Mary Ann Hartman worried the little girl across the street was going to die.
Hartman’s baby monitor captured the 23-month-old’s screams and stifled sobs as her 300-pound foster mother sat on her. She recorded the horror coming from the house where the foster mother yelled and ridiculed and the children cried.
Hartman mailed the recording to El Paso County child welfare authorities with a note: “She really needs you. I am doing my part by writing to you, but you must do the rest.”
Then Hartman waited. She called the county when she heard more screaming, when she heard foster mother Jules Cuneo refuse to give the toddler food.
She wondered if anyone would rescue the girl with the toothy grin and big brown eyes.
No one did.
More than 40 percent of children who died of abuse and neglect in the last six years in Colorado — many beaten, starved, suffocated or burned — were known to child protection workers who could have saved them.
Those 72 children died despite warnings from relatives, neighbors, teachers and strangers — or even the baby monitor recording of blatant abuse sent to caseworkers. Many of their deaths were not only preventable, they were foretold.
It happens, on average, every 30 days. Somewhere in Colorado, a police officer investigates a child’s death from abuse and neglect only to learn the victim is a familiar face to county social workers.
Eight such kids have died so far this year.
A Denver Post and investigation of the Colorado child welfare system revealed a pattern of disturbing failures in which warnings were ignored, cases closed without even a visit and children given to foster parents who killed them.
Caseworkers and their supervisors failed to complete investigations in the time required by law 18 times before children ended up dead. They routinely — at least 31 times — did not contact neighbors and acquaintances who might have told them a child was at risk of harm or even death. More than half of the time, caseworkers violated at least one state rule when conducting abuse investigations, according to an analysis of fatality case reviews by the state Department of Human Services.
The system is plagued by a lack of accountability and transparency — every county in Colorado decides how to run its own child protection department, with minimal input from the state. It is so disjointed, state officials cannot pinpoint the average workload of caseworkers, and cannot fire or discipline a county employee.
Despite years of warnings from expert panels and earnest expressions of concern from three governors and legions of legislators, Colorado’s $375 million system to protect kids from dying remains stubbornly broken.
More kids have died of abuse and neglect in this state in the last five years than in the five years before that, and an increasing number of those children were known to child welfare workers before they were killed. This is despite that galvanized attention on the child welfare system.
“It’s 2012, and all the advancements we have in our society, whether it’s technological or medical, we can’t figure out how to keep kids safe?” said Stephanie Villafuerte, director of the Rocky Mountain Children’s Law Center, a nonprofit law firm that often represents foster children. “You are talking about dead children.”
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No one at El Paso County took Mary Ann Hartman’s letter and baby monitor recording seriously enough.
Alize Vick, the girl across the street, died five months later, in October 2007, after her foster mother hurled her five feet, head-first into a coffee table. Cuneo was enraged because the toddler wouldn’t talk to her.
A caseworker said she listened to the recording and visited the home. But the worker determined it wasn’t enough to take Alize away from Cuneo.
In many other cases that resulted in dead children, a caseworker never came at all.
Almost half of the children known to social services who died of abuse and neglect since 2007 had at least one call “screened out,” or not investigated, because child welfare workers deemed the allegations did not meet the threshold for child abuse or they didn’t have enough information.
Caseworkers had seven chances to help Ciarea Witherspoon’s family before she was left alone in a bathtub.
Seven times — the majority of them before Ciarea was born — someone called authorities to say things were not right at the family’s house. The allegations piled up.
What would it take for authorities to intervene?
Not the reports of guns and fighting. Not the claims that her father threatened to throw her mother in the trash and that he threatened to kill her. Ciarea’s 7-year-old brother had bruises and went to school with a black eye. Her brother was covered in feces, acted much younger than his age, and he sometimes pretended to slam his head into a wall and said his stepfather hurt him. He told people at school he might get cocaine under the Christmas tree.
In every instance, authorities chose not to intervene. Three of the seven calls were screened out. The four other times, caseworkers assessed whether there were safety threats and ultimately recommended against opening an investigation.
Then in June 2009, 6-month-old Ciarea and her 2-year-old brother were left alone at bath time. By the time her father returned from answering the door and cooking some chicken, she was face down in the water and unresponsive. She lived for nine more months — on a ventilator, with a feeding tube and a leg amputated due to an infection.
As she lay unconscious in the hospital, the state put her in foster care. Ciarea died March 18, 2010.
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Caseworkers assigned to Ciarea’s family violated several state regulations, including failing to interview key people after allegations of abuse prior to the little girl’s death. Arapahoe County officials told The Post there was “absolutely no connection” between the policy violations and the girl’s death, and that the problems were caseworker “training issues.”
That happens regularly.
In more than half of child abuse deaths in the last six years, caseworkers did not follow state policy regarding how to investigate neglect and abuse allegations, according to The Post’s review of state fatality reports. Of 59 reports released to the newspaper, 31 listed violations of state rules.
Caseworkers erred by screening out calls that deserved follow-up, failing to check on children within the time allowed by law and neglecting to communicate with law officers or another county’s child welfare division when a child moved, according to state reviews of the deaths.
