How DCFS failed these kids

Abusive BehaviorFamilyCrime, Law and JusticeHomicideChild AbusePersonal ServiceJustice System

The children often died in obscurity without an obituary or headstone — their family histories darkened by poverty, mental illness, violence and drugs.

They had something else in common, too. The Illinois Department of Children and Family Services had been warned about possible abuse and neglect, but the staff assigned to protect them ultimately failed, according to state officials and records obtained by the Tribune.

More than 200 children with prior DCFS involvement were slain from 2000 through 2011, records show, but the facts rarely were made public, largely because of confidentiality laws.

The DCFS Office of Inspector General investigates such deaths, but its annual report does not include names or hometowns. Trying to put faces on some of these children — and tell their stories — the Tribune compared the death summaries contained in the most recent report against police, court, prison and medical examiner records. Confidential DCFS and hospital documents also were obtained.

The newspaper identified eight examples detailed in the inspector general's 2012 report in which DCFS or its contractual workers made serious errors, broke rules or falsified case notes.

"DCFS tries to explain these (failures) by isolating the problem to an individual worker instead of looking at the bigger picture," Cook County Public Guardian Robert Harris said. "But, if your caseloads are too high, and you have poorly trained workers dealing with extremely complex cases and issues, that's a systemic failing."

DCFS officials have moved to try to reduce caseloads, close overdue investigations and unclog the state's child abuse hotline — shortcomings reported by the Tribune in recent months. Every death, they say, is troubling, and if worker error is to blame, appropriate discipline is pursued.

The most recent published data on abuse-related fatalities of DCFS-involved children show Illinois has a slightly higher rate than other states. DCFS Director Richard Calica said the best the agency can do is ensure its staff is well-trained and following uniform standards.

"In my field, we have no crystal balls," Calica said. "Being able to predict the future probability that a particular individual is going to harm a child is almost nonexistent. Taking a kid away from a family can be as harmful as leaving them there. It's a judgment that's almost impossible to make, and they have to make it really quickly with limited information.

"The deaths disturb me, but there's nothing I've been able to put my hands on and say, 'I'm going to fix it.'"

Advocates argue that only increased public scrutiny of such cases will bring meaningful reforms to an agency struggling with severe budget cuts and hundreds of employees facing layoffs. The confidentiality, they say, prevents accountability.

Detailing the circumstances behind such deaths is crucial, said Theresa Covington, director of the National Center for the Review and Prevention of Child Deaths, a Michigan-based nonprofit group.

"I do believe agencies sometimes try to hide behind these laws that place confidentiality above the welfare of children and prevent public scrutiny that can lead to system reforms," she said.

The stories of eight children who deserved better follow. What happened to them has not been publicly reported until now.

Adonis Bright

17 months, Chicago. Died June 27, 2011

Despite the turmoil in his life, Adonis could still flash a smile and let out an infectious laugh.

Records raise questions about what signs of trouble DCFS and a contractual private agency might have missed. The child was the subject of two hotline calls determined to be unfounded despite repeated hospital visits and suspicious bruises, documents reviewed by the Tribune show.

The boy's mother, Jacqueline Bright, was 17 and a state ward with a long history of mental illness when he was born in January 2010, the inspector general's report said.

Seven months after Adonis' birth, DCFS investigated a hotline call that the baby was at a hospital with a broken leg, his second ER visit in weeks.

Bright's boyfriend, Tinnell Smith, said he fell on the infant while they played, an explanation that officials said could not be ruled out. The DCFS investigator closed the case without finding credible evidence of abuse, the records state.

But because Bright was pregnant again, DCFS initiated a safety plan in which the boy stayed with her adult cousin. Documents indicate the caseworker with One Hope United, a nonprofit human services agency providing DCFS intact family services, checked on Adonis weekly.

The boy thrived during the four months with the cousin, the caseworker's notes state. After giving birth, Bright regained custody and moved back in with Smith, records show.

Within months, Adonis lost weight and suffered unexplained stomach ailments and other illnesses. By late April 2011, Bright took her son to the hospital at least twice.

During the second visit, the doctor noted a facial bruise that looked like a handprint. "There is a high suspicion of child abuse in this child based on physical findings, labs and history," one report said.

The hospital called the DCFS hotline, but Bright was allowed to take the child home.

Records are unclear on how DCFS responded to that second hotline call in April. DCFS said it responded promptly. But the One Hope United caseworker wrote in his case notes on May 10 that he could find no record that DCFS assigned an investigator to go to the home for a required well-being check.

