abuse carries a maximum penalty of six months in prison and a $500 fine.

Mr. Edson did not return a telephone message left at his home seeking comment on the indictment. A Rare Prosecution

A spokeswoman for the Social Services Department, Norma G. Anderson, who has worked at the agency since 1973, said it was the first time in her memory that an employee had been indicted on criminal charges for failing to follow through on a suspected case of child abuse.

Mr. Edson has been transferred to an agency responsible for providing emergency food and shelter, Ms. Anderson said.

She said the Social Services Department did not know when or how the boy contracted AIDS because there was no requirement for a child placed in foster care to have a medical examination.

Two Illinois child-welfare workers have been reassigned while the state reviews their handling of a case involving a 2-year-old boy in Wood River who police say was beaten by his mother's boyfriend.

The death on Aug. 15 of Michael Cecil has led to an investigation by the Illinois State Police Division of Internal Investigations of the way the Department of Children and Family Services handled the abuse complaints.

Man gets 40 years in second baby killing

 

 

In the latest example of New York City's inability to track troubled families, a Bronx woman whose 10-month-old boy suffocated last week was supposed to be contacted by city caseworkers once a month but had not been visited since last April.

The disclosure again raises questions about the failure of the city's strained child welfare agency to investigate and monitor cases of child abuse and neglect before death occurs.

The Bronx woman, Marsha Foot, 30 years old, has been charged with manslaughter in the death of her son, Michael Anthony Baker, who was left in an overheated apartment while Ms. Foot visited her boyfriend overnight.

Her case was apparently overlooked because the city, in an effort to lower the caseloads of some child abuse investigators, shifted hundreds of cases to workers in another unit of the Human Resources Administration, the city agency that handles child welfare cases.

The problem, officials for the caseworkers union said, was that the workers who received the transferred cases were already carrying large caseloads of their own. As a result, the union officials said, hundreds of families went unattended for months. 'Insufficient Attention'

''Cases were literally sitting in boxes, untouched,'' said Charles Ensley, the president of the Social Services Employees Union Local 371. ''It's amazing more tragedies haven't occurred.''

William J. Grinker, the head of the H.R.A., refused to comment on the handling of the Foot case, as he has for more than a week. He cited the confidentiality of social service records.

But when asked to comment on the disarray described by the union leader, Mr. Grinker acknowledged that his own investigation had found that ''insufficient attention'' was paid to the workers receiving the cases.

''We were concentrating on the other units,'' Mr. Grinker said, ''and these suffered as a result.''

In a confidential memorandum obtained by The New York Times, Mr. Grinker wrote last week that his review of the Foot case showed a ''sustained lack of appropriate follow-up and an apparent lack of adequate supervision and control.''

In the memo, addressed to his deputy commissioner, Brooke Trent, Mr. Grinker also said there were ''serious systemic deficiencies'' in the way cases like Ms. Foot's were handled.

Mr. Grinker told Ms. Trent to have a plan of ''corrective action'' ready by Jan. 27. Koch Urges Discipline

The H.R.A.'s child protection agency, Special Services for Children, has been struggling for years with ever-growing caseloads and a strained work force that quits at dizzying speeds. And despite some progress, critics say management has been unable to allocate its limited resources to deal effectively with the problems.

Mayor Koch said he told Mr. Grinker to take the strongest disciplinary action possible if he found any wrongdoing by caseworkers.

''It will never be brooked as an excuse that 'my caseload was too high,' '' Mr. Koch said. ''If you are going to tell me that these people have too much work to do, so do most city employees,'' he said.

When asked if the problems might lie with management, Mr. Koch said that ''management will certainly be looked at'' and ''they'll try to upgrade.'' But, he said, ''if you think the employees are off the hook - no way.'' First Charges in 1987

Ms. Foot's 10-month old son died after he and his 2-year-old sister were left in a closed bedroom with a heater turned on, police officials said. The temperature in the room rose to more than 110 degrees.

City records indicate that Ms. Foot was first charged with neglecting her children in the fall of 1987.

Details of that case were not available, but on Dec. 23, 1987, a family court judge ordered that the city's child welfare agency monitor Ms. Foot's home for a year. The judge also ordered periodic testing for drug use.

The case initially belonged to a worker in an investigative unit called a Protective Diagnostic unit, and the family was visited several times.

But in the spring of 1988, as part of the effort to bring caseloads down in the diagnostic units, the Foot case was transferred to a Family Service unit. There, in the months that followed, the case was assigned to two different workers, but no contact was ever made. Caseloads Running High

Michael died less than a month after the court-ordered supervision expired.

Union officials said the Family Service unit caseworkers assigned to Ms. Foot had up to 70 cases to handle.

City officials acknowledged that the caseloads in the Bronx units at that time were high, ranging from an average of 54 families per worker in May to 33 in December.

The goal for caseloads in the diagnostic units, a measure used the most often to determine how well the city is doing, is an average of 20 cases per worker. Officials said it is currently 19.

City officials said yesterday that they could not yet provide any data on how often families assigned to the Family Service units were visited. Mistakes in Cortez Case

The disclosures about the Foot case come only a few weeks after the agency acknowledged that it had badly mishandled another case, involving Jessica Cortez, a 5-year-old girl who was beaten to death in Brooklyn.

In the Cortez case, city workers made numerous mistakes over the years, including confusing various children in the household and failing to look up records that might have alerted them to danger signals in the home.

Despite increasing complaints of child abuse, Mr. Grinker, who took office two years ago, had for a time been making progress in reorganizing the agency and hiring hundreds of new caseworkers.

But shortly after the much-publicized case of Lisa Steinberg, a 6-year-old Manhattan girl who was beaten to death, complaints of abuse and neglect skyrocketed and protective/diagnostic workers were once again swamped.

Last spring, the agency began a push to remove certain kinds of cases from these workers, including families that were under court-ordered supervision. City officials said this included about 10,000 families.

 

 

 

Child welfare workers visited a Bronx foster mother 26 times and saw no indication that the children were being abused before last Saturday night, when one child in her care was killed and the other was seriously injured, city officials said yesterday.

The city would release only sketchy information about its monitoring of the foster mother, Mary Ann Ayala, and the two children in her care, Millicent, 6, who died, and her sister, Stephanie, 4, who is hospitalized.

Ms. Ayala has been charged with murder and attempted murder in the case.

The officials, from the Human Resources Administration, which oversees the foster care system, would not say whether the visits were routine or involved allegations of abuse in the household. Several neighbors have said they reported Ms. Ayala to child welfare officials for abusing the children.

One official, Sheila Jack, an agency spokeswoman, saidthere had also been five telephone calls by caseworkers to the Bedford Park home and three medical examinations of the children, the most recent on Jan. 29, 1992. Another spokeswoman, Linda R. Fisher, said the 26 visits began in April 1990 and have been at least monthly ever since. "In the course of the contacts the records indicate that the children's health or safety wasn't in danger," Ms. Jack said.

Still, the information appeared to show that the city had failed to meet its own standard for monitoring foster families.

Caseworkers are required to visit the homes of foster families every month, and therefore should have visited the family at least 35 times, starting when Millicent was placed in Ms. Ayala's care in March 1989.

People close to the case said the Child Welfare Administration also failed to bring the family back to court a year later, for a mandatory review of the city's plans for the children's future. By missing that date, the children were technically out of the foster care system, child welfare advocates said.

Commenting on the case, Lenore Gittis, of the Legal Aid Society's juvenile rights division, said, "In a sense nobody was responsible for these kids because legally when the placement lapses, the legal responsibility for the kids went back to the parents."

The foster arrangement began after a neglect petition was filed in 1989 against the mother, Norma Zabala, for drug use. The father, Edward Ayala, had been in jail on a drug conviction since 1987 and was released just four weeks ago. Death by Hypothermia

Ms. Jack refused to comment on whether caseworkers had adequately monitored the family, nor would she provide any details about the children's legal status.

Ms. Jack said she could release certain details about the case because it involved abuse in a foster family, rather than a biological or adoptive family. Usually the agency refuses all comment on child-abuse investigations.

An autopsy concluded that Millicent died of hypothermia, the medical examiner's office said yesterday. The police said she had been immersed in a bathtub of cold water.

The police, who said that the girl's body temperature had dropped below 85 degrees, reported initially that she apparently died from a beating.

Stephanie, who also suffered from hypothermia, was reported in stable condition yesterday at Montefiore Medical Center.

Defense's Story ?Too Convenient'
Prosecutors agreed Bass had mental problems, but insisted she knew right from wrong. A prosecution expert said the appearance of "Sharon" was too convenient and rejected the multiple-personality diagnosis.
"Her motive was control over two rebellious children," Miller said.
Jurors had been picked in Phelps County in south-central Missouri and were sequestered. They began deliberations Friday.
Bass' boyfriend, Tony Dixon, 37, is also charged with child abuse and endangering a child in the case. His court date has not been set.
Medical experts had called the case one of the worst they had seen.
When police arrived at the Bass home after a 911 call from one of the Bass children, they found Gary upstairs lying on a filthy mattress, emaciated and so badly infected that his burned toes and part of his empty stomach had gangrene.
Gary died Oct. 22, 1999 ? two days after Larry died from malnutrition ? because his body could not use the medicines to fight infection.
Bass' three surviving children are in foster care.
The case also was an indictment of the way Missouri's Division of Family Services handled abuse cases.
Records recently made public showed social workers thought Mary Bass' children had been abused repeatedly, but didn't recommend removing them before the two boys died.
Agency officials have said the state has since changed its procedures.
"I can't go back and try to second-guess and rehash [the workers' decisions]," said Denise Cross, DFS director. "All I can try to do is learn from them."

Woman guilty of killing two 8-year-old triplets

KANSAS CITY, Mo. -- A woman who said her multiple personalities were responsible for the deaths of two of her 8-year-old triplet sons was convicted of two counts of second-degree murder Saturday.

Mary Bass, 32, had pleaded not guilty by reason of insanity. Her lawyers and defense experts said she had severe psychosis and a personality named "Sharon" who controlled her actions.

Police said Bass locked Gary and Larry Bass in a room and deprived them of food and dipped their feet in scalding water as punishment. The boys died in October 1999.

Bass' other triplet, and two other children are in foster care.

11-year-old sues mother

The Associated Press
KANSAS CITY, Mo. -- Jerry Bass was 8 years old when his mother fatally abused his triplet brothers in what authorities called one of the worst cases they had ever seen.

A lawsuit filed on the boy's behalf claims that Jerry, now 11, is entitled to compensation from the Missouri Division of Family Services for the loss of his brothers, Gary and Larry.

The lawsuit, filed this past month in Jackson County Circuit court, also names as defendants the boys' mother, Mary Bass; her boyfriend, Tony Dixon; and two former workers with the Division of Family Services, Kimberly L. Rosa and Melissa Johnson.

It claims that the defendants' actions contributed to the deaths of Gary and Larry Bass and deprived the three brothers of constitutional rights. It doesn't specify the amount of damages sought.

"Jerry Bass has been denied the companionship, services, guidance, training and counseling of his brothers," the lawsuit reads. "He has suffered damages (and is) entitled to collect damages that his deceased brothers would have been able to recover had they lived."

The Bass brothers were victims of abuse that included being starved and beaten with a belt. Gary and Larry died in October 1999 of malnutrition and infections caused by severe burns from being placed in hot bath water.

A jury in October 2000 convicted Mary Bass of murder and other charges. She is serving eight life sentences in prison. Dixon pleaded guilty to charges of child abuse and endangering a child and was sentenced to 20 years in prison.

During the investigation into the criminal case, authorities learned that the state agency had received several hot line calls about the Bass family and had been to the home several times to investigate.

Spokeswoman Deb Hendricks said Family Services officials couldn't comment on the lawsuit while it was in litigation.

Kansas City attorney D. Scott Forrester, a court employee, is listed in the lawsuit as a representative of Jerry Bass. The boy lives with adoptive parents.

Forrester said he couldn't comment on the case while it was in litigation. John E. Turner, who is listed as the plaintiff's attorney, also declined to comment.

The lawsuit poses challenges for plaintiff's attorneys, said Ellen D. Jervis, a Kansas City attorney who has filed previous litigation against the Division of Family Services. Even though the wrongful-death portion of the lawsuit seems clear-cut because the mother and boyfriend were convicted of their crimes, the case against the state agency could be lengthy and more complicated.

"This was one of the most egregious cases we've seen in our area in a long time, but it's still going to be an uphill battle," Jervis said.

She pointed to an abuse case in Wisconsin, where a similar state agency had information that a father was beating and harming a young child before the child's death. The case eventually went to the U.S. Supreme Court.

"The U.S. Supreme Court said that the state has no duty to intervene in situations where the violence is being done by a private actor," Jervis said. "That to me would be the biggest hurdle."

And at 14, she was dead -- battered, sexually abused and left in a gutter in the Fordham section of the Bronx. Her body was not identified until late October, more than eight months after she was found and nearly buried as someone else's child.

It was a brutal end for a girl whose prophetic fear, friends said, was that nobody would notice if she was gone. In retrospect, it seems that she was destined for that final cruelty. Perhaps she was. But it was only the last indignity suffered by Marleny, whose concluding years were spent in a rough passage through New York City's foster care system, one that friends, relatives and foster parents say, seemed to fail her at almost every turn.

Marleny was shuffled from foster home to foster home and, in perhaps the bitterest turn for a girl so desperate for the security of a home, was denied the chance to live with a family who wanted to adopt her. As a result, she frequently ran away, eluding those who cared for her but were not equipped to keep her life from falling apart.

Marleny's case may be more extreme than most, but it is not altogether unusual. According to the Administration for Children's Services, which oversees the city's foster care system, about one-third of the 40,000 children in their charge are teen-agers, many of whom are chronic runaways.

Most of these children disappear for only a few days, agency officials say, often to see a boyfriend or girlfriend or relative.

In some cases, though, they said, a repeated pattern of running away signals a deeper problem, either in the child or in the child's placement.

Although agency officials deny that the handling of Marleny's case is representative, critics say stories like Marleny's underscore an all-too-common failure by both the city and the private agencies that manage the foster cases to either properly care for their most difficult wards -- referred to by the agency as AWOL's -- or keep track of them as they meander through the system.

''They need to change the system for these kids,'' said Alice McLeod, Marleny's last foster mother, adding that her efforts to place the girl in drug treatment or another specialized program were rebuffed by Graham-Windham, the private agency that handled her case.

''The caseworkers need to stay on the cases of these kids that run away, but a lot of the time they don't,'' Ms. McLeod said. ''Often they just sit around and pass them off from foster home to foster home. Maybe now they will change the rules and do something right.''

Two weeks ago, city officials said that a review of Marleny's case records at Graham-Windham shows ''deficiencies in AWOL case practice procedures'' at the private agency, which contracts with the city.

They added that they were reviewing Graham-Windham's current AWOL cases and had received a plan from the agency outlining ways to improve its tracking of runaways.

