PORT RICHEY — The mother couldn't care for her babies because she was in prison. The father was a petty criminal himself with no clue how to care for newborns.
But when Nicholle West gave birth to twin girls on Oct. 15 while locked up near Ocala, the people who were supposed to protect them packed them up and sent them to Port Richey with their father, Thomas Ludwig.
In December, authorities said, Ludwig killed one baby, Diella, smashing her skull when she wouldn't stop crying. The other baby, Shyloh, was placed in state care, and Ludwig was arrested Monday on a charge of first-degree murder.
By Wednesday, the head of the state agency charged with protecting at-risk children, George Sheldon, found himself apologizing and explaining how another child slipped through the net.
"I think it clearly demonstrates what we've still got to work on ... that ultimately the Department of Children and Families is responsible," Sheldon said. "The fact of the matter is when the life of a child is at stake, we can't afford to pass the buck."
Missed opportunities. That's what Sheldon, who took over DCF in August, said led to Diella's death.
The first one, according to the agency's 12-page review of the case, passed before the twins were even born.
Caseworkers were already familiar with the twins' mother because she had an older child under state care. DCF automatically intervenes when such parents have more children.
West, 30, has been arrested at least a half-dozen times in Pasco County, most recently for felony methamphetamine possession. On Oct. 3, she was charged with violating her probation and sent to Lowell Correctional Facility in Marion County. Before giving birth, she told caseworkers she wanted Ludwig to get the girls.
But according to the DCF review, caseworkers in Marion and Pasco counties didn't explore whether Ludwig, 24, was actually fit to care for them.
This despite misgivings of the babies' maternal grandmother, who said Ludwig "was not appropriate and seemed not to care" about the children, the report says. He had previous arrests on charges of stealing a car, writing worthless checks and failing to pay child support.
The caseworkers recommended he participate in substance abuse and parenting classes.
Investigators also failed to check their own files for earlier child abuse investigations involving Ludwig. It turns out allegations had been made against him in 2002 and 2004. Whatever the details of those charges, which were redacted in the DCF report released this week, they led authorities to recommend he not be allowed around children unsupervised.
In addition to child protective investigators in Pasco and Marion counties, the twins' case was also handled by Youth and Family Alternatives, a subcontractor of DCF.
The report says YFA's workers, who were to follow up on services for the babies after they were born, had no information about Ludwig and did not consider him part of the case.
The report, however, concluded that "there was nothing to prevent them (YFA) from researching his background or even conducting a home visit as he did reside in Pasco County."
Once the girls were born and moved with their father across counties and jurisdictions, what followed was a series of miscommunications, the report says. And no one, it appears, took the lead on ensuring the twins' safety.
"We needed someone with a sense of urgency," said DCF's regional director, Nick Cox. "It's difficult to understand why we had no planning or preparation in place for the birth of these kids."
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Thomas Ludwig came from a large family. He was one of 16 children adopted by Steven and Debbi Ludwig and homeschooled in Port Richey in a devout Christian environment.
Thomas' biological brother Andrew gave the family such a hard time — terrorizing his siblings, flinging picture frames, punching holes in the walls — that the couple locked him out of the house in 2000, afraid he would hurt the other children.
In a widely publicized case, police charged the couple with neglect. A month later, amid public outrage, the charge was dropped.
Back then, 15-year-old Thomas Ludwig tried to explain Andrew's behavior. He recalled seeing him beaten in foster care. "I was basically just like Andrew," Thomas told the Times. "When we came here, everything changed. We were taught to obey and started fresh."
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After Marion investigators failed to evaluate Thomas Ludwig from the outset, Pasco investigators didn't take the baton, the report says.
A Pasco investigator visited him three times over 38 days — each visit at a different residence. In those visits, the report says, he refused to submit to a drug test, lied once about where the babies were, admitted to previous drug abuse and could not prove he had any income.
"Despite those concerns," the report says, "the initial overall risk assessment was rated as moderate."
Ludwig was renting a bedroom from a married couple on Richwood Lane in Port Richey. When he came home the night of Dec. 20, his arrest report says, one of the babies was crying. Ludwig put them down to sleep and came out of the bedroom. When he went back in a few minutes later, he "snatched" up Diella, snapping her head backward, and then shoved her back down on the bed, the arrest report said.
He called the crying baby a "little bitch" and told her to shut up, the report said.
Then his roommates heard a loud bang, and the wailing stopped.
Diella was flown to a Tampa hospital, where she was pronounced dead the next day. A medical examiner concluded she died of blunt force trauma.
Ludwig, charged with first-degree murder, remains jailed without bail.
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Officials with the Pasco Sheriff's Office, who perform child protection investigations for DCF, defended their actions Wednesday. They said there were never any signs of child abuse or neglect, and no lawful reason to take the twins from their father.
"Prior to the death of the child, we did not have any actionable items that would allow us to interfere with his parental rights," said Col. Al Nienhuis.
He added, "We don't see in this case how our involvement could have prevented (the death) under the law. It's a very tragic but unforeseeable event."
Marion officials did not return a phone call from the Times; nor did Youth and Family Alternatives.
Sheldon, who is overseeing an agency once known for hiding the details of its high-profile cases behind privacy laws, took the unusual step of quickly releasing the report of Diella's death.
What it showed, he said, was that the protocols in place weren't followed.
"I recognize that we can't cure all the problems of society," Sheldon said. "But we could do a much better job than was done in this case."
Times staff writer Jodie Tillman contributed to this report. Molly Moorhead can be reached at firstname.lastname@example.org or (727) 869-6245.