Transparency lost in reviews of Florida child abuse deaths

In December 2009, the state panel that reviews child abuse deaths released a 179-page report. The document included a detailed analysis of what killed Florida children the year before, dozens of charts and graphs describing both the victims and perpetrators of child abuse, and brief memorials for several of the youngsters whose lives were cut short.

The task was grim but important: studying past child fatalities to prevent future ones.

This year's version of the Child Abuse Death Review Committee's annual report, by comparison, is 17 pages long, six of them devoted to definitions, references, background and methods. It also contains charts — a dozen of them — but little else. Unlike prior years, the report contains no memorials for individual slain children, and no discussion of the state's role in protecting them.

To find evidence of the panel's existence is no simple matter today. In recent months the Florida Department of Health quietly scrubbed any reference to the Child Abuse Death Review Committee from its website, where the library of prior reports had been posted for public examination for more than a decade.

This past March, the Miami Herald published a series of stories under the heading Innocents Lost that detailed the deaths of 477 children whose families were known to the Department of Children & Families. Since then, steps have been taken to stanch the tragedies: Lawmakers passed legislation overhauling DCF's child protection system and set aside nearly $50 million in new money for more investigators and other reforms.

The law, for the first time, articulated the Legislature's intent to hold the welfare and safety of children above the rights of parents accused of abuse and neglect. Lawmakers stated that they wanted to see more openness from agency administrators, and mandated a website to track child deaths.

DCF, in turn, vowed to learn from its mistakes, even if it meant enduring an occasional public relations beating. In an October report that detailed the shooting deaths of Sarah Lorraine Spirit's six small children by their grandfather — the single largest child abuse loss of life in recent memory — administrators made this pledge: "There will never be one child who dies without DCF working to determine what changes can be made or processes improved to prevent further tragedy."

In fact, though, reviews of each child death, required under federal law, have become increasingly thin and decreasingly critical, making it difficult for the public and the news media to gauge DCF's performance. At the same time, several respected, highly engaged members of the statewide Death Review Committee, under the auspices of Surgeon General John Armstrong, have been purged.

"This is not the direction we had expected DCF and the Department of Health to go in," said Sen. Eleanor Sobel, a Hollywood Democrat who chairs the chamber's Children, Families and Elder Affairs committee. "I think you get the best results when you communicate openly, and not when there is any kind of cover-up."

"There is no other place to get this information, and this is not the way government should work in the sunshine," added Sobel, a Senate sponsor of legislation that overhauled DCF last spring. "The goal is to learn what is happening in the state, so we can use our resources wisely."

A health department spokesman, Nathan Dunn, said the statewide committee "determines the content of the annual report, not Dr. Armstrong or the Department of Health. He added: "The 10 professionals appointed by Dr. Armstrong have over 170 years of experience in child welfare, law enforcement and related fields and are committed to eliminating preventable child abuse and neglect deaths."

Dunn said the committee's website was taken down for "updating ... to make it more user-friendly and transparent. It will be back on line this spring."

A DCF spokeswoman, Alexis Lambert, said that "to increase transparency, Florida is one of the only states in the country that posts five years of continuously updated child fatality data online." She added: "DCF reports are focused on reviewing the decision-making in each case in order to help guide future preventative measures Florida's communities can take to save lives."

Oversight of Florida's child welfare program, and its worst failures, has sometimes bent to political winds. Wary of bad publicity — and of tort lawyers getting rich from DCF missteps — the state often diluted its own watchdog programs, some critics claim.

For instance, Linda Swan, a DCF quality assurance supervisor from the Panhandle who earned a reputation as one of the state's toughest investigators, repeatedly admonished DCF not to rely on "promissory note" safety plans — written pledges by troubled parents to refrain from dangerous behavior. Her warnings went unheeded until the Herald described the proliferation of such pledges, and lawmakers set strict limits on their use in the overhaul bill.

Swan was laid off as the Northwest Florida death review coordinator in 2011. She called DCF's oversight of death reviews a clear "conflict of interest," and said the agency had long manipulated the program for political ends.

"One of my bosses said 'we don't want you to air our dirty laundry,' " Swan said.

As early as 2008, a former chairwoman of the death review committee, acting as a special counsel to DCF, wrote that such reports suffered from "a striking lack of rigor."

Along with the "lack of rigor," some death reviews contain information that is clearly erroneous.