''The AWOL problem is one that greatly concerns us,'' said Leonora Wiener, a spokeswoman for the Administration for Children's Services, which says it has no way to calculate how many children in its care run away. ''We are doing what we can to help reduce AWOL's.''

Although the city would not provide details of Graham-Windham's plan, and the private agency forwarded all inquiries to the city, a city official who spoke on the condition of anonymity said that it calls for caseworkers to communicate regularly with the police when a child is missing, a practice not now in use.

City and law enforcement officials say such weak links in oversight may have contributed not only to Marleny's remaining missing for more than eight months, but also to the police's inability to link her name to the body they found shortly after her disappearance.

''We found a body but didn't have a record of a missing person coinciding with it,'' said Sgt. Nick Vreeland, a Police Department spokesman. ''We were lucky to have ever identified her.''

Hopes for a Better Life Are Quickly Dashed

This final calamity was but the last of many to befall Marleny, according to police records, as well as interviews with the girl's family, friends and foster parents.

Marleny's life began to unravel almost from the moment her mother sent her to the United States, hoping to give her child a better life than her native Dominican Republic could provide. It was the end of 1993, shortly after the child's ninth birthday, and her father had agreed to take her in at his home in New Jersey.

But about six months later, Marleny abruptly returned to her mother after telling her great-aunt, Maria de la Cruz, that her father had been sexually abusing her, the police said. It was a claim that Marleny would make often in the years to follow, both to friends and to the authorities. While the charges were investigated, they were never substantiated, police records show.

The girl returned to New York on Sept. 15, 1994, moving into Mrs. de la Cruz's apartment in the Bronx and waiting for her mother to join them. But a few months later, Marleny received word that her mother had been killed in a car accident.

At the graveside, Marleny found out from other relatives that her mother had actually been shot to death during an argument over drugs.

''She was depressed and she cried,'' said Mrs. de la Cruz, adding that Marleny's depression concerned her so much that she began sending her to a therapist. ''She asked why there were bad people in the world.''

Truancy, Thievery And Suicide Attempts

But after five months, Marleny refused to go. As more time passed, the girl who once loved to dance to flamenco music with her aunt became sullen and distant. By 1997, according to police records, Marleny, then 13, had stopped going to school and had begun to steal from her aunt.

She also began running away, and was hospitalized after several attempts at suicide. Mrs. de la Cruz looked to the Administration for Children's Services for help. ''I decided that I couldn't continue like this,'' she said.

However, Marleny's problems remained after she was placed in the Graham-Windham group home in Hastings-on-Hudson, N.Y., six months later. Most noticeably, she continued to run away, an administrator of the home said. He said the plan was to place her in foster care as soon as something opened.

Marleny did not wait. Friends said that in late September, she ended up at an apartment in Yonkers and found what would prove to be one of the few bright moments in her short life.

Alecia Lawrence, 16, had gone to the apartment to see friends and noticed Marleny in the corner. They began to talk, Marleny pouring out her childhood and crying that no one cared whether she lived or died.

''She was this abused kid being shipped from home to home, who didn't really care about herself and didn't think anybody else did, either,'' Alecia said. ''But something was telling me to bring her to my house. All she needed was love.''

Marleny followed Alecia home, and soon the two girls were inseparable, singing in the bathroom to rhythm and blues artists like Mary J. Blige and hanging out so much together they became known, with two other girls, as the Four Musketeers.

Alecia's mother, Angela, decided that she should try to keep the child and possibly adopt her. But when she inquired about it, Mrs. Lawrence said, the agency told her it would be impossible because she had not been licensed as a foster parent; police documents in the case support her assertion. Mrs. Lawrence said the agency also discouraged her from adoption, saying the process was too long and cumbersome.

''I was going to keep her,'' said Mrs. Lawrence, whom Marleny called Mommy, ''but they said there would be too much red tape.''

Graham-Windham took Marleny away in the middle of December, placing her instead in the care of Aggie Johnson, a foster parent in the Bedford-Stuyvesant section of Brooklyn.

Just two days later, the girl vanished after borrowing money from Mrs. Johnson. Although police officers later found the child huddled in a Bronx stairwell, Mrs. Johnson said that the agency never told her and instead transferred the girl to yet one more foster home, Mrs. McLeod's.

Mrs. Johnson said she did not know what happened to the girl until she read news stories in October about her body being identified.

''It is one sad story after another,'' said Marsha R. Lowry, the director of Children's Rights, a nonprofit child-advocacy group that is suing the city over what it says is chronic mismanagement.

''Youngsters are simply placed wherever there is an open bed, with no particular care about the child's needs,'' Ms. Lowry said. ''This is especially true when they are teen-agers, who are just written off.''

Leaving on an Errand, Never to Return

For Marleny, Mrs. McLeod's home would be her last stop in foster care. Last Jan. 29, as had been the case so often before, the girl left on an errand and never returned. Mrs. McLeod said she reported the girl missing the next day and called the agency for months to see whether Marleny had been found. She was worried because Marleny was a fragile girl, easily impressed by older men in the neighborhood and often addled by drugs.

Officers in the 46th Precinct in the Bronx found the child at the home of Clara Cabreja, a friend of Marleny's mother, on Feb. 6. They then called Graham-Windham to report finding her and closed the case, the police said. But Graham-Windham maintained that it did not receive the call, city officials said.

In either case, workers at the agency never retrieved the girl or checked on what they wrongly assumed was a continuing police investigation into her disappearance, said the officers, who spoke on the condition of anonymity. Marleny simply left the woman's home after a day or two and vanished forever from the foster care system set up to protect her.

Mrs. Cabreja said she did not report the child missing because Marleny often came by, but rarely stayed long. When Marleny did not return, Mrs. Cabreja said she assumed that the child was back at her foster home.

On Feb. 23, police officers found the body of a sexually abused and beaten girl near Valentine Avenue and 183d Street. The body was taken to a city morgue, where it remained unclaimed for two months, until a family said it was their missing daughter's.

The family was holding a wake when Bronx detectives showed up at the funeral home and told them that the young girl was not theirs; their daughter was in fact alive.

With no other leads on their Jane Doe, detectives began to sort through school records of more than 500 habitual truants and then began showing a picture of the body to every foster home in the Bronx, the police said.

In late October, detectives knocked on Mrs. McLeod's door and showed her the photograph. It was not the pretty girl she had remembered leaving her home that day in her favorite blue plaid shirt and jeans, the one with the bronzed complexion, the dark curls and the ready smile. But it was Marleny Cruz.

''If she had stayed with me long enough, she would have realized that someone cared about her,'' Mrs. McLeod said.

''She was a sweet person who just got caught up in the system, like a lot of children out here,'' Mrs. McLeod said. ''If someone had been there for this one, she might still be alive.''

Marleny Cruz, who friends said most feared being unloved and unknown, now rests in an unmarked grave in Monmouth County, N.J.

By KIT R. ROANE  , Published: November 30, 1998

In 1988, Jessica Cortez, a 5-year-old Brooklyn girl, was found dead of a broken neck in her mother's apartment. The authorities discovered that she had been sexually abused and beaten over months.

In that case, too, child welfare officials had known for years the children in Jessica's family had been abused. But a Family Court judge awarded Jessica's mother custody of her children without being told of any past allegations of child abuse. At one point, two different caseworkers, unaware of each other, were investigating the family. Deaths Despite Efforts

Child abuse experts say that about half of the children who die of abuse in the United States are known to child welfare officials before they are killed. Last year in New York City, 105 children died. Forty-two were known to welfare officials.

