TAMPA — Since he was born, Gabrielle Crawford fought his way through multiple birth defects. He was never expected to live past 2. He died last December. He was 8 months old.
On Thursday, the Hillsborough County Medical Examiner's Office called Gabrielle a homicide victim. The state Department of Children and Families called his death another example of the failure of Hillsborough child protectors to avert a tragedy unfolding before their eyes.
Gabrielle was the ninth child in an active case to die in the past two years. No other region in the state has a child death rate as high.
He was a twin born two months premature last March. He had hydrocephalus, a condition known as water on the brain. He endured on a ventilator and a feeding tube, first at Tampa General Hospital and later at a nursing home.
Then in September, the nursing home discharged him with a shunt behind his ear and a feeding tube. He was given to his 33-year-old mother who for more than 10 years had been under state supervision for substance abuse, untreated mental health issues and domestic violence. Her four older children had been taken away.
On Dec. 2, Gabrielle died. He had a broken leg, a broken arm and a bruise on his forehead.
In January, DCF decided not to renew its $65.5 million contract with Hillsborough Kids Inc., the county's lead child protection agency. Eckerd Youth Alternatives, which provides similar services in Pinellas and Pasco counties, will take over in July.
The nine deaths, said Mike Carroll, DCF's Suncoast regional director, "were the driving force to change lead agencies." He said DCF and Eckerd would immediately began reviewing "every single child" under supervision in Hillsborough County, about 2,500 children.
A DCF report that looked into what was done or not done to protect Gabrielle and his twin brother, Micha, found multiple agencies involved in the case and numerous red flags raised for months.
Throughout, the mother, Rosalee Crawford, was under the supervision of Hillsborough Kids. The case involved five case managers and three supervisors.
But DCF concluded: "It does not appear that any adult was a champion for these children."
HKI's director of community relations emailed a response that said, "Hillsborough Kids is deeply grieved that this child died at the hands of a perpetrator."
HKI acknowledged some case management policies weren't followed. It said it was addressing that with its subcontractor agencies and also re-evaluating all cases with young children.
"We are also requiring our providers with cases of newly born children who haven't been removed or added to a dependency case to be brought to the immediate attention of our leadership," HKI said.
In its own investigation of Gabrielle's death, DCF said that since 1999 "there have been 11 abuse/neglect reports received on this family. The investigations have consistently included maltreatments related to substance abuse, physical injury, inadequate supervision and family violence."
Rosalee Crawford's two oldest children were taken from her in 2002. Two more were taken in 2010.
But when Crawford became pregnant again in 2011, no plan was made for taking the newborns, or for placing them under state supervision.
About a month after the births, a case supervisor visited the babies at the hospital for the first time. A case management staffing session under Hillsborough Kids' direction was held two days later.
At the session, the babies were rated at high risk, owing to their poor condition at birth.
The session didn't include the Office of Attorney General, which handles all Hillsborough dependency cases. "Service providers for the mother also were not present," the report said.
After the meeting, a case manager supervisor contacted the Attorney General's Office, which asked for the mother's records. They were never provided, and there was no follow-up.
During a dependency court hearing two weeks later, no mention of the twins was made to the judge.
Court records show that the mother's pregnancy and residence at the Alpha House came to the court's attention in January 2011. But DCF said the actual births and the twins' medical complications weren't revealed to the court until July.
After the March births, both babies were temporarily safe.
Gabrielle was hospitalized. Crawford and baby Micha, who spent almost two months in a neonatal unit, lived at the Alpha House, a shelter for mothers in crisis. There, she and the baby received 24-hour care and she received psychotropic medication.
The crisis arose in September when Gabrielle stabilized. The nursing home then caring for him announced he was ready for discharge.
Crawford was told Gabrielle would have "many medical needs" and would never be able to eat without a tube or sit up by himself.
Alpha House refused to accept him because it wasn't able to care for a baby with such severe medical issues, DCF said. It meant that Crawford would have to leave the shelter, "a key stabilizing force in her life."
Crawford and the twins ended up in an apartment, on their own.
State regulations require babies born into an active case to be entered into the child welfare information system. "Case management failed to meet the intent of this requirement," the DCF report said.
At the same time, caseworkers were trying to reunite Crawford with one of her older children, who was in foster care.
In its report, DCF found that none of those stressful circumstances "was adequately factored into ongoing family or risk assessments.''
"There was an absence of qualitative documentation regarding ongoing casework activities and documentation was inconsistent."
Some of those "inconsistencies": lack of knowledge as to whether Crawford was taking her psychotropic medication; whether she was getting any mental health treatment; whether she was getting tested for illegal drugs.
Caseworkers visited Crawford's apartment twice in October and reported all was well. They made no recommendations for Gabrielle. Crawford said she didn't need any therapeutic services. DCF said most of the documentation relied on what the mother self-reported.
"There is little documentation regarding the necessary actions needed to continually assess their safety and need for service coordination," the report said.
On Dec. 2, 911 dispatchers fielded a frantic call: An infant wasn't breathing.
The call came from Charlotte Tobias, a friend of Crawford's. Tobias had allowed Crawford and her twins to spend the night at her Tampa home. She said Crawford had shown up about 1 a.m. She said Crawford told her she couldn't get Gabrielle to stop crying.
Micha slept in a car seat. Gabrielle lay in a bed between his mother and Tobias. He cried most of the night. He seemed inconsolable. Tobias said he had a large blue mark on his forehead.
Just after 8 a.m., Tobias said Crawford woke her, asking for a light for her cigarette. Gabrielle was lying on his back. Tobias thought he was sleeping. She got up and left the room.
Then she heard Crawford screaming. She found Crawford holding Gabrielle, attempting a crude form of CPR. She said the baby was unresponsive, cold to the touch.
He was dead.
Besides the bruise on his head, Gabrielle also suffered a broken arm and leg, according to Tampa police records.
The DCF report concluded that — similar to previous child death cases — the checks and balances failed.
"It appears individual issues were considered in isolation at staffings, court hearings and by case management staff rather than looking at the whole picture."
Micha, the surviving twin, was placed in foster care the day after his brother's death. Crawford didn't attend a Dec. 4 shelter hearing. She has moved out of her apartment.
Tampa police said Thursday that no charges have been brought against Crawford.
Detectives are still investigating. Her past arrests include a 2008 felony charge of grand theft. Adjudication was withheld.
Robin Rosenberg, deputy director of Florida's Children First, summed up the case this way: "Gabrielle didn't need a 'champion.' He just needed people to do their damn jobs. We have the right to expect that all the child welfare professionals — case workers, supervisors, attorneys and guardians ad litem — will do their jobs every day, for every child.
"That plainly didn't happen here."
John Barry can be reached at firstname.lastname@example.org or (813) 226-3383.