Take the case of Logan Suber. A DCF post-mortem report on Logan — the infant died on Nov. 5, 2011, one day after DCF closed its investigation into allegations that his mother's drug abuse endangered his welfare — says Logan was living at his maternal grandparents house, where investigators believed his grandparents would ensure he was safe.

But a police report detailing the 2-month-old's death said Logan and his mother were living in a barn — alongside horses and "large bales of hay" — when his mother accidentally smothered him on a couch inside the barn. Police said they found Xanax, Valium and marijuana, and a drug pipe in Kortney Suber's purse.

Few of the reviews completed this year contain more than three pages of substantive information, a striking contrast to past years, when reviews delved deeply into what went wrong. Fewer still contain sections for recommendations or "areas for improvement" — as was common in prior years.

38-pound victim

Yanelli Jaylin Vasquez's autopsy details 15 separate injuries to the girl's 38-pound body. The decisive blows landed near the child's liver, resulting in a catastrophic loss of blood. The Dec. 13, 2013, beating was administered, police say, by Yanelli's grandmother, Caridad Cobb, with whom the state DCF placed the girl two years earlier.

Yanelli remained with her grandma, records show, though DCF's hotline was told Cobb "beat the crap" out of Yanelli's younger brother months earlier "because he was crying." Cobb admitted to "popping" her toddler grandson at school.

The 3-year-old girl's death review takes up three pages and one sentence. It devotes three paragraphs to DCF's history with Yanelli and her family, though records, as a whole, are hundreds of pages long. The review gives equal time to Cobb's claim that Yanelli accidentally drowned in a bathtub, though police say the story is fiction. Cobb was charged with first-degree murder.

What the death review did not say: Yanelli and her little brother were yanked from their child care center after Cobb was accused of beating her grandson there — and the children never were returned to day care. That's a red flag for child abuse investigators.

It also doesn't say that DCF allowed Yanelli to stay in the home even after her step-grandfather, Michael Cobb, was charged with domestic battery on his sister in November 2011. Though Michael Cobb was charged with the battery — and his sister was not — reports said the children would be safe so long as the Cobbs signed a safety plan promising to keep the sister away.

"Case manager feels that moving the kids due to the incident is not necessary," a report said.

Lillie Cobb, Michael Cobb's mother, who lived next door to the family, said she and her adult daughter had grave concerns about Caridad Cobb's handling of the two small children — though no DCF investigator or caseworker had ever asked her family for an opinion.

"She could be vile," the 75-year-old Lillie said, adding the children appeared to be petrified of their grandmother.

Lillie's daughter, 53-year-old Janice Cobb, who lives with her, said she, too, had never been interviewed by DCF. Though she never saw or heard Caridad Cobb abuse the children, she said, she often wondered why she never saw the youngsters leave the house. "I never saw them come outside to play. They were never exposed to other children. I didn't see them socialize. They never got sunshine."

DCF's review of Yanelli's death — an opportunity for self-examination — fails to mention that the 2012 investigation of Caridad Cobb did not include any interviews with so-called "collateral contacts," such as the family next-door.

Concerns about Jimmy

The death review for 2-year-old Noelani Isabella Marmolejo may have been less rigorous; the results of DCF's investigation into her killing took up less than two full pages. The agency's history with the girl's family takes up about half a page.

In January and September of 2013, DCF's abuse hotline received two reports that Noelani was being physically abused: In January, she had "a knot and bruise in the center of her forehead, and a scratch over her left eye." The following September, the toddler had "bruising and swelling on the right side of her head." Records show investigators spent four days on the first probe, and nine on the second, though regulations allow 60 days for such investigations.

Such truncated investigations have become common in DCF's Northeast Region, and an Inspector General report on the June 21, 2013, death of a 2-year-old boy, Ezra Raphael, said investigators were encouraged to wrap things up quickly to "alleviate the need to see the child again, and additional work would not have to be completed."

The death review provides only a brief outline of the two cases, and left out a variety of details that might have shed light on agency missteps, including the fact that Noelani appeared to be fearful of her mother's boyfriend, and, at times, her own mother.

On Nov. 1, 2013, when Noelani was hospitalized with "extensive" head injuries, her grandmother, Fabiola Marmolejo, screamed at a DCF investigator, a report said. The grandmother said she had repeatedly noticed bruises and other injuries to Noelani, and had begged DCF to remove the toddler from the reach of Reyes-Delgado, known to friends as "Jimmy."

