DENVER—A state inquiry into the deaths of 13 children who died in 2007 while under human services care prompted several rule changes designed to correct flaws in the system.
The inquiry found that children with parents moving around the state were difficult to keep track of, including 7-year-old Chandler Grafner, who weighed 34 pounds when he died in May 2007.
Grafner’s guardian, 27-year-old Jon Phillips is on trial in Denver for murder, after prosecutors said he starved Grafner.
Among the 10 rules adopted by the state Friday is the requirement that all people living in a house be interviewed, not just the person in charge of the child’s care. Also, social workers now need to call other counties to confirm they’ve received a case being referred to them, and there is a greater effort to promptly document cases investigated on weekends and holidays.
Grafner’s case was investigated on a Saturday.
“In one or more cases, there were notes that caseworkers had that had not made it into the database so that other people could look at them,” said Liz McDonough, a spokeswoman for the Colorado Department of Human Services, which oversees the human services departments of the state’s 64 counties. “You have to take that into account when assessing the level of risk to child.”
In Grafner’s case, Denver human services worker Salwa Ramadan testified Friday that she did not know that Chandler and his younger brother had been in contact with human services in Jefferson County. Chandler’s younger half brother, Dominick, was Phillips’ biological son. Chandler and Dominick were placed in Phillips’ care by Jefferson County human services, but the information wasn’t in a database checked by Ramadan, according to testimony.
She didn’t know Phillips wasn’t Chandler’s biological father, which could have influenced her efforts to place the children in foster care or try to find biological relatives, according to state rules.
Ramadan said she noted several disturbing details, including that Chandler had not eaten breakfast the day police conducted a welfare check Jan. 20, 2007. “I’m bad. I don’t get things,” the boy told an officer who asked him if he had eaten, according to court testimony.
Ramadan also noted that Chandler spoke about Phillips’ concerns that Dominick was beginning to act like Chandler.
Police conducted a welfare check and took the boys to a crisis center staffed by Ramadan, after school officials noticed that Grafner had a bruised ear.
Other changes adopted by the state were:
Clarifications of certain types of abuse, and types of findings; the addition of risk factors in considering whether to remove a child from the home, including age of victim, high mobility and substance abuse; requirement that the past history of a parent be reviewed regardless of the number of referrals; and more detailed documentation of interviews and other client contacts.