 Man Is Given 22 Years In Girl's Beating Death

LEAD: A Brooklyn man was sentenced yesterday to 22 years to life in prison in the death of Jessica Cortez, a 5-year-old girl who was found savagely beaten in a Brooklyn apartment last year.

A Brooklyn man was sentenced yesterday to 22 years to life in prison in the death of Jessica Cortez, a 5-year-old girl who was found savagely beaten in a Brooklyn apartment last year.

The man, Adrian Lopez, 27 years old, of 300 Bushwick Avenue, remained silent during the sentencing before Justice Ruth Moskowitz in State Supreme Court. Mr. Lopez pleaded guilty last month to charges of murder, assault and endangering the welfare of a child.

Jessica was found near death in the apartment in the Williamsburg housing project in the Bushwick section on Dec. 14, 1988. She died a short time later, suffering from a broken neck, a fractured arm and other injuries.

She was the daughter of Mr. Lopez's girlfriend, Abigail Cortez, 25, also of 300 Bushwick Avenue. She is to be tried this month on charges of murder, manslaughter and endangering the welfare of Jessica and her son, who was also found beaten and is now in foster care.

Mother Seized In Slaying Of 5-Year-Old

 

 

The 6-year-old boy asked the prosecutor, Deborah Seidenberg, to turn off the lights. Then, she said, he climbed into her lap and told how his father, Rufus Chisolm, fatally beat his 5-year-old brother, Adam.

The thrashing started when the boys' father caught Adam horsing around with his brothers on the bed. Adam fled to the kitchen, where his mother, Michelle Mann, told the father that Adam had broken a household rule by eating a piece of her Entenmann's cake.

Enraged, the father beat Adam again. The mother did not try to stop the abuse, the brothers told the prosecutor, but yelled at Adam that he was bad. Later that day, March 5, 1990, Adam died, his head bashed and his liver split in two.

After his death, Adam's parents went to prison and his brothers were scattered to foster homes. Now, more than four years later, the brothers are still in foster care, despite Federal and city policies that say children should be returned to their parents or put up for adoption within 18 months of entering the system.

While Adam's short life and brutal death became the subject of a 1991 PBS documentary and a national symbol of New York City's failure to protect children from abuse in their own homes, advocates for children say the brothers' long stay in foster care is symptomatic of another problem: the child welfare system's failure to find stable, permanent homes for children once the abuse stops.

And for the three brothers, the consequence may be their eventual return to their mother, who just finished serving four years of a two- to six-year sentence for assault, for beating two of the childen with a belt, then using cocoa butter to try to make the scars fade.

Thousands of children spend years in foster care, caught in a bureaucracy that often fails to provide services needed to reunite them with their parents or to establish the legal grounds for terminating their parents' rights.

Many are children of drug-abusing mothers, torn between foster parents who have raised them from birth and mothers trying to get their lives back on track. Because the choices are so hard, child-welfare authorities often let their cases slide for years, experts say.

But the situation for Adam's brothers was far more remarkable. Despite years of bone-cracking abuse the boys suffered, despite the glare of publicity Adam's case attracted, and despite the successful prosecution of both parents for child abuse, advocates for children say the city has since stumbled badly in assuring the surviving boys a secure, safe home. Planning Children's Return

For two years after Adam's death, the city continued to plan for the childrens' return to their mother, though city officials knew that the children had endured abuse dating back to 1983 and that efforts to rehabilitate Ms. Mann with social services in 1984 and 1986 had not worked. The family had been reported to city authorities 10 times between 1983 and 1990, when Adam died, city records show.

Finally, in 1992, all the parties involved with the family -- from psychiatrists to caseworkers to lawyers -- concluded that the children should be placed for adoption. But the fragmented, complexly layered bureaucracy was excrutiatingly slow to carry out that decision.

By the time the first court hearing was held on terminating the parents' rights this year -- almost four years after Adam's death -- the mother was out of prison. The city's Child Welfare Administration recently changed course again. It withdrew its petition to take away the parents' rights and restored the plan to return the brothers to their mother. The father, who pleaded guilty to manslaughter in Adam's death, is eligible for parole in 1997.

Officials at the Child Welfare Administration declined to comment on the reasons for the delays in moving the brothers toward adoption, citing state confidentiality laws.

But in court papers, the city says it is no longer trying to take away the parents' rights to the children out of respect for the wishes of the brothers themselves, who are now 10, 12 and 13 and say they do not want to be cut off from their mother. City officials say it is unlikely the boys will return to the mother soon, but they don't rule it out in the future. Mother Denies Abuse

Despite her guilty plea, the mother now denies that she ever abused her children. She has told caseworkers and her lawyer that she herself was severely battered by Mr. Chisolm, Adam's father, and that she never went beyond controlled spanking of her children.

"Michelle needs to get her act together first before regaining custody of the children," said her lawyer, Mitchell Dinnerstein. "She's mature enough to realize that she's not ready immediately."

But civil liberties lawyers who sued the city over its handling of the case said that because of the severity of the abuse and the long prison terms facing the parents child welfare officials should have moved quickly after Adam's death to terminate the parents' rights and to find adoptive homes for the children.

"If they can't even deal with this high-profile case properly, what does that say for other abused and neglected children in city custody who don't receive the same type of media attention?" said Robin Dahlberg, a lawyer with the Children's Rights Project of the American Civil Liberties Union. "The failure to move forward with adoption is a symptom of the bureaucratic and administrative chaos that pervades the Child Welfare Administration."

The A.C.L.U. sued the city after Adam's death, charging that it failed to protect the children from their parents, and is seeking $3 million from the city on their behalf. The suit is still pending. The Children Boys Show Scars Of Years of Abuse

As deputy bureau chief of the child abuse and domestic violence unit of the Bronx District Attorney's office, Ms. Seidenberg said she had seen many horrible cases, but what happened to Adam was unusually cruel.

His brothers told her that they were not supposed to drink their father's juice or eat their mother's cake -- rules that Adam did not always follow. The parents picked on Adam and padlocked the refrigerator to keep him out, the children told her. When he died, Adam had had nothing to eat for a couple of days, the autopsy found, and his body was scarred from previous abuse.

"When I asked the boys why there was a lock on the refrigerator, they said, 'Because Adam is bad and he tried to take food,' " said Ms. Seidenberg, who is now in private practice. "When the police opened the freezer, the steaks fell out. It was packed with meat." 'I Saw the Guilt'

Adam's brothers, then 6, 8 and 9, were traumatized by his death. "I saw the guilt in these kids," Ms. Seidenberg said. "They felt like Adam was blamed for what they did. I'm not even sure Adam ate the cake."

After Adam's death, the city placed his siblings in a foster home through a private, nonprofit agency, St. Joseph Services for Children and Families. But the boys were too agressive and disturbed for one family to handle, and they were split up. The oldest went to a residential treatment center for emotionally disturbed children. St. Joseph's placed the two younger brothers in separate foster homes.

A baby sister, who bore no physical signs of abuse, was also placed in foster care, and unlike her brothers she is still on track to be adopted.

Doctors said the three boys suffered from post-traumatic stress disorder.

"They couldn't function in school," Donna McFarlane, their caseworker at St. Joseph's later wrote, "and almost every week they would be suspended from school."

In the summer of 1991, more than a year after Adam's death and several months after his parents had entered their guilty pleas, St. Joseph's and the Child Welfare Administration reviewed the Mann case and decided to persist with the original plan to return the children to their mother. Case records offer no specific reasons for this decision.

The brothers began to visit their mother once a month in prison. Caseworkers and therapists reported that Ms. Mann did not seem close to her sons and that sometimes the visits profoundly upset the children. "They didn't go up to her," said one caseworker, Maria Rios. "They didn't miss her."

