Baby Diella Ludwig ended up dead — her body shaken, her skull crushed — after her father couldn't take any more of her crying.
That she ever ended up in his care, in a filthy house with not even a crib to sleep in, resulted from a string of decisions and oversights by child welfare workers trained to protect vulnerable children like her.
Now that Thomas Ludwig, 26, has been convicted of Diella's murder and sentenced to life in prison, the state Department of Children and Families says it operates differently because of lessons learned from her death.
"Ludwig had a profound impact on practice at DCF," said the agency's regional director, Nick Cox.
Employees there are mindful of "Ludwig violations," he said, and they use sayings such as "closing the loop" and "owning the case" that arose after the infant died Dec. 20, 2008.
Diella and her twin sister, Shyloh, had been born that October to a mother in prison — immediately drawing the intervention of child protection workers for DCF, the Sheriff's Office and private agencies contracted with DCF. At the mother's request, caseworkers sent the babies home with Ludwig, who had no stable home or job, a history of arrests and a previous accusation of abuse.
According to DCF's internal review, the agencies failed to communicate with one another about their concerns in the case. And among all of them, no one took the lead in watching out for the babies.
That gave rise to the idea at DCF of a "case champion."
It's not a bureaucratic distinction, Cox said, not a name on a line at the top of a form.
"It's a culture change," he said. "We're trying to promote that everybody who touches the case needs to feel like they take responsibility for the case. … We need to make sure we know who owns the case at any given time.
"That's what really fell apart in Ludwig."
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On the witness stand last week, Ludwig said he was born in Alexandra, Va., and raised mostly in foster care. He lived in many places — New Orleans, Tampa, Pinellas County — before he and his two siblings were adopted by a devout Christian couple in Port Richey.
Steven Ludwig, an insurance salesman, and his wife, Debbi, a stay-at-home mom, lived in a large home near the water and homeschooled all 16 of their adopted children and one biological child.
The family made news a decade ago when Andrew, one of Thomas' biological brothers, caused such problems that the parents locked him out of the house. He was terrorizing his siblings, flinging picture frames and punching holes into the walls, raising fears that he might hurt the other kids.
Authorities charged the couple with neglect, but in a storm of public outrage, the charge was soon dropped.
Back then, a 15-year-old Thomas tried to explain Andrew's behavior. He recalled seeing him beaten in foster care. "I was basically just like Andrew," Thomas told the Pasco Times. "When we came here, everything changed. We were taught to obey and started fresh."
But as an adult, Ludwig picked up charges of stealing a car, violating probation, cashing bad checks and missing a child support payment.
In 2002, when he was 18 and still living at home, one of his sisters made an allegation against him. That complaint and a related one in 2004 were investigated by DCF and cleared as unfounded.
DCF officials said they couldn't reveal anything about the allegation. Steven Ludwig told the Times last year that he couldn't remember what the accusation was but that it arose from having so many kids living in a crowded house.
Although no charges were filed, investigators recommended that Thomas Ludwig not be allowed around children unsupervised.
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DCF and other agencies had access to all of this information in 2008 when they were deciding what to do with Ludwig's soon-to-be-born daughters. But according to DCF's own review, caseworkers didn't explore whether Ludwig was actually fit to care for them.
Instead, they took the suggestion of the twins' mother, Nicholle West, who had her own history of petty crimes and who had lost custody of her other children because of drug abuse.
"We basically followed the mom's lead on this," said Cox, the DCF director. "The (children were) placed with the dad because he was the dad, and we really did nothing to background him."
From that point forward, Ludwig repeatedly showed troubling signs, and still no one sounded the alarm. He lived in three different places in a little more than a month, and the last home didn't have electricity. He refused to take a drug test and was documented as yelling at the babies and calling them names.
Cox said the circumstances of the tragedy highlighted this sad fact: None of the caseworkers stepped up to take the lead on this case.
"Now we are very, very conscious of who's responsible, who's owning the case … so that we make sure we address the kids' and parents' needs," he said.
Youth and Family Alternatives was one of the agencies contracted with DCF in the Ludwig case. Chief executive officer George Magrill said he could not talk much about the repercussions because of a pending lawsuit filed by Shyloh Ludwig's guardian. DCF settled earlier this year with West for $250,000 for its negligence in the case.
But Magrill offered that the Ludwig family was "one of the most complex situations that we've ever faced."
"We were one of the agencies that was actually advocating for the infants not to be handed over to the father," Magrill said.
The Pasco Sheriff's Office's child protection team also was involved. A spokesman said he couldn't comment because that agency, too, has received notice of a possible lawsuit.
At DCF, Cox said, new employees are indoctrinated with the lessons from the Ludwig case. "Closing the loop" means following up on the elements of a case plan. Talking about decisions in cases — as well as questioning them — is encouraged.
"When we do case reviews, it's all about questions that arose from Diella Ludwig's death," he said. "The child didn't die in vain in terms of the department's practice."
Though the agency has a history of knee-jerk reactions to tragedies, Cox said he thinks the changes resulting from this case will be lasting.
"I think it's had probably as big an impact on our practice as any case has," he said. "From our perspective, it was that significant. What happened there was very, very troubling. The worst thing in the world is to have a death that could have been avoided."
Molly Moorhead can be reached at firstname.lastname@example.org or (727) 869-6245.