The caseworker continued his weekly visits. The boy appeared fine, he wrote.

In June, the mother called him to report a violent armed robbery at the Chicago apartment she shared with Smith, records show. She said intruders put a gun to Adonis' head and dangled him by his feet. The caseworker visited Adonis, but the boy wasn't taken into protective custody.

"This family is resilient and will not let each other down," he wrote.

Adonis was killed later that month. Police said Smith, 24, confessed to beating the boy after arguing with the mother. He is serving a 25-year prison term for fatally punching and karate kicking the 17-month-old boy after the mother left the apartment to calm down.

DCFS later tried to interview five of Smith's relatives who were home when the child was hurt, but, records state, the family fled to an undisclosed location after "six men with guns came to the house and told them that they didn't want no baby killers on the block."

Mark McHugh, executive director of One Hope United, said confidentiality laws bar him from discussing Adonis' case.

"All of us take the protection of children and welfare of families seriously," he said. "The death of a child, especially in a program like this, is rare. Very rare. When it does happen, the staff is devastated."

Members of Adonis' family could not be reached. In autopsy notes, one doctor said she found evidence of healing injuries.

"This (abuse) has been going on for some time," she wrote.

Nashawn Lewis

19 months, Chicago. Died July 31, 2009

Something seemed off with the once rambunctious toddler in the final weeks of his life. He looked sick and recoiled when touched.

The sad truth was revealed at the South Side boy's autopsy. Besides recent trauma, doctors found old burns on his lower body. Those on his feet were so severe, the skin melted, making his toes appear webbed.

The inspector general's review determined caseworkers at a DCFS-funded transitional living program, where the young mother and her son were placed, failed to act on several warning signs, including the teen's dropping out of school and frequent no-shows for services. The facility also was operated by Lakeside Community Committee, the Chicago foster care agency.

Workers never reached out to Nashawn's father or investigated the mother's new boyfriend, according to records. Staff went eight weeks without seeing the boy the summer he died, and despite their concerns, caseworkers never called police or the hotline, the inspector general found.

The mother, Nashella Johnson, served a short prison term for child endangerment. She admitted self-treating her son's burns because the then-19-year-old feared the state would take him away, according to records.

Her boyfriend, Tyrone Wilson, 31, faces murder charges. Police said he confessed to hitting Nashawn when the boy's cries woke him.

The inspector general recommended, in response to the case, tighter controls and more oversight — such as protective day care for kids who are too young for school — when the parenting ward has a history of mental illness, substance abuse or violence. Johnson met all of those requirements, records show.

Two weeks before her son's death, Johnson returned to her transitional living apartment and said she wanted to come back. She brought Nashawn along. The next meeting, days later, she came alone and said her son was out of town with his father. The caseworkers never met the dad or his family as should have happened.

The boy died one week later. Johnson told the Tribune she blames herself.

"I feel like, at that point in my life, there was probably nothing they could have done," she said of her caseworkers. "It was all under my control."

Angel Hill

2 years old, Chicago. Died Oct. 11, 2010

She loved princesses, all things purple and splashing through the Millennium Park fountain.

At birth, DCFS placed Angel with her grandmother, Beatrice Topps, after an older sibling suffered a broken leg in their mother's care, according to records and interviews.

Topps said she was nervous about letting her grandchildren out of her sight but felt she had to go along with a court order letting her daughter, the children's mother, have unsupervised overnight visits.

Six months later, Angel suffered a painful death.

Her autopsy showed 17 internal injuries, including trauma on her head, stomach and heart.

A contractual foster care agency that DCFS is supposed to monitor knew the mother was dating a recently paroled convicted murderer but insisted Angel and her two siblings were safe, records show. The judge overseeing the custody case barred the boyfriend from having contact with the children, but she allowed the mother's overnight visits to continue.

Topps said that by the time she found out about the boyfriend, it was too late.

"I just felt like something was being hidden from me," she said. "If I had known, I would have asked them to revoke my daughter's visitation, but (the foster care agency) told me I had nothing to worry about, that everything was OK."

The mother, Angel Green Hill, 34, and boyfriend Anthony Prater, 39, face murder charges.

Prater was paroled in May 2009 after serving part of a 35-year sentence for stabbing a rival gang member at Harper High School in West Englewood in 1989.

Robert Harris sued Lakeside Community Committee, alleging negligence. The inspector general agreed. Both allege the caseworker at Lakeside failed to act after learning that Angel had suffered an earlier injury in the mother's South Chicago neighborhood home.