In July 1992, more than two years after Adam's death, city officials met with the childrens' therapists, caseworkers and lawyers. Everyone present agreed that the parents' rights should be terminated, case records show.

The St. Joseph's caseworker, Ms. McFarlane, said in a deposition that she was convinced at the time that the children would be abused again if released to their mother. She wrote in her July 1992 report that the mother "is in complete denial about the horrible events of the past" and that "she has never for once accepted responsibility for what happened."

"The reality of the matter is that a child died and both parents were part of it," Ms. McFarlane wrote. "The children are not bonded" to Ms. Mann, she added. "They need stability in their lives and at this point adoption appears to be in their best interest." The Bureaucracy Paperwork Delays Steps to Adoption

The childrens' foster parents were then interested in adopting them. Ava Lampert, the middle brother's therapist, wrote that his foster parents had helped "to change him from the very frightened, grieving, confused and quite unstable little boy to the decent, nice, stable, bright and warm child that he is today."

But the paperwork to move the children toward adoption traveled slowly through the bureaucracy. Not until February 1993 -- seven months after the meeting at which everyone agreed the boys should be placed for adoption -- did Ms. McFarlane formally ask the city to change the children's goal to adoption.

It had taken three years for the city to take the first step to have the children adopted, twice as long as Federal policy says it should have taken.

Ms. McFarlane blamed the Child Welfare Administration for the delay. She said that city officials insisted on more meetings with the childrens' therapists before acting. Finally, she said, she sent the paperwork on without the the city's go-ahead. Ending Parents' Rights

After Ms. McFarlane sent in the paperwork, it took three more months -- until May 1993 -- to approve the switch to adoption. And it was not until September 1993 -- three and a half years after Adam's death -- that city officials actually went to Bronx Family Court, seeking to terminate the parents' rights.

The first hearing on the case was not held until January, and it was adjourned because the father was not present.

Then in March, the mother got out of prison. The next month, the city and the children's Legal Aid Society lawyers asked for another postponement of the court hearings to talk to the brothers about whether they wanted to be adopted.

The passage of time itself had an effect on the adoptive prospects of the children. After years of visits with their mother and of living in foster homes, the two younger boys were ambivalent and confused about adoption, according to reports from psychiatrists. Only the oldest boy, now 13, said unequivocally that he wanted to live with his mother.

All the brothers are still emotionally scarred by the years of abuse they endured and witnessed, the doctors said. The youngest brother has had a particularly rocky time in foster care. His first foster mother died of cancer seven months after Adam. His second foster mother asked that he be removed from her home because his behavior was unmanageable, records show. Last summer, he ran away and lay in the middle of a busy street.

One of the psychiatrists who evaluated the children, Myles S. Schneider, said cutting the children off from their mother now "would exacerbate their already profound problems with anger." The Mother A Victim of Abuse Looms as a Threat

The biggest question mark is the mother herself. Will she ever be able to care for her sons? And what will happen when the father of her children gets out of prison?

She herself grew up in foster care and told doctors that she had been a victim of physical and sexual abuse since she was a child. She gave birth to her first son at age 16 and began living with Mr. Chisolm when she was 17. She says she was brutalized by him until she went to prison, and doctors say she still suffers from major depression and post-traumatic stress disorder.

Her lawyer, Mr. Dinnerstein, said she felt safe for the first time in her life in prison and is terrified Mr. Chisolm will come after her when he gets out of prison.

"She was a severely battered woman," Mr. Dinnerstein said. "The abuse of the children was a result of Rufus's conduct to them. She has acknowledged throughout that she was unable to protect her children from his violence." Courting Disaster

The civil liberties lawyers say that the city's plan to return the children to their mother would court disaster. But they have been unable to persuade the city to set a goal of long-term foster care for the younger sons that would still allow them to see their mother, while assuring they are not returned to her.

They are not contesting the plan to return to oldest brother to his mother because he will soon be 14, the age at which he is legally entitled to a say in where he lives.

"The city is now free to return the children to their mother at its discretion," said Ms. Dahlberg, the A.C.L.U. lawyer. "And the nationally recognized policy that kids should have permanent, secure and safe families apparently has not reached New York."

But Grace Goodman, a lawyer in the city Corporation Counsel's office, said the city decided to withdraw the legal petition to terminate the parents' rights, approved in June by Judge Marjorie Fields of Bronx Family Court, so the children can continue seeing their mother, as they wish.

In court papers, Ms. Goodman described the likelihood that the boys will be returned to their mother as "extremely remote." But in a recent interview, she was less definite. "It certainly won't happen soon," she said, "but I can't tell you how long soon is."

 

 

When it came to what was best for Lindsey Beth Ochoa, there was no dispute. The caseworkers, the family, the district attorney and the judge all agreed the 2-year-old girl should go home to her mother.

But there was one warning. Everyone - from the child abuse investigators who initially removed her from the abusive home to the counselors who tried to help her mother be more protective to the district judge who eventually reunited mother and daughter - said Gene Maselino DeLaCruz should ...Read more ....

 

In 1986, Shulamis Riegler beat her 8-year-old son Israel so badly that he was hospitalized in a coma. Doctors noticed human bite marks on his shoulder.

When the boy recovered, he and his two little brothers spent several years in foster care before going home in 1988 and 1989.

Then, barely a year later, Mrs. Riegler beat another son, Yaakov. She twisted his leg so viciously that she heard his thigh bone crack. The retarded boy, 8 years old, 3-feet-8 and 48 pounds, was taken to the hospital in a coma and never woke up. Known as Abusive

Yaakov was one of seven children who died in 1990 after repeated beatings and whose families were known to New York City's child welfare system as abusive or neglectful, a recent city report found.

In the report, the only public accounting of how the city's Human Resources Administration handled such cases, Yaakov was an anonymous statistic, unnamed because of strict state confidentiality laws that protect the privacy of informants and families, even, as in Yaakov's case, when the mother has pleaded guilty to killing her child. Mrs. Riegler is to be sentenced today to 7 1/2 to 15 years in prison.

Yaakov's story, pieced together through interviews and medical, school and court records, is about an affectionate if sometimes demanding boy, who could speak only in monosyllables, but whose bruises and broken bones would later tell of his pain. It is about a mother who married at 19, had children quickly and was overwhelmed by the unending tasks of homemaking. Agency's Scattered Work

And it is about a child welfare system that was unable, despite repeated warnings, to help the child. The work the agency did was so scattered and uncoordinated that at one point a city worker was ending the supervision of Mrs. Riegler -- because she had supposedly learned to be a nonviolent parent -- on the same day that another worker was investigating a new report that Yaakov was being abused. And confidentiality laws also played a part, preventing Mrs. Riegler's probation officer from finding out about new reports of abuse in her home.

Lastly, it is a story about a pediatrician who, though he knew of Mrs. Riegler's abusive history and was called on several times to treat Yaakov's wounds, said he recognized in the Riegler household only a harried mother, not a battered child.

When Mrs. Riegler pleaded guilty in State Supreme Court in Brooklyn last month, Judge Francis X. Egitto condemned the city's child protection system -- a system whose goal is to reunite children with their natural parents whenever possible -- and the boy's doctor for not saving Yaakov's life.

"It's not just Mrs. Riegler who is guilty of the death of Yaakov," the judge said. Birth 'Confidentiality' For the Mother

Yaakov Riegler was born on July 1, 1982, the third son of Moses and Shulamis Reigler. The family lived in the insular Orthodox Jewish world of Borough Park, Brooklyn.

