Third of three parts
The parents of Jason Warren signed a Department of Children & Families safety plan promising to stop doing drugs. Jason died when he was squashed in bed while both parents were stoned, reports say.
Emanuel Murray's mom signed a DCF safety plan to keep her very violent boyfriend away from the baby. She didn't. Emanuel, flung from a moving car by the boyfriend, was soon laid to rest.
Aliyah Branum's mother promised in a safety plan to avoid using "excessive corporal punishment" on the youngster. She slammed the child's head into a wall for crying.
All empty promises. All dead children.
Rather than ask a judge to order parents' cooperation with services and supervision, DCF often has troubled parents sign "safety plans" — words scrawled on a form, sometimes illegibly — pledging to become better parents. Many times, the promises are broken, and with fatal consequences.
In at least 83 cases over the past six years, children whose parents signed at least one such written promise died. But DCF continues to rely on the documents.
Safety plans are supposed to work like contracts: The parents, step-parents or grandparents agree to stop whatever it is they are doing to endanger a child — overindulging in pain pills, getting drunk, engaging in fistfights around the children, cohabitating with a dangerous beau. In return, DCF agrees not to take your kids.
In theory, they are a way to make parents face up to their demons, be they drug abuse, mental illness or family violence. Such plans are supposed to provide detailed road maps to recovery, and hold parents accountable when they fall short.
Except the plans often don't hold them accountable, because the agency has a track record of not noticing — or not acting — when the contract is broken. Except to impose another safety plan.
"Safety plans that rely on willpower as a strategy are not secure," said Paul Vincent, who as director of Family and Children's Services in Alabama turned that state into a national model.
Jess McDonald, who ran the Illinois child welfare system from 1994 until 2003, and is credited with dramatically improving it, said such promissory note safety plans are "compensation for not having sufficient resources," and generally don't work.
Last year, amid a series of critical news articles in the Miami Herald, DCF asked Casey Family Programs to review 40 child deaths in which the agency had prior family involvement. The consultant called the department's safety plans "inadequately resourced" and ineffective.
Interim DCF Secretary Esther Jacobo acknowledged safety plans have been executed and managed poorly.
"We have kind of known they have failed, and we have kind of been at a loss as to how to fix it," Jacobo said. She said the agency is now training investigators on how to appropriately use the plans, and supervisors are being required to review each one.
In its analysis of 477 deaths of children with a DCF family history, the Herald found:
• Although administrators had received troubling warning signs as early as 2008 that parental pledges did little to protect vulnerable kids, the agency continued to rely on such pacts — without altering the plans to give them teeth, or requiring meaningful follow-up, such as unannounced home visits or random drug testing to ensure compliance.
When Chase Anglemyer was born, his three siblings already had been removed from his parents owing to a well-documented history of drug and alcohol abuse. Amanda Brown and Daniel Anglemyer continued to abuse drugs after Chase's birth, DCF said. Instead of sheltering Chase along with his siblings or asking a court to order services, DCF put in place two safety plans, one of which tacked on additional tasks in a services plan they were already failing to fulfill.
A month later, Brown was found "passed out in front of the toilet with her pants down," while Anglemyer was "passed out in the hallway" from allegedly using pills, a report to the agency said. DCF still did not intercede. Ten days later, Chase was found dead in his parents' bed.
The cause of Chase's death remains unexplained, and no one has been charged, although both parents tested positive for drugs. A detective reported seeing "empty beer cans, an empty bottle of Arbor Mist wine, and an empty 1.5-liter rum bottle" in the home where Chase's body was found, according to a review of the boy's death.
• When DCF investigators found they could not rely on the promises of drug-addicted or violent parents, they enlisted relatives or "communities," extracting pledges from grandparents or neighbors to intervene when children were in danger — conscripting conflicted relatives and near-strangers as a surrogate for agency monitoring. Those plans also proved ineffective.
Camden Paul, for example, was living in a Jacksonville-area mobile home with her mother and maternal grandparents — all of whom, DCF was told, were heroin users. DCF never drug tested the family. Instead, it asked the 3-year-old's great-grandmother to sign a "community support agreement" pledging to maintain daily contact with the family.
On April 3, 2009, mother Brittany Paul left Camden home alone in the trailer to check into a hotel with a male friend, a DCF death review said. Her explanation: She thought her grandmother was watching the baby. The grandmother denied it. While Camden was alone, the trailer erupted in flames, killing her.