The agency, she said, allowed Noelani to remain with mother Olivia Blake and her boyfriend "even though she tried to tell them that Jimmy was abusing the child."

Noelani succumbed to "traumatic head injuries," an autopsy said, and Reyes-Delgado was charged with murder.

Some death reviews remain open for years, rendering them invisible to scrutiny. Two-year-old Lamar Braddy, for example, died on Oct. 18, 2012, while in the care of his state-approved caregivers — one of whom had lost her own children, one to a mysterious death, others to adoption. An autopsy said Lamar died of chest trauma, a homicide, though neither caregiver has been charged. The review of Lamar's death was not made public for two years.

'Too graphic'

As the rigor of DCF's review of such deaths declined, so, too, did the independence of what was originally designed to be a check on the state's child welfare program. The Statewide Child Abuse Death Review Committee was created by statute in 1999 following the killing of a Kayla McKean. Her father buried her in the Ocala National Forest on Thanksgiving Eve in 1997 before reporting her missing, setting off a furious — though futile — search. She had been the subject of several reports to the state's abuse hotline.

The committee, Florida law says, is tasked with achieving "a greater understanding of the causes and contributing factors of deaths resulting from child abuse."

Beginning about two years ago, the Department of Health's top administrator, Surgeon General Armstrong, purged a number of members with years of experience, replacing them with newcomers. When the agencies that made the appointments objected, they were overruled.

In March, for example, the chairman of the state's Medical Examiner's Commission asked Armstrong to reconsider his dismissal of Central Florida Medical Examiner Barbara C. Wolf from the panel. "I have selected (Wolf) to remain our appointee" to the committee, Bruce Hyma, the Miami-Dade medical examiner, wrote in a March 31 letter. "I have chosen Dr. Wolf for her expertise, her institutional knowledge, and her passion for the health and well being of children."

Wolf was removed anyway, along with Connie Shingledecker, a major who heads Manatee County's child protection unit, and, Terry Thomas, a now-retired child abuse expert with the Florida Department of Law Enforcement — both of whom served on the panel for about a decade.

Wolf, the medical examiner for five Central Florida counties, had risen to chairwoman when she was told she could no longer serve. She said Armstrong had sought repeatedly to have her removed from the panel, telling her and other team members their reports were "too graphic."

This month, Armstrong canceled his agency's contract with Randell C. Alexander, a professor at the University of Florida's medical school who had headed the state's Child Protection Team. Alexander had delivered remarks critical of the state's child protection efforts to a federal commission investigating child deaths earlier this year.

Armstrong's agency also abolished the job held for 10 years by Michelle Akins, who oversaw the health department's local child death reviewers. Two years earlier, Armstrong had removed Akins from the statewide team. She had drawn the ire of DCF by questioning the agency's decision to stop counting dozens of child deaths each year that resulted from drowning or accidental suffocations in bed.

Shingledecker, a major in the Manatee County Sheriff's Office, said both Alexander and Akins had been instrumental in helping the committee produce "what I believe are the best reports we put out."

Sobel, the lawmaker who co-sponsored the reform bill, said it appeared as if Armstrong had "wiped the slate clean, shut down the website, and changed the whole direction of this committee."

Most of the staples of the report, which had been published annually for 13 years, are now gone, including the short vignettes that served as memorials for individual children, and a "dedication" that, in 2009, said members remembered the slain youngsters "for their innocence, and honor them by committing ourselves to work tirelessly to see that no child dies from a preventable death."

Gone is any detailed analysis of the most persistent threats to Florida children's safety, such as alcohol and drug abuse, criminal or violent histories, or mental illness.

Gone, too, is any discussion of DCF's role leading up to the fatalities, or any analysis of whether any deaths were "preventable." In the 2009 report, the committee concluded that 65 fatalities, or 32.6 percent of that year's total, were either "definitely" or "possibly" preventable by the state.

Detailed recommendations comprised 12 pages in the 2009 report. Only one page was devoted to calls to action in this year's installment, and one of the seven recommendations was for less transparency: the panel suggested eliminating a requirement in state law that some meetings be taped, arguing such recordings inhibit candor.

"The more transparent we are — as painful as it is — the more chance we have of saving the next child," said Pam Graham, a professor in the Florida State University College of Social Work and ousted member of the Child Abuse Death Review Committee.

"If you are serious about saving children's lives, you have to look at these things with a discerning eye," she said.