By the time he was rescued last year, the 5-year-old South Los Angeles boy was so malnourished his kidneys were failing. His hands were so badly burned he could barely open them.
Child welfare officials traced his history, trying to make sense of what had happened. According to documents obtained by The Times, they learned that eight separate agencies in Los Angeles County had pieces of information on the household:
One had evidence that the mother and her girlfriend were abused and neglected as children. Others knew both had committed violent crimes. Still others were aware that both women had been ordered into mental health treatment and that the sickly boy had missed appointments with county doctors.
Over the years, these agencies had come into contact with the boy or his caregivers 108 times -- yet no one had pieced together how much danger the child was in. Indeed, county social workers had closed a 2005 child abuse investigation because the evidence was "inconclusive." They might never have stepped in but for a concerned stranger who delivered the child into their hands.
It was a lesson in how poor communication had put a child's life at risk -- but it was hardly the first. For at least 18 years, Los Angeles County has repeatedly received urgent and sometimes gruesome reminders that its agencies don't share vital information about potentially abused or neglected children, according to a Times investigation.
There have been numerous calls for reform -- but little action. In the passing years, an unknown number of children have been harmed or killed.
At least a dozen reports have landed on county leaders' desks since the early 1990s saying agencies that work with troubled families must improve their ability to talk to each other. County supervisors have freely admitted that the system is broken, and even have voted several times to establish computer systems to open communication channels.
Solutions have been doomed by bureaucratic infighting, turf wars, privacy concerns and limited political attention spans. When horrific deaths or abuse drop out of the news, the board and department heads often focus elsewhere, leading to long stretches of inaction -- until another case gives them a terrible jolt.
"I couldn't believe it," former Supervisor Yvonne B. Burke said last year, upon learning of the 5-year-old's ordeal. "Our system has to be just tighter. . . . This is a time when we really have to be vigilant."
She joined her four colleagues in once again ordering county workers to draft a plan to improve information sharing. The plan has yet to materialize.
Meanwhile, county officials recently acknowledged that at least 32 children in L.A. County died from abuse or neglect in 2008. That set off another round of questions about what was needed to make kids safer.
"If we had a computer system that allowed us to the see the domestic violence, medical or mental health history in some of these families, some of these children might have been saved," said Trish Ploehn, director of the county Department of Children and Family Services.
To those who have followed the issue over the years, these words are sadly familiar.
Baby boy starves
The evidence was there for all to see in 1991.
A baby boy, Travon S., had starved to death. On sheets of paper stretching across two walls, then-Sheriff's Det. Ron Waltman diagramed in rich detail how Los Angeles County had repeatedly failed the child.
His audience included dozens of people -- officials from the coroner's office and Family Services, supervisors' appointees, health authorities and others. Police had known about violence between the parents and drunken brawls with neighbors. County doctors had treated the child, even dispatching health workers to find him after missed appointments. Family Services workers had investigated allegations of child abuse.
Ten agencies in all had connected with the family 52 times over the years, starting before Travon was born -- but, as Waltman made abundantly clear, none were talking to the others.
"People just snapped to attention," Deanne Tilton Durfee, the longtime director of the county's child abuse task force, recalled in 1995. "It was beautiful to see how dumb we really were."
County supervisors tapped Tilton Durfee to push for changes in Sacramento. The next year, legislation was passed intended to make it easier for mental health, medical, educational, criminal and family services agencies to share records. For Los Angeles County, such a computerized system would cost little to operate -- about $600,000 a year.
But the effort quickly lost steam.
For nine years -- from 1992 to 2001 -- the system was stalled as L.A. County agencies squabbled over who should pay what for the system and which staffers should be allowed to use it, said Tilton Durfee.
Four more years went by as the union representing social workers argued that the system would unreasonably increase workloads, Ploehn said. The union did not respond to a request for comment.
Finally, in 2005, the Family and Children's Index was ready for use. But it proved an enormous disappointment -- even to those who built it.
In response to privacy concerns among supervisors and lawmakers, it provided a minimal amount of information. And even that was cumbersome to retrieve.
For instance, Family Services could get records from the Department of Mental Health only if the two agencies were already working together on a case. Then they had to form a three-person committee to investigate. Then investigators had to contact mental health workers for details because information in the computer was so limited.
Individual agencies were free to decide which cases to enter into the index. They were not guided by the factors that Family Services investigators used to compute risk.
"It was junk in, junk out," said Waltman, who has left to work for the San Luis Obispo County Sheriff's Department.
Many agencies -- including schools, the county coroner, probation and the Los Angeles Police Department -- provided no information at all.
That proved a problem as investigations increasingly were carried out by less experienced social workers, many of whom lacked personal contacts in other agencies.
Today, just 11% of caseworkers for the Department of Children and Family Services use the index, according to department statistics.
A child's suicide
In 1998, a 12-year-old boy killed himself at an emergency shelter for foster kids, the MacLaren Children's Center in El Monte. Jason Pokrzywinski had been under the watch of an aide when he slipped away and inhaled propellant from a can of hairstyling foam.
Though the death may not have been preventable, investigators found that mental health professionals, physicians and social workers at the facility were not sharing information even as they worked side by side.
Children's advocates mobilized. Members of the county's Commission on Children and Families -- a volunteer panel appointed by county supervisors -- enlisted the board's support in developing a new system to link various agencies to prevent neglect and abuse.
Then turf battles erupted. The commission and Tilton Durfee's task force, which have a long-standing rivalry, did not work together.
