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The system that is supposed to protect Colorado children from abuse is inconsistent, communication among workers is sporadic and workers across the state are waiting for basic training to help them do their jobs, a state review has found.

The review began in January, after the deaths last year of 13 children whom counties were supposed to be protecting from abuse.

Some of the 13 cases involve children whose names are familiar: Chandler Grafner, the 7-year-old boy who starved to death in a Denver apartment in May; Neveah Gallegos, a 3-year-old Denver girl whose body was found in a shallow ravine in September after a massive search; LoReyna Barea, who was 7 when she died of “blunt force injuries and acute dehydration” in March 2007.

In other cases, the children lived and died almost unnoticed. One, a boy who was born and died last Christmas Eve, was never given a name. The review was done to determine whether, in those 13 cases, something was missed or could have been done differently and might have saved a child’s life.

“In several cases the answer for me was yes,” said Karen Beye, executive director of the state Department of Human Services.

“There were children who died in large metropolitan counties, and in small rural counties, in counties that are rich in resources and counties with very few resources,” Beye said.

In three of the 13 cases, county departments didn’t collect enough information from callers reporting suspected abuse before they decided not to investigate those claims.

In six of the cases, reviewers could not determine whether county workers had checked to see if the family had a history with the child-welfare department.

In one case, a referral was not entered into the computer for four months.

County child-welfare directors across the state have received the report. Child-welfare officials in Denver, where three of the 13 children died, did not directly address the state review.

Rather, Denver officials referred to an independent assessment they commissioned, which was delivered last month.

“We believe that our third-party review improvement work plan addresses the corrective actions required in the state fatality report, several of which have already been implemented,” said Valerie Brooks, acting manager of Denver human services.

Statewide, as many as 160 children may have died from abuse and neglect in the past five years. But even that number is uncertain, because different computer systems have different numbers for child deaths.

The children died at a time when reports of suspected child abuse or neglect rose 43 percent across the state, from just over 50,000 in 2000 to more than 71,000 in 2007.

“Resources have not kept pace,” Beye said.

Gaps in cooperation

Money for training child-welfare workers was reduced by one-third during the state’s 2002-03 budget crisis, Beye said. As a result the state, “does not currently have sufficient training resources,” she said.

Because of the shortfall, some workers around the state are investigating allegations of abuse or handling ongoing cases without basic training on how to perform those duties. State officials could not say exactly how many workers have not been trained.

Beye estimated the department needs less than $100,000 to eliminate the backlog, and said she hopes to find funding for that in the next few months.

The review found that communication problems between counties, documented as far back as 2002, persist. This is especially worrisome because families often move across county lines, the state reviewers said.

That mobility also underscores the need for county workers to be diligent in documenting cases on the state’s computer system, Beye said.

To address the problems, the Department of Human Services has made numerous recommendations, including a sweeping review and perhaps overhaul of regulations governing child-abuse investigations and potential expansion of state authority to oversee county child-welfare departments.

Some of the recommendations would require legislative approval, but some could be accomplished quickly — such as requiring investigators to talk to everyone in a household where abuse or neglect is suspected.

Gov. Bill Ritter is expected to make additional recommendations at a news conference today.

In Colorado, each county operates its own, largely autonomous child-welfare system, a structure shared by 12 other states.

State reviewers had hoped to collect information about county workers, such as how long they had been in their jobs, their level of education and training and their caseloads.

Several counties balked at providing much of the data, and one unidentified county refused to provide any information on employees, citing confidentiality rules.

Beye said overall, counties cooperated and she would not characterize the relationship between counties and the state as adversarial. Still, tensions between the two levels of government were evident. In several fatality reviews, counties disagreed with state findings and recommendations.

Contacted Tuesday about the findings involving Zoe Garcia, a 7-year- old who died in Weld County, Judy Gri ego, director of the county’s Department of Social Services, said: “We felt the review was insufficient. The facts do not support the findings. We felt the report should be rewritten by a qualified review team.”

Public-health involvement

Beye said she has been working to improve relations, and will continue to do so.

“If we don’t find ways to work together, it will be difficult for us to improve the system,” she said.

In addition to examining state and county practices, the review looked at common characteristics of the children who were killed and their families.

Of the 13 children killed, five were a year old or younger.

In 70 percent of the cases reviewed, the child’s family had been involved in a domestic-violence incident.

The strong connection between domestic violence and child abuse is one reason child-welfare departments and public health providers need to work together more closely, Beye and the report concluded.

A number of child-abuse researchers nationwide agree. One is Dr. Richard Krugman, dean of the University of Colorado medical school.

“I think there are parts of the child-protection system that would be better done by the health system,” Krugman said.

Krugman said his comments don’t reflect the university’s position, but personal views developed over decades of child-abuse study.

“I’m suggesting that the health and mental health and public health approach be given the same amount of time and effort as the child welfare and legal systems have gotten.”

Of the 13 cases reviewed, 46 percent of the children killed were Latino; 38 percent were Caucasian.

Hispanic children died at a rate higher than typically seen in Colorado, or seen nationally, the report found.

Beye said that may be cause for concern.

“We may need to look at our ability to serve Hispanic families and our ability to be culturally competent.”

Many of the 13 children lived in families that were in flux, with relatives and domestic partners moving in and out of the household, and families moving from place to place often.

Abuse and neglect cases are complex, and working to combat them is not an exact science, the report stated.

And even if all the recommendations are adopted, Beye said, “there is no guarantee, no assurance that no child will die of abuse in the state of Colorado in the future.”

Karen Auge: 303-954-1733 or kauge@denverpost.com

Common traits

The state review of 13 child deaths in 2007 and a more general review of the deaths of children over the past five years revealed these statistics: