PORT RICHEY — Caseworkers had told Thomas Ludwig not to leave bottles of formula propped in the babies' mouths. Newborns, who have little control of their neck muscles and swallowing reflex, can choke that way.
But on Dec. 20, according to reports, that's what Ludwig did: He propped a bottle against a pillow in front of his 2-month-old daughter, Diella. Then he left her and her twin sister, Shyloh, in the bedroom and went to check out a house fire down the street.
When Ludwig returned about 15 minutes later, according to new documents recently released by the Department of Children and Families, Diella wasn't breathing.
The documents, which include caseworkers' reports on the twins as well as an internal memo from DCF Secretary George Sheldon, revisit numerous turns where agencies and caseworkers failed to protect the babies. Not only did officials not communicate with each other, the documents show, they also failed to assess Ludwig's ability to care for the twins from the beginning, then took no action despite alarming signs he was neglecting them.
At the hospital, it was determined that Diella had inhaled a large amount of formula into her lungs. She died the next day.
But not from the formula.
Police reports say Ludwig's roommates had heard him yelling at the babies when they wouldn't stop crying. Then they heard a loud bang and the crying stopped.
Authorities later found Diella had bleeding and swelling in her brain — a result of shaken baby syndrome. They determined that caused her death.
Ludwig was charged earlier this year with first-degree murder. Shyloh is in foster care.
Ludwig, 24, had a history of criminal charges and drug use. Yet, the twins were placed in his care after they were born in prison to a mother who also used drugs.
Lessons to be drawn
Nicholle West, 30, remains incarcerated at Lowell Correctional Institution near Ocala. Because she already had three children removed from her custody, state officials got involved while she was pregnant with the twins.
But the different agencies involved — child welfare workers in Marion and Pasco counties as well as caseworkers for private agencies contracted by DCF — did not communicate with each other, Sheldon wrote in his memo.
The night Diella went to the hospital, the Pasco caseworker who responded knew little of West's situation.
"It is not known how long the mother has been in jail and there are no details surrounding her drug charges," the caseworker wrote.
This despite the information being available on publicly accessible Web sites.
Troubling facts about Ludwig's circumstances also failed to set off alarm bells among those working on the case.
Child protection workers who had checked on Ludwig and the babies found him living in a different location each time — three different places in a little more than a month.
His last residence, a rented house on Richwood Lane, had no electricity and was filthy, the documents say.
Ludwig had no crib set up for the twins, only pillows on the floor and a stroller for them to sleep in, the documents say. Investigators found that he yelled at the babies and called them names, and pushed their heads into pillows when they cried.
Despite the numerous signs of danger, and the numerous people and agencies having contact with Ludwig and the babies, Sheldon said, no one took the lead.
"This case re-emphasized the need for 'case champions' who will advocate for the children/family when barriers are identified and to ensure cases do not 'slip through the cracks,' " Sheldon wrote.
His memo, sent to other DCF managers, followed a meeting last month to review and draw lessons from the case. Among those in attendance were State Attorney Bernie McCabe and Pasco Sheriff Bob White.
"As we review this case," Sheldon wrote, "it is clear that inadequate and poor communication between individuals and agencies, a failure to follow established policies and procedures, and a lack of follow-through all contributed to this tragedy."
Molly Moorhead can be reached at firstname.lastname@example.org or (727) 869-6245.