Mrs. Riegler had trouble coping with the demands of raising and disciplining her boys, she later told a psychiatrist. Sometimes she lost her temper and struck them.

Yaakov was almost 4 when she beat her eldest son, Israel, so harshly that he arrived at Maimonides Medical Center unconscious. Medical records show that his body was covered with bruises and that he had burns in various stages of healing on his face, back and arms.

"The child is not so good on his feet and he falls a lot and could have hit his head," Mrs. Reigler told the hospital social worker at the time.

But later that year, Mrs. Reigler pleaded guilty to attempted assault and was placed on five years probation, with a requirement that she receive psychiatric treatment. Her children were sent into foster care. The two oldest, Israel and Zelig, 6, were sent to live with an uncle by the Ohel Children's Home and Family Services, a private foster care agency under contract with the city. Yaakov was sent to a home that cared for retarded children.

Mrs. Riegler regularly attended appointments with a Manhattan psychiatrist, Arthur Cronen, and began visiting her children in late 1987.

Dr. Cronen said Mrs. Riegler had very little self-confidence and a troubled marriage. "She had no pressure valve, no place to ventilate," he said. She told the doctor she felt that her husband undermined her when she disciplined the children: when she tried to get the boys to bed, her husband would say, "Oh, don't listen to her."

Dr. Cronen tried to get Mr. Riegler to come for counseling, too, but after the first few sessions he quit, saying his back hurt. So Dr. Cronen concentrated on teaching Mrs. Riegler how to control her temper. She seemed to be improving, he said, and did well on extended visits with her children.

Between September 1988 and September 1989 Mrs. Riegler got her children back one at a time, Yaakov last. She also gave birth to a boy, Ben-Zion. And she stopped seeing her psychiatrist. Her last face-to-face session with Dr. Cronen was in March 1989. After that, they only chatted occasionally on the phone. "It seemed O.K.," Dr. Cronen recalled. "She said things were fine." School Beloved Aide Grows Suspicious

When Yaakov came home, he was enrolled at Public School 205. He was happy with simple things: playing with construction paper, saying his colors out loud. He doted on Jo Anne Pesce, a teacher's helper in his class.

"He always wanted to hold my hand," Ms. Pesce said.

But just a month after school began, Ms. Pesce began to notice that Yaakov was bruised. One day, he pointed to his chest and said, "Boo-boo." She lifted his shirt and saw bruises on his chest and back. Later, she said, she saw an impression of fingernails on his cheek. Another time, the skin above his right ear was bruised and cut.

Worried, Ms. Pesce went to the school guidance counselor, Elizabeth Lantiere. Mrs. Reigler's explanation was that Yaakov had fallen down on the kitchen floor.

Mrs. Lantiere, unaware of Mrs. Riegler's history of abusiveness, was uncertain what to do. The boy was difficult to understand. He had brothers at home. Maybe they fought, Mrs. Lantiere told herself. 'I Didn't Think of This'

"Jo Anne was most worried," Mrs. Lantiere said. "She kept pestering me. But I didn't think of this kind of abuse from the mother."

Nonetheless, on Nov. 27, 1989, Mrs. Lantiere called the state child abuse line. Her report stated only that there were marks on Yaakov's face, ear and back.

The case was assigned to a city child abuse investigator, David Schwartz, who had been hired eight months earlier -- one of hundreds of caseworkers hired to handle an exploding number of abuse reports.

Mr. Schwartz went to the school the day after Mrs. Lantiere called. Ms. Pesce said she lifted Yaakov's shirt to show Mr. Schwartz the marks on the boy's back. "He was shocked," she said.

But that same day in Family Court, the Human Resources Administration, apparently unaware of the new investigation by one of its own workers, asked a judge to approve a final return home for the Riegler children and end its supervision of the family. Judge Did Not See Yaakov

Ohel, the agency that the city had assigned the case, recommended that the family be reunited. Yaakov was not present in court where the judge could have seen his bruised face. School officials said no one from Ohel ever contacted them to ask how Yaakov was doing. Lester Kaufman, Ohel's executive director, said he could not comment because of confidentiality.

Days after the abuse report was filed, Yaakov disappeared from school for virtually the entire month of December and much of January. On Feb. 7, 1990, the school attendance officer called the boy's home. Mrs. Riegler told her that Yaakov "is sick til further notice," a school log shows.

Mrs. Riegler's peremptory tone aroused the school's suspicions. A week later, Mrs. Lantiere's records show, she called Mr. Schwartz and left a message that Yaakov had been absent too much. The school's truant officer went to Yaakov's home. Mrs. Riegler told him over the intercom that Yaakov had an ear infection. The records have no further details on the incident, and it is unclear whether the truant officer insisted on seeing the boy.

During this time Mrs. Riegler was also on probation for Israel's beating. But in March 1990, a year and a half before her five years probation were up, the city's Probation Department moved to end its supervision. Such early releases are not unusual when the person on probation keeps appointments and the department learns of no new problems. Twice, her probation officer had asked Human Resources for any reports that the mother had again abused her children, and was told the information was confidential. Trouble Throwing a Ball

On March 5, Yaakov briefly returned to school and his teacher noticed he was having trouble throwing a ball in gym. His right elbow was swollen and bruised. School records show that the teacher called Mrs. Riegler, who said she hadn't noticed anything, but would take Yaakov to a doctor.

An autopsy after his death found signs of a partly healed broken right elbow, which may never have been treated.

On March 15, 10 days after the school noticed the swollen elbow, Mrs. Reigler took Yaakov to the family pediatrician, Max Bulmash. The doctor said he noticed nothing wrong with the boy's elbow. "Unless I'd put him through the maneuvers of ball throwing," the doctor said recently, "I would not have noticed that."

Yaakov did have a scrape on his forehead. Dr. Bulmash said Mrs. Reigler told him that Yaakov had walked into a wall -- an explanation that the doctor said he found plausible. Yaakov was a clumsy child who bumped into things, the doctor said -- a description of the boy that school officials dispute. A Reminder to Call Welfare

A handwritten note at the bottom of Yaakov's chart that day includes a reminder the doctor wrote himself to call city child welfare workers. Dr. Bulmash said he did not suspect abuse, but did think Mrs. Riegler was having trouble coping with Yaakov and needed homemaker services.

"He was a lovable child, no question," the doctor said. "He was responsive to human touch, but he needed care like an infant. He frequently soiled himself and got into things."

Dr. Bulmash said that some time before Yaakov's death, he had heard that Mrs. Reigler had beaten one of her other sons. He had also talked with the city investigator, Mr. Schwartz. At one point, Mrs. Reigler called him while Mr. Schwartz was at her home, complaining that the investigator was snooping around. Mr. Schwartz told the doctor over the phone that he had found no problems, Dr. Bulmash said.

Mr. Schwartz declined to speak about the case.

The doctor said he never saw any signs of abuse on Yaakov, nor did he ever call the state child abuse number. Crisis Putting Off Frantic Teachers

Yaakov's absences from school began again, starting two days before he went to see Dr. Bulmash and lasting for two solid months, until May 15. During that time, the school again called the child abuse line to report the absences.

On May 21, 1990, just a week after Yaakov finally returned to school, Ms. Pesce noticed that his right cheek was bruised. Again, she took him to Mrs. Lantiere's office. The counselor took out dolls. When she asked who had hurt him, the boy picked up the female doll and said, "Mommy boo-boo."

Two days later, Mrs. Lantiere got in touch with Mr. Schwartz, the investigator, to let him know Yaakov was back in school and still bruised. 'Used to Make Me Crazy'

"Mr. Schwartz used to make me crazy," Mrs. Lantiere said. "The teachers were begging me every day to call and find out. He never said anything concrete. He would say, "We're looking into it. We're aware of it."