Federal authorities balked, saying the new system would compete with an existing network they had paid for that allowed child welfare authorities across the state to share information. They threatened to pull their money.
The county could have forgone federal funding or tried to incorporate its new system into the federally sponsored one. Instead, supervisors abandoned the commission's idea altogether, according to commission members.
Every year since then -- and twice in 2001 -- the commission has recommended creating a better communication system, dressing the same idea in different phrasing. In 1999, they called it an "Internet Passport;" in 2003, "Health and Information Education Local Information Exchange," or HELIX.
Last fall, after the rescue of the 5-year-old from South Los Angeles, county officials seemed to be taking the idea seriously once again. About a dozen officials -- including supervisors' aides -- took a foundation-sponsored field trip to study a successful system in Allegheny County, Pa., home of Pittsburgh. The system is known as Data Warehouse and connects 80 separate computer systems with one central database.
By whatever name, the idea never got off the ground in L.A. County
Injuries, then death
On Oct. 10, 2005, a toddler with a severely broken arm was taken to Garfield Medical Center in Monterey Park by her great-aunt.
Severely dehydrated, Sarah Chavez stared blankly and did not respond to pain. After rebuffing doctors' requests to do a CT scan and other tests, the aunt took the girl home.
The next day, Sarah was dead. She had just turned 2.
The primary cause was a severed lower intestine, caused by a blow to her abdomen, the coroner found.
A month later, the partly decomposed body of an infant boy, Mikeal Wah-hab III, was found on the bed of an empty room in a cheap Monterey Park motel, covered with a beige blanket. The coroner said he died of a head injury.
Michael J. Gennaco, a special counsel hired by the supervisors, reviewed both deaths for the county, finding -- yet again -- that no one was piecing together information across agencies. His findings were detailed in two confidential reports addressed to the supervisors and reviewed by The Times.
According to Gennaco, Sarah Chavez had come to the attention of police and social workers on Jan. 1, when her mother gave birth to a stillborn infant into a toilet.
Police learned that the toddler was living with her great-aunt and great-uncle in Alhambra. After visiting the home, officers noted in their report that the girl showed signs of abuse, taking pictures of bruises under each eye and a cut on her nose. She was placed in foster care.
When it came time to present the evidence of abuse to a court, however, a new social worker was handling the case. Without ready access to the police report and photos, she did not cite or produce them.
The court referee ordered Sarah reunited with the great-aunt and great-uncle.
The uncle was later convicted of involuntary manslaughter and child abuse. The aunt pleaded no contest to being an accessory.
"It appears that various DCFS personnel were unaware of vital information concerning Sarah," Gennaco wrote. "It is also apparent that various [other] agencies . . . may have been unaware of basic information concerning Sarah, either because information is not routinely shared, or because it is not easily accessible or obtainable.
"Whatever the reason, the failure to access or communicate important child welfare information -- either within DCFS or between agencies in the child welfare system -- is a fundamental flaw that placed children in the system at risk."
Gennaco noted similar failings in the death of the infant found in the motel.
Weeks before, the baby had been judged healthy by Family Services investigators who examine children living on skid row.
What the investigators did not know was that the family had had contact with at least four agencies in the prior two months -- housing, social services and mental health agencies as well as a nonprofit that processes mental health benefits.
An employee at the nonprofit told his boss that he was concerned about the father's ability to care for the child.
Family Services investigators knew nothing about what these agencies had observed.
Seeing no obvious signs of abuse and finding no records of a hotline call alleging abuse, the investigators found no cause to check further even into the records of Family Services own database. Had they done so, they would have learned that an older sibling had been removed from the family three years earlier after testing positive for cocaine exposure.
The boy's father, charged with assault on a child, pleaded not guilty. A pretrial conference is set for next month.
Supervisor Gloria Molina took a deep personal interest in the infant's case, launching a system in which county departments began to effectively share information about children on skid row. But she was unable to expand the program, in part for lack of money.
Gennaco's final report was delivered May 19, 2006. Instead of acting on his broader concerns, the board quietly ended his assignment reviewing child deaths.
He had been doing the work for free.
Evidence of torture
In the end, the evidence was etched on the South Los Angeles boy's emaciated body: cigarette burns on his genitals, whip marks, scars on his hands from a hot stove.
Strangers stepped in before the county did. Within days of one another, one called after hearing the 5-year-old complain about his burns in a Metro Rail station, and another called from a college admissions office where the mother had applied, saying the boy appeared hurt. A third person plucked him off the street and delivered him to authorities.
Until he was rescued, the sum total of what social workers were able to glean from fellow agencies was that the mother had gone to prison in 2005 and the boy had received all necessary vaccinations. Family Services should also have known from its own records that the mother and girlfriend were abused as children -- a risk factor for becoming an abuser.
"I was angry and hurt because we had spent nearly 20 years trying to avoid this very situation," Tilton Durfee said. "It was so clear that this case was preventable."
In a way, the 5-year-old was lucky. He lived.
At least three other children died in 2008 who might have been saved by a better computer system, according to Family Services Director Ploehn.
They included a 2-year-old Pomona girl who died of malnourishment, a 2-year-old Los Angeles boy whose mentally retarded mother left him with a violent stranger and a 6-month-old Carson boy who suffocated when his mother put a sock in his mouth.
In each case, social workers lacked vital information possessed by other agencies that probably would have led them to remove the child from the home.
At a recent meeting during which the latest deaths were discussed, county supervisors expressed shock at the recurrent tragedies.
"Who let these children fall through the cracks?" asked Supervisor Mike Antonovich.