The worker ignored the judge's order to ensure the boyfriend didn't live there and trusted the mother despite her troubled past, the lawsuit states.

Officials at Lakeside declined to comment.

Harris alleges the caseworker didn't mention the new boyfriend to court officials, who stumbled upon his existence while reading the mother's latest therapy report during a hearing to determine if she should get her children back. Asked if she did the required background check, the caseworker said there was "something about murder" from long ago, records say.

Carpediem Coffey

7 months, Hickory Hills. Died Feb. 4, 2008

When he was 3 months old, Carpediem suffered a broken leg. His parents said his 3-year-old sister stepped on him, but the doctor who treated him was suspicious and called DCFS.

The investigator found credible evidence of abuse. Still, rather than take the baby into protective custody, the worker created a fake safety plan, lied to her supervisor, forged documents and fabricated case notes of interviews and home visits she never made, the inspector general's report said.

Four months after the ER visit, the infant died of severe head trauma.

His mother, Angelica Bisaga-Coffey, 28, confessed to shaking her son and slamming his head against a changing table.

Bisaga-Coffey said it made her feel better to see him cry, according to records. She was sentenced to 10 years in prison on aggravated battery charges.

"She was a young mother with a history of mental illness and postpartum depression," said her lawyer, Patrick Campanelli. DCFS "knew the baby was abused before and did nothing."

The inspector general recommended the investigator be fired. She later resigned. In the safety plan, she said Bisaga-Coffey's mother would stay with the couple, and a friend would help. But three days later, Carpediem was released from the hospital to the friend, who took him to the parents' south suburban home without Bisaga-Coffey's mother.

The investigator told the parents to lie about the safety steps being followed if asked, records state.

Records also show the investigator did nothing despite knowing the baby missed five doctor's appointments. She falsely documented that the mother passed a mental evaluation and told her supervisor she sent the case to DCFS' intact family services program when a referral was never made, the inspector general determined.

The father, Anthony Coffey, said he found Carpediem limp and unresponsive. Coffey, of Glendale Heights, said he tried in vain to awaken the child.

He went along with the investigator's plan, he said, so his son wouldn't be taken away. Coffey said it wasn't until later that he learned documents had been forged in his name.

"I never signed anything," he said. "I know for a fact my son would still be alive and here with me today if they had done their job."

Daniel Kiezel

6 weeks, Chicago. Died Sept. 11, 2009

Danny was in trouble even before he drew his first breath.

He was born with a mix of Vicodin, morphine and other drugs coursing through his body, the inspector general's report said. Two weeks later, after his mother failed to produce proof of a prescription or bring Danny in for a follow-up visit, a doctor called the DCFS child abuse hotline.

DCFS records show the child was removed from his parents' care and placed with his grandmother. But when he died at 6 weeks old, it was in his parents' Portage Park home.

A DCFS investigator had falsified his case notes, stating he had placed Danny with the grandmother when, in actuality, no safety plan for the infant was ever pursued, the inspector general's report said. The investigator lost his job.

"DCFS bungled this from the beginning," said Ken Shubert, the child's grandfather. "They should have taken the baby when he was born with drugs in his system. Maybe the little guy would still be alive."

The cause of Danny's death remains undetermined, according to the autopsy. No one was ever charged.

DCFS said it found credible evidence of "death by abuse." The parents were described by the police as uncooperative and high on drugs, the inspector general's report said.

The father said Danny fell under the water during a bath, but no water was found in the child's lungs, the report said.

Shubert said the boy was the only child of his daughter, Sabrina, who died of a heroin overdose months later.

He has only one close-up photo of his grandson, which is displayed on a shelf in his Glen Ellyn home.

Alma Perez

13 months, Kankakee. Died Feb. 19, 2010

An investigator was suspended for failing to protect Alma, who was killed 16 days after her baby sitter called DCFS to report bruises on the girl's face, the state report said.

She should have been taken into protective custody but instead remained in an unsafe home because of a delayed response and sloppy investigation, the inspector general found.

The baby sitter called the hotline Feb. 3, 2010. It took two days before the investigator saw Alma. By then, the bruises had faded, but the sitter showed the DCFS investigator digital photos of the injuries she took four days earlier.

The investigator never collected copies and only showed his supervisor the photos he snapped, in which bruises no longer were visible, according to records and interviews.

He inaccurately characterized the facial injuries as bruises on her legs and a black eye in his written risk assessment. The inaccuracy was relayed to a nurse practitioner in a faxed referral form seeking an evaluation of the girl's injuries. The investigator never spoke to her, and she was never told that the mother was accused of abuse, records show.