The next day, Mrs. Riegler again took Yaakov to see Dr. Bulmash. The doctor said he saw no suspicious bruises. "I always undressed him entirely," he said. "I never noticed anything."

That day, Dr. Bulmash gave Yaakov stiches for a cut near his eye. The mother told him her son had cut himself with scissors at school. "The explanation was plausible and didn't seem suspicious," the doctor said. "But I thought a child like that shouldn't be handling scissors."

He said Yaakov's eye might have been bruised, though he made no note of it. "A cut near the eye will settle blood around the soft tissue of the eye," he said. Oozing Gash on Head

A month later, on June 20, Yaakov's teacher noticed an oozing gash on top of his head, which was "severely bruised." Mrs. Lantiere called Mr. Schwartz's supervisor, Harold Damas. He promised to look into it, she said.

That same day, Mrs. Riegler took Yaakov to see Dr. Bulmash. The doctor's chart notes "a wound on back of head." The mother "denied knowing how it happened," he wrote. "I elected to treat with Bactoban."

A week later, Mrs. Lantiere called Mr. Schwartz again. School was almost out for summer, and she wanted to be sure Yaakov was safe. He assured her that the city was referring the family to the Ohel agency.

She sighed in relief, only to learn later that the children remained in the home without Ohel's supervision. Death A Month of Signs And Excuses

The next school year began ominously. On Sept. 13, Yaakov's teacher noticed a burn under his right eye. The next day, Mrs. Lantiere was on the phone to Mr. Schwartz, asking him to find a home for Yaakov "where he will not be getting hurt all the time," her notes say.

Sept. 18: Yaakov is black and blue on his chest, his hip, along his spine and close to his collarbone.

Sept. 19: "Yaakov is walking strangely. His left knee gave way while walking up the stairs." At lunch time, he was "extremely frightened of water," school records say. "He screamed and his whole body was trembling."

Sept. 24: He had scratches on the left side of his neck and a bruise on his cheek and forehead. He had fingerprints on his neck.

"I was frantic," Mrs. Lantiere said.

Sept. 25: Mrs. Lantiere called Mr. Schwartz again.

Sept. 26: She went over the investigator's head and called the state child abuse line, the third such report made by the school. Appeared to Be Burn Marks

The next day, another H.R.A. investigator, Keith Glascoe, visited the Riegler home. He later told a hospital social worker that he had seen what appeared to be burn marks on the boy. Yaakov told him that both his mother and father had hurt him, but that his mother hurt him more. Mrs. Reigler's explanation was that Yaakov always fell and hurt himself.

Mr. Glascoe visited the school and told the principal, Philip Tritt, that he was having trouble finding an Orthodox Jewish foster home for Yaakov.

Sept. 29 was Yom Kippur, the holiest day of the Jewish year, a day of atonement. Yaakov stayed home with his mother while his father and older brothers went to temple.

Mrs. Riegler was pregnant with her fifth child, and felt sick. Yaakov had diarrhea and soiled himself several times. Mrs. Riegler had to clean up after him repeatedly. She later confessed in court that she "lost control" and beat Yaakov. His head hit hard against the wall.

The comatose boy was taken to Maimonides, where his brother had been treated four years earlier. Mrs. Reigler blamed Yaakov's injuries on his clumsiness, just as she had with Israel. She told a hospital administrator that she was praying in the dining room when Yaakov fell.

The mother, dressed in a nightgown, sat talking with Dr. Bulmash, who had came into the emergency room looking "white" and very upset, the hospital social work report stated.

"I did not push him!" hospital workers heard her shout.

On Oct. 14, 1990, Yaakov died.

In a subsequent trial of the parents in Family Court, it took a medical examiner almost an hour just to describe the bruises on Yaakov's arms. Epitaph Mild Punishment, Much Secrecy

Postscript: Yaakov's death led to new calls by the city's Probation Commissioner, Catherine M. Abate, to ease confidentiality laws. New legislation is pending.

Dr. Bulmash is under investigation by the Brooklyn District Attorney's office, which is trying to determine whether he violated laws that require doctors to report signs of child abuse to the state phone line.

H.R.A's child fatality review panel recommended that the agency report Dr. Bulmash to the state Office of Professional Medical Conduct, but was prevented from doing so by the agency's lawyers, who said confidentiality laws forbade it.

Mrs. Riegler's probation officer, Yvonne Hernandez, who was carrying about 160 cases at the time Mrs. Rieger's probation ended, was mildly disciplined for sloppy record keeping. Her supervisor agreed to early retirement after an internal investigation of the case, probation officials said.

The abuse investigators, Mr. Schwartz and Mr. Glascoe, as well as their supervisor, are still working in the same Brooklyn office. H.R.A. would not say whether they were disciplined, citing confidentiality.

Mr. Riegler pleaded guilty to failing to stop Yaakov's abuse and is on probation. Yaakov's brothers are living with an uncle.

 By CELIA W. DUGGER ,Published: February 10, 1992

Desi Irving was conceived on a chilly February night when her mother exchanged sex for booze with a man she barely knew.

Months later, in the throes of labor, Mildred Irving would pull a sheet over her face to avoid seeing the baby she said she couldn't love and planned to put up for adoption. No one wanted to hear that.

Two years later, it seemed no one heard Irving's plea for help after she admitted abusing Desi to at least two women, even showing them the welts her whippings had left on the toddler's back and the marks the metal of her ...

Desi Irving died Feb. 6 from a beating by her mother's hand. An autopsy revealed that Desi had than 100
scars and bruises nearly covering her body. She had been burned with cigarettes and lighters. She had
suffered 12 bone fractures, including both her legs and her pelvis. A broken upper arm had calcified,
"essentially turning it into stone", according to the autopsy report. Mildred Irving was sentenced to 40
years for killing 3- year-old Desi.

He had been demonstrating ''inappropriate behavior,'' the authorities said, and two health workers were restraining him. A few minutes later he was dead.

The State Medical Examiner said Andrew died of traumatic asphyxiation and chest compression. But now the police and several state agencies are seeking answers to these larger questions: whether it was necessary to restrain Andrew, whether the restraint method was properly applied and whether the state should prohibit the restraint hold that was used.

Vincent J. Trantolo, a lawyer for Andrew's mother, Lucinda McClain, puts it more simply. He wants to know why Andrew died.

''My client asked me to do two things: find out what happened to her child and make sure this doesn't happen again,'' Mr. Trantolo said.

Andrew's death on March 22 has already prompted the State Department of Children and Families to look at whether the hold applied to Andrew should be banned. Mr. Trantolo said the hold involved crossing a patient's arms in front of him and holding his wrists from behind.

''It's very clear in this case that something went terribly wrong,'' Linda Pearce Prestley, the state's Child Advocate, said.

Mr. Trantolo said he wonders if Andrew, who was 4 feet 6 inches tall and weighed 90 pounds, should have been restrained to begin with. He said that the Portland police, who are conducting the criminal investigation, told him that Andrew was screaming and disobeying orders when he was restrained, but that he was not kicking or biting or slapping.

''I got the absolute impression that there was no violent behavior at the time,'' Mr. Trantolo said.

The Portland police are not commenting on their investigation.

Advocates for the mentally retarded and the mentally ill say that physically restraining patients is becoming less common, but still sometimes ends in injury or even death. Within the last few months, a boy in Arizona died of oxygen deprivation after being held to the floor by psychiatric workers, and a man died in Cleveland when he was sandwiched between two boards while being transported to a psychiatric hospital, said Ronald S. Honberg, director of legal affairs for the National Alliance for the Mentally Ill.