In the course of the death review, the girl's grandfather told DCF that Paul "had a history of leaving the child unsupervised," and had set a pair of bedsheets on fire earlier by "passing out" with a lit cigarette.
The DCF report lamented that Brittany's family members never told anyone that Paul was leaving her toddler at home alone. No one was charged.
• Multiple children died as a result of the precise failures the safety plans were designed to fix.
When 22-year-old Gregory Tillman was arrested in Orlando, accused of beating his girlfriend, a DCF investigator was concerned not only for Sonia Lugo, but for the couple's 3-month-old baby, Jean-Pierre Tillman.
"Child will not be exposed to any domestic violence," read a safety plan Lugo signed in October 2007. "Mother will protect the child."
Tillman, who had a tattoo of the Grim Reaper on his right arm and went by the street name "Bad News," agreed to what DCF called a "verbal safety plan" to curb his aggression. Four months later, he became enraged with Jean-Pierre's crying and shook and beat the boy, hurling him against a wall. An autopsy said he likely also was drowned.
Tillman is serving a life sentence at Columbia Correctional.
• Parents violated their safety plans with impunity. Some parents violated safety plans only to be offered another one, which sometimes contained the same provisions.
One-year-old Fernando Barahona suffered a series of skull fractures as well as a half-dozen bruises to his forehead and his spine; one bruise looked like a hand print. Altough family members blamed the injuries on the family dog, health care providers told DCF they believed someone had abused Fernando. The sole caregiver present when he was injured was Ronald Midkiff, his mother's boyfriend.
On May 18, 2013, Fernando's mother, Elvia Fernandez, signed a safety plan: "Ronald Midkiff cannot have any contact with the children. Any violations of this safety plan may result in legal action."
The safety plan was ignored. Shortly after it was signed, DCF received a report that Midkiff had been at the children's daycare and had hit Fernandez on the head and yanked one of her children by his hair.
On June 3, someone strangled Fernando. Midkiff was in the house that night with Fernando's mother, contrary to the safety plan. Fernando's death was ruled a homicide, although no one has been charged.
A little relapse
Frequently, parents were allowed to write their own plans, replete with spelling and grammar errors. Some of the plans were barely legible. One handwritten plan by a couple stated: "We do not expose are children to drugs or alchol … and where following through or case plan." Five weeks later, their son, Ben Powell, died of pneumonia while his father was drunk, according to DCF records. The parents were staying in the home of friends and forgot to bring along his nebulizer, a device to aid breathing, the file says. There were no charges.
Virginia Pouncey, a Lortab addict, told DCF at the birth of her infant that she had suffered "a little relapse" when her grandfather died, and smoked one "joint" to feel better. A drug test at the time showed Pouncey had used not just marijuana, but methadone, the anxiety drug benzodiazepine, and opiates.
Newborn Marvin suffered the consequences: He endured withdrawal from his mother's drugs and was having trouble feeding.
DCF allowed Virginia Pouncey to craft her own safety plan. In it, she promised to keep doing what she had been doing.
"I will continue to take care of my children the way that I have been," she wrote, adding: "I also will continue to go to (Narcotics Anonymous) meetings and stay clean as I have been." Pouncey also promised not to expose her children to drugs.
During the next month, Pouncey refused to take a drug test and dropped out of a methadone clinic. In two prior DCF cases, Pouncey did not cooperate, and had been jailed for violating probation in a drug-related matter.
Although agency lawyers determined DCF had sufficient cause to ask a child welfare judge to oversee the family, the petition was never filed — part of an "ongoing problem" with the area's legal office.
Marvin died before he was 3 months old, in a twin-size bed with his mother and older siblings, a dangerous co-sleeping arrangement that was made more hazardous by Virginia Pouncey's use of narcotics, a Child Protection Team doctor wrote. She tested positive for marijuana, opiates and benzodiazepines.
After Marvin's death, department lawyers filed the court petition on behalf of his surviving siblings. There were no criminal charges.
For years, DCF investigators, supervisors and high-level administrators had been warned that executing promissory safety plans was a poor alternative to real social work. In the Panhandle, one administrator who analyzed child death cases for a living, Linda Swan, warned her colleagues several times to discontinue the practice.