The nurse practitioner who saw the girl the next day determined the faded bruise near her eye was consistent with the mother's explanation that Alma was hurt when her sister pulled her out of her crib. The medical professional told state officials she would have ruled differently if shown the original photos or told of the abuse allegation.

The DCFS investigator recommended that the hotline allegation be unfounded, meaning no credible evidence of abuse existed. Three days later, on Feb. 19, Alma was rushed to the hospital. Bruises covered her face and torso.

Police said her mother, Gregoria Perez, beat and suffocated the baby to stop her crying.

Perez, 26, is facing murder charges. DCFS has taken Alma's older sister into protective custody.

It was later learned the Spanish-speaking baby sitter called the hotline two days before Feb. 3 but hung up because a bilingual specialist wasn't available. DCFS is required to have Spanish-speaking workers on duty or provide an automated translator service.

Jay'Meon Wyatt

21 months, Chicago. Died July 18, 2010

Two months before Jay'Meon died, the child abuse hotline received an urgent call.

A nurse said she had just left a Bronzeville apartment and was worried about the disabled toddler who weighed 13 pounds. She said his mother, Doulesha Wyatt, refused to go to the hospital because her husband "doesn't like people in their business."

The investigator was at the door within hours of the call. She determined the home was safe enough for Jay'Meon and his two sisters even though the mother had a bloody wound and might have been stabbed, according to records.

The investigator's notes do not mention any discussion with doctors about a history of domestic violence or the mother's fragile mental state.

In her written risk assessment, the investigator inaccurately answered "no" to questions about whether the child had a disability that could make him more at risk of harm, DCFS records show.

And key interviews with neighbors who would have attested to her mental condition weren't pursued.

The investigator and a supervisor determined the hotline allegation of "failure to thrive" was unfounded. But due to problems in the home, they recommended that an intact family services caseworker monitor the family.

Jay'Meon died five days later. Doulesha Wyatt confessed she threw him into the radiator while under the influence of alcohol.

Her mother, Josephine Bridges, told the Tribune: "My daughter was too fearful to cry out for help. They should have taken the babies out of that house and given them to me. I would have taken them in a heartbeat."

Wyatt, 25, is serving 79 months in prison for involuntary manslaughter.

Speaking generally, DCFS Inspector General Denise Kane said investigators sometimes mistakenly believe confidentiality issues bar them from disclosing to doctors and nurses a family's relevant history, such as domestic violence and substance abuse.

"This was a big myth in the field," Kane said. "There has to be a full professional exchange between the investigator and the medical professional."

Ashton Sistak

2 years, Savanna. Died Aug. 30, 2010

Ashton died after suffocating in an inflatable bouncy castle at his baby sitter's home near Freeport in northwest Illinois.

The inspector general's report found the DCFS investigator broke agency rules and missed repeated warning signs, leaving Ashton with the woman even though her family had 25 prior DCFS investigations involving allegations of abuse, domestic violence, drugs and inadequate supervision.

The boy's mother lost parental rights to an older son in 2009 due to drugs and domestic violence, the report said. She gave birth to Ashton in another state but returned to Illinois the month before his death.

Seven days after a hotline call alleging the mother went out drinking with her new husband and left the child alone, DCFS received a second, similar complaint, the state report said.

The mother had left Ashton in the baby sitter's care while she and her husband were out of state at a social event, the report said. One day after the second hotline call, the investigator went to the sitter's house and took pictures of Ashton, who had facial bruises and scratches, according to the report.

The worker investigated the baby sitter's family in five earlier cases, but on his written assessment, he marked the house as safe and answered "no" to the question of whether there was prior history, according to records. The investigator left Ashton there without going inside the home as required, the inspector general's report said.

At the time, the sitter was watching six other children under age 12. Police said the woman told them she was doing chores while Ashton played in the enclosed castle.

The baby sitter said she heard the sound of the mechanical pump being turned on and off, but she never investigated further. After some time, she looked out the window and saw Ashton lying motionless inside the castle, records state.

The boy died in his father's arms the next day.

"I stayed until the coroner took him out," said Mark Meador, the mother's ex-boyfriend. "I didn't want to leave him alone."

Authorities determined Ashton's death was accidental. No one was charged, but DCFS ruled the baby sitter was negligent and took her children into protective custody, records state.

Meador said he repeatedly went to the local DCFS office asking for help as he sought custody of his son. The boy, he said, was often dirty and had diaper rash.

"They'd always say, 'We're working on it.'"

cmgutowski@tribune.com

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