Kristine Ragaglia, Commissioner of the State Department of Children and Families, said she is setting up a task force to look at whether Connecticut should establish a higher standard on physical restraints.

Officials at Elmcrest Hospital, where Andrew died, are not commenting on this case, but said that the hospital's protocols for restraining patients were followed. The two mental health workers involved in restraining Andrew have been suspended pending the results of the investigation into the boy's death.

But the Department of Children and Families does not have its own regulations on physical restraints. Margaret H. Dignoti, executive director of Arc of Connecticut, an advocacy group for the mentally retarded, said she may fight to get that changed.

Ms. Dignoti said her group lobbied hard for a law, passed in 1994, that required the State Department of Mental Retardation to set strict regulations on which restraints may be used on clients. She said her group may work to have those regulations expanded to other state agencies.

''I'm heartbroken,'' she said. ''This is a little boy. These kinds of things shouldn't still be happening.''

Published: March 30, 1998

 

But despite the hospital's recommendation that the baby and her two older brothers be removed from their mother's custody, no action was taken, said the hospital employee, who requested anonymity.

Yesterday, the mother, Myryam Orellane, 33 years old, was charged with the beating death of her 8-month-old daughter, Ashlei, on Tuesday night.

The case again raises questions about the child welfare system's ability to respond to reports of abuse. Earlier this week, it was revealed in another case that 15 months before her mother and stepfather were arrested on child-abuse charges, school officials had reported their suspicions that a child, Taisha Carter, was being abused.

Sheila Jack, a spokeswoman for the city's Human Resources Administration, said that because of confidentiality rules she could not discuss the case. Charged With Murder

For more than 24 hours after the baby's death, Ms. Orellane insisted that her 6- and 8-year-old sons had beaten and caused the death of her daughter, the police said.

The police said she had rehearsed and primed her sons and her companion to lie to support her story. Finally, visibly relieved, she confessed to the abuse at about 2 A.M. yesterday and was charged with second-degree murder, detectives said. Her two sons were placed in foster care.

Ashlei died less than 12 hours after her mother took her to a clinic at North Central Bronx Hospital for a checkup and 10 hours after a man had called a state hot line with a tip that the child was being mistreated. Hours before the baby died, a child guidance clinic in the Bronx received a tip from a pediatrician who suspected child abuse because of old bruises and healing fractures that Ashlei had.

Officials at North Central Bronx Hospital, where Ashlei was born and where she was hospitalized in August as well as treated on previous occasions, said they had notified the city's Child Welfare Administration about possible abuse, but declined to comment on other aspects of the case. The two sons had also been treated at the hospital, but it was not clear for what.

Ms. Orellane lived alone with her three children in a $600-a-month attic apartment at 4042 Hill Avenue in the Wakefield section of the Bronx.

On Tuesday at about 11 A.M., Ms. Orellane brought Ashlei for a checkup at North Central Bronx Hospital, hospital officials and the police said.

The hospital employee who requested anonymity said everything appeared normal. Ms. Orellane then walked home with her baby. The police believe the abuse took place between 1 P.M and 3 P.M., when she was alone in her apartment with the baby. Her companion came over in the late afternoon and told the police the baby was alert but looked pale, then gradually became less active and began throwing up.

At 8:15 P.M. on Tuesday, the police responded to a report of a child having trouble breathing at Ms. Orellane's address. The baby and her mother were taken to Our Lady of Mercy Hospital, where the baby died just after 10:30 P.M. A nurse's report stated that the child had bruises to the face, stomach, lower back and buttocks and that the mother contended they had been caused by her 6-year-old son.

On Aug. 29, Ashlei was admitted to North Central Bronx Hospital with a bad bruise to her left cheek, the hospital employee said. Though Ms. Orellane told the hospital that her son had hit her, the doctors and nurses treating the infant were suspicious and notified the Child Welfare Administration. The hospital recommended that both the infant and the brother be placed outside the home.

The police also said yesterday that the child had been admitted to the hospital and that it had informed the Child Welfare Administration of the possibility of abuse.

After an investigation, the child welfare agency rejected the recommendation and Ashlei was released from the hospital into her mother's custody on Sept. 10, the hospital employee said.

The employee said he was providing the information to show that the hospital had followed proper procedures.

Under pressure from the Child Welfare Administration, Ms. Orellane called the Astor Child Guidance Clinic, an outpatient mental health center in the Bronx, on Monday, requesting help for her 8-year-old son, said Joan DiBlasi, assistant executive director of the clinic. An appointment was scheduled for next Monday.

At midday Tuesday, the clinic got a call from a pediatrician who said he believed Ms. Orellane was beating her daughter as well as neglecting her. Ms. DiBlasi said she did not know the pediatrician's name or where the doctor was calling from but added that the clinic immediately called Ms. Orellane to reschedule the appointment earlier.

Police slip, child returned

In early October 1994, 20-month-old Antoinette Heath-Tewee and her 3-year-old sister were found wandering their neighborhood while their mother, Roberta Heath, went drinking.

Heath had lost custody of her children before because of neglect, according to federal court records.

The neglect case was assigned to a tribal police investigator, with a report due 30 days later, according to the records. When police failed to submit a report at a Nov. 15 custody hearing, the girls were returned to their mother.

Antoinette and her mother moved in with the family of George Picard Jr., 37, who, according to federal court records, had a history of psychological problems and convictions in tribal and federal courts on assault and weapons charges.

During the next six weeks, Picard slapped Antoinette in the face, punched her in the head and beat her with a military belt and a cane, federal court records say.

Nobody, including her mother, intervened. Antoinette died three days after Christmas.

Picard was charged with manslaughter but pleaded guilty to a lesser assault charge. He was sentenced to 6 1/2 years in prison and has since been released.

Roberta Heath was convicted in tribal court of child abuse and neglect and was sentenced to one year in jail, according to federal court records.

Antoinette's death, like Wynter's, attracted little attention beyond the reservation.

The case of Andres Saragos was different.

Andres died after his legal guardian, Tamera Coffee, left him locked in a car for nine hours on a 90-degree day in July 2000.

Fifteen months earlier, Warm Springs police investigated suspicions of child abuse after seeing bruises under Andres' eyes, according to the boy's medical records, which also say Andres reported that Coffee hit him. Tribal officials say they looked into this report and other concerns about Coffee but could not substantiate them.

The boy's death was widely covered by news media in Oregon. It prompted outrage on the reservation and brought to light significant flaws in the tribes' overburdened child welfare system.

Warm Springs leaders took the extraordinary step of hiring outside experts to help correct the problems.

The resulting report, by the Portland-based National Indian Child Welfare Association, called for a revamping of Warm Springs' approach to child custody issues.

The report has never been made public, but Terry Cross, the group's executive director, said it called on the tribes to strengthen their Child Protective Team, a committee of law enforcement officials, physicians and social workers who are supposed to advise on child welfare cases.

Warm Springs' policies say the team is supposed to coordinate child welfare efforts. On other reservations, such committees act as a watchdog over the various tribal authorities and courts that deal with kids.

The report found the team was "ineffective and on the verge of collapse," according to a summary of its findings. Cross said he recommended that the improvements be made quickly.

Main, the director of tribal Children's Protective Services, said that tribal leaders have yet to act on that portion of the report.

The tribes did try to carry out another recommendation: that agencies improve the handling of abuse reports to make sure all were promptly and fully investigated, so that what happened to Andres would not happen to another child.