In an early case, Angeline Russ signed two safety plans, one promising not to drink "to the point of intoxication while caring for her children," and another vowing to avoid domestic violence. On March 20, 2009, she accidentally smothered her 2-month-old daughter, Kimora Unity Russ, in bed after drinking, by her count, four to five beers.
"The safety plans established and documented departmental expectations, but realistically, would not have done much to ensure the safety of the children," Swan observed.
More than a handful
At 24, Fabia Clark cared for nine children: a 17-year-old niece and nephew, both diagnosed with developmental disabilities, who became her responsibility upon their own mother's death; and seven who were Clark's, including a 4-year-old with Down syndrome; and another child with developmental disabilities.
Three times since 2005, DCF had been warned that Clark's drug use and inattention to her children left them in danger. In April 2009, three of Clark's small children — all below the age of 4 — were found by a neighbor "running in the street," and nearly struck by a car, a DCF report said. When the neighbor returned the toddlers, she was met at the door by a leather strap-wielding Clark.
The agency closed the new case when an investigator "addressed a safety plan with the mother" — the details are not specified in a report — and installed an alarm on her front door to alert her when the kids were making a break. Neither measure proved effective.
Two weeks after the investigation was closed, 16-month-old Kevin Walker was found at the bottom of a dark green pool brimming with dirty diapers, toys and shoes. Although they had taken care to secure the front door, neither Clark nor DCF had considered the four sliding glass doors plus a bathroom door leading to the fetid pool.
Hope for the best
Logan Hancock died of a cracked skull. It was the second time someone had bashed in the newborn's head.
In July 2013, Logan was hospitalized with a depressed skull fracture. It was the kind of injury, his doctor said, that resulted from abusive trauma. Logan's mother, father and grandmother were present around the time the injury was inflicted and were questioned, the DCF file said. All of them denied responsibility, which worried authorities even more because it suggested the family was "hiding abuse."
At first, the agency planned to involve a judge in Logan's protection. Instead, parents Stephanie Schoonover and Steve Hancock signed a safety plan promising to provide "appropriate adult supervision" and a home free of hazards. Caseworkers and counselors also would visit the home from time to time. One service provider — DCF removed that detail from a report — expressed concern over the arrangement, but said he or she "hoped for the best."
On Sept. 6, 2013, Schoonover shook Logan and then slammed his head against his crib, killing him. She confessed to police, records show.
Said McDonald, the former Illinois child welfare chief: "How can you possibly manage safety when don't know who the perpetrator is yet, but you know there is one?"
'Red flag case'
When William Sloan was born on Dec. 5, 2008, his two siblings were already in foster care, owing to his parents' severe drug abuse and his mother's mental illness, a DCF report said. When William came to the department's attention two days after his birth, a DCF supervisor in Bay County observed: "This is a red flag case."
The boy's father, John Robert Sloan, refused to talk to the agency, angry over what he called DCF harassment: Members of the family had been investigated 11 times. The newborn's mother, eager to keep William and hoping to regain her other two children, signed a safety plan agreeing to refrain from drug use and to provide adequate care and supervision for William.
Six months after Tonya Osburn signed her safety pledge, conditions had worsened, reports show: The home had no electricity and was "trashed," a caseworker wrote. Osburn had stopped taking her mental health drugs, and was kicked out of a treatment program. Mother and baby were sleeping on a mattress on the floor, contrary to all safety precautions. "Dog crap" littered the home.
Another hotline report arrived, saying Osburn was acutely ill with bipolar disorder, and would sleep and not watch the child. After a visit with his mom, William returned, the report said, wearing the same clothing, including a shirt that appeared to be burned by a cigarette. The report added that Osburn had not fed the child in as long as two days and that "she has left the child with 'just anyone' while she goes out and parties at bars."
On May 21, 2009, Sloan and Osburn were asked to sign another safety plan, this time pledging not to do drugs, or to leave William in a hazardous home.
Five weeks later, John Sloan bought a fifth of Lord Calvert, with Coke as a mixer, the DCF file said. His wife had left him. Father and son went to sleep around midnight. Sloan awoke later to play video games, then "passed out" at about 4 a.m. — with William next to him on the couch. He found the infant dead the next morning, smothered.
According to the death review, Sloan talked to a friend afterward and confided: "Yep, I drank it all by myself."
He was charged with manslaughter. Two years later, a judge dismissed the case after Sloan's lawyer argued there was no evidence to suggest he had been drunk.