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Appalling failures preceded death

No one did a face-to-face interview with Thomas Ludwig or evaluated his criminal and abuse history as required by state law.

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No one did a face-to-face interview with Thomas Ludwig or evaluated his criminal and abuse history as required by state law.

Diella Ludwig's short life began while her mother was in prison. Now her biological father could spend the rest of his life incarcerated for his role in the 2-month-old's slaying in December. But those contributing to the newborn's death reach beyond the family tree to a government network that repeatedly failed to protect the baby and her twin sister from their 24-year-old father. It's an all-too-familiar tragedy for Florida's child protection system. And it remains unacceptable.

In this case, Thomas Ludwig had no parenting skills, no job and no permanent place to live, but did have a criminal record and a history of abuse. He lied to investigators, admitted to substance abuse and refused to submit to drug testing. Still, incurious or inattentive investigators allowed him to be the primary caregiver to newborn twins, Diella and Shyloh.

The babies' own maternal grandmother sounded warnings to Pasco County child protective investigators five weeks before the births, saying Ludwig "was not appropriate and seemed not to care'' about the children. The investigators failed to unearth a 2004 report of abuse allegations involving Ludwig that recommended he not have unsupervised contact with children.

That critical information was not shared among investigators, child protection workers and social agencies in Marion County, where Nicholle West was in prison, and Pasco, where Ludwig lived and where he took the twins after their October birth. Earlier this week, authorities charged Ludwig with first-degree murder. He is suspected of fracturing Diella's skull on Dec. 20 to stifle her crying.

George Sheldon, Secretary of the Florida Department of Children and Families, said nobody displayed a sense of urgency in Diella's case. Indeed. Rules were in place, but weren't followed. Cases weren't transferred properly between agencies. Piecemeal case management meant imperative information wasn't distributed, or worse, was ignored by those needing to know.

But also missing was a display of plain common sense. Pasco Sheriff's Col. Al Nienhuis said there was little his agency — which does child protection investigations for DCF — could do under the law to prevent the baby's death because it did not observe abuse. Perhaps Nienhuis should rethink the agency's training standards. Its investigators didn't review Ludwig's history of abuse and rated the potential threat to the newborns as moderate even though they knew Ludwig lied to them, declined drug testing, couldn't account for the babies' sleeping arrangements or, at times, their whereabouts, and most flagrantly, lived at at least three different addresses over a 38-day period. How many red flags did investigators need?

Sheldon deserves credit for providing a thorough public accounting of yet another breakdown in Florida's child welfare system. But the candor is overshadowed by the horrible outcome and the appalling systematic failures preceding the infant's death:

• Case workers — checking a separate case involving the twins' sibling — had at least two months before the babies' birth to determine the suitability of granting custody to Ludwig.

• Youth and Family Alternatives of Pasco, a subcontractor providing services for DCF, failed to follow numerous guidelines, including a home visit and safety assessment to determine "the potential effect the addition of the new child may have on the family's current ability to handle stress'' and whether the newborns needed to be in foster care.

• Nobody conducted an assessment of the potential home environment, did a face-to-face interview with Ludwig or evaluated his criminal and abuse history as required by state law when newborns are released to the nonincarcerated parent.

• Marion County child protection staffers said they wanted an out-of-town inquiry of Ludwig, but failed to transfer the case to the Pasco Sheriff's Office.

Diella Ludwig is not a victim who fell through the cracks of Florida's child protection system. She died because the system failed her time and time and time again. Every leader of each agency involved must accept responsibility for that failure and move swiftly to prevent it from happening again. Sheldon and his boss, Gov. Charlie Crist, need to ensure that work gets done.

Appalling failures preceded death 01/29/09 [Last modified: Thursday, January 29, 2009 7:37pm]
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