Child protection investigators worried all month that 13-month-old Ezekiel Mathis might be in danger in his mother's home. In early May, they tried twice to put him in foster care. Each time, the state Attorney General's Office wouldn't allow it.
On May 9, a Hillsborough County circuit judge also tried to rescue Ezekiel, after the baby's 2-year-old sister appeared in court covered head to toe with bruises and was put in foster care.
Judge Tracy Sheehan issued a written order for deputies to immediately check on Ezekiel's well-being. She didn't want him left behind. The next day, investigators made a third request to the office of Attorney General Pam Bondi for authority to remove the baby, the Sheriff's Office said. The request was again denied.
Ezekiel died Wednesday night. Caseworkers had just checked on him that day and found him with Damarcus Kirkland-Williams, 21, the mother's boyfriend. The mother, Swazikki Davis, also 21, was under state order to keep him away from her child.
Authorities say the boyfriend beat Ezekiel to death only hours after caseworkers left.
On Friday, the state Department of Children and Families, which contracts for services from the Sheriff's Office and the attorney general, took responsibility for failing to save the little boy.
"While every party involved in this tragic case had the best interest of Ezekiel in their heart, a lack of urgent communication prevented all of us from having a timely and complete assessment of the situation," said David Wilkins, DCF secretary.
"Clearly the presence of Kirkland-Williams in Ezekiel's home should have triggered a crisis response."
Kirkland-Williams, who is 6-feet-10, was charged on Thursday with first-degree murder and aggravated child abuse. Deputies say he admitted that he attacked the child while angry with Ezekiel's mother.
She wasn't in the room when he threw the child, he said. He aimed for the bed, but the baby struck a dresser, he told investigators.
Next, he said, he put the baby in bed on his stomach. Ezekiel would not stop crying, so the boyfriend hit him twice on his back, deputies reported.
Judge Sheehan remembered seeing Ezekiel's battered sister on May 9. The mother wouldn't explain her bruises, Sheehan said, and the child was placed in a foster home.
During the hearing, the judge discovered that the baby still lived with his mother. Sheehan ordered the Sheriff's Office "in no uncertain terms" to immediately determine whether Ezekiel needed to be taken out of the home, too. She said she put the order in writing.
Jose Docobo, chief deputy for the Sheriff's Office, said child protection investigators had tried repeatedly to remove Ezekiel. That was corroborated by DCF. But in each case, the state Attorney General's Office ruled it could not find "legal sufficiency" to do so.
The attorney general's media director said by e-mail Friday that Ezekiel had shown no signs of physical abuse. Jenn Meale said the mother had agreed to remove Kirkland-Williams from the home and to comply with a "safety plan."
"We requested additional information from the Sheriff's Office," she said, "and no further information was provided to us. The Sheriff's Office did not elevate the issue to the regional director of DCF, which is an option in all cases."
In jail records, Kirkland-Thomas listed his occupation as an auto detailer at his father's shop on Florida Avenue. He was in violation of probation, which he was recently given after pleading guilty to burglary and dealing in stolen property. He had no record of violent offenses.
He and his girlfriend, Davis, were to have traveled to Jacksonville Friday to celebrate his mother's graduation with her master's degree in criminal justice. His mother, Angel Williams, said she is a child protection investigator there. She got a call from Davis, telling her about the murder charge.
"He would never hurt a child," Williams said of her son.
But Davis' family members were long suspicious of Kirkland-Williams.
Yyoni Bunkley, 31, sister of the baby's mother, said she saw bruises on the older sister. She could tell the girl was afraid of him.
"You can just tell when a child has been abused," Bunkley said. "I don't understand why they would take one child and not the other."
Bunkley said the boyfriend had previously been questioned by the Sheriff's Office after he was observed being aggressive with the girl at a park.
"He should have been arrested."
The baby's mother at first said the allegations about her boyfriend and Ezekiel couldn't be true. She said he cared for Ezekiel and played with him. Ezekiel called him "Da Da."
The night Ezekiel died, she remembers that Kirkland-Williams tried to give him CPR.
On Friday, Davis sobbed and ran to her bedroom when she found out her boyfriend had admitted to investigators that he threw the baby.
Mary Davis, her mother, remembers picking Ezekiel's name from the Bible when her daughter was only two months pregnant. She didn't know Kirkland-Williams well, but at one point she kicked him out of her daughter's apartment on N 21st Street.
"He really didn't have nothing going for himself," she said. "I think he was threatening my daughter and she wasn't saying anything."
An autopsy of the baby by the Hillsborough County Medical Examiner's Office showed the cause of death to be blunt impact trauma to the head and torso with lacerations to the liver and spleen. Officials ruled the death a homicide.
Kirkland-Williams was held in jail without bail Friday.
DCF Secretary Wilkins announced changes in procedures on Friday. "I am requiring that department leadership be immediately notified of situations where the complexity of the case requires our direct involvement," he said.
Attorney General Bondi announced that she has asked her statewide prosecutor, Nick Cox, to find out whether any policy or law changes are necessary. She said she assigned Cox because he is a former DCF regional director.
Times staff writers Robbyn Mitchell and Dan Sullivan and news researcher John Martin contributed to this report.