Each case is a judgment call, and caseworkers can’t always prevent evil, said Ruby Richards, child protection manager for the Colorado Department of Human Services.
“Caseworkers don’t kill these kids,” she said.
Since 2007, the state has reviewed the deaths of 30 children who had an assigned caseworker — a worker who at minimum was tasked with visiting a home to find out whether ongoing oversight was needed. These are cases where allegations were not screened out but were elevated to require at least one follow-up.
That included Maria Darlene Gardner and her family.
El Paso County caseworkers were warned on Jan. 23, 2008, by an employee at a family services center that Gardner, distraught over her husband’s suicide, was making funeral arrangements for herself and her five young children.
A caseworker tried to “problem solve” with Gardner and helped her make a plan for babysitting so Gardner could go to therapy. The caseworker called Gardner the next day, and the mother told her she was “fine” and not suicidal. But five days later, on Jan. 28, Gardner gathered her five children in her Colorado Springs home, doused them with gasoline and set them on fire.
Four children survived, but not 16-month-old Ashya Joseph.
One child was on fire as he called 911.
“Why did you? … You killed them. Why did you kill them? I loved them,” the 8-year-old boy says during the phone call. The children’s burns covered 20 to 90 percent of their bodies.
Before Gardner set the fire, she looked into a video camera and explained she couldn’t live now that her husband was dead, and she wanted to bring her kids with her. She is serving an 85-year prison sentence.
A state review of Ashya’s death found El Paso County caseworkers had been alerted to problems involving physical abuse in the home six other times, beginning in 2004, but did not remove the children.
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The job of a caseworker is partly about following the law and partly about following instinct.
Caseworkers teeter along a thin line of respecting people’s rights to privacy in raising their children and the legal definition of abuse and neglect.
Parents can spank their kids, but they aren’t allowed to leave . The law doesn’t say what age a child can stay home alone; it’s a judgment call.
State law says child abuse includes the failure to provide “adequate food,” but that’s not exactly black and white. Just because a child’s home has only a half loaf of bread and Pop-Tarts to last two weeks, that isn’t necessarily cause to assign a caseworker.
The law also says abuse investigators must consider “accepted child-rearing practices” of the child’s culture.
Caseworkers are criticized when they tear children away from their parents and crucified when a child on their watch ends up dead.
“Social services is damned if we do and damned if we don’t,” Richards said.
State officials concede there are failures, times when inaction ends in a child’s death, but that there are examples, too, when a caseworker does everything right and a child still dies.
Gov. John Hickenlooper said caseworkers are “doing some of the hardest jobs on earth” and that state officials are reviewing child deaths, looking for ways caseworkers can improve.
“Was it they were busy? Were they overworked? Did they make several calls and they couldn’t connect on this allegation of neglect? They made three calls and they just got distracted?” he said. “What we’ve tried to do is create solutions for those parts of the problem we control.”
In the case of little Torrey Brown Jr., a caseworker chose not to intervene after the baby’s grandmother warned his life was in danger.
Torrey’s mother had said he was a crybaby, that she was going to strangle him, that he would end up in a casket, the infant’s father and grandmother recalled.
Torrey’s grandmother, Corinthiah Brown, got to keep Torrey for only one night after she told an Adams County caseworker she feared for his life. Then, after the caseworker told her she was overreacting, Brown said, she was ordered to give him back.
The baby was gone within a few months.
After a painstaking, 52-day search through trash 20 feet deep at a Commerce City landfill, .
Brown wishes caseworkers had taken her more seriously. And she wishes that even when they didn’t that she hadn’t backed down.
“I tried to stay out of the way,” she said, tears streaking her cheeks as she sat in her Aurora living room. “I never thought it would turn out like this. This is what I get.”
The state does not track whether its child welfare workers are overburdened with work, whether they are overwhelmed with so many kids they don’t try as hard as they should to talk to relatives, neighbors and babysitters to find out whether kids were safe.
Colorado is one of 11 states that do not report caseload data to the federal government.
In this state, each county decides what to pay caseworkers and how much work to give them. Expert panels have suggested the state study staff workloads, but state officials said that is not a priority.
The number of calls reporting alleged child abuse and neglect has jumped 20 percent from 2007 to fiscal 2011, yet the number of investigations opened based on those referrals went up by only 5 percent. In fiscal year 2011, only about half of the 107,854 referrals were investigated.
And state officials do not know whether Colorado has more caseworkers now than it did five or 10 years ago; counties, which are in charge of their workers, aren’t required to tell the state.
Adams County, for one, has three fewer caseworkers now than five years ago. In the same span, annual referrals regarding child abuse and neglect increased by 1,245.
Child advocates question whether there are an adequate number of caseworkers and whether Colorado and its counties spend enough to retain the best workers.
“You actually do get what you pay for,” said Des Runyan, executive director of , who is frustrated by what he sees as Colorado’s minimalist spending on child abuse prevention. “The good people find other things to do.”
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Colorado’s two previous governors — a Democrat and a Republican — zeroed in on one key flaw that hinders child safety in Colorado: a county-run child welfare system with limited state oversight.
After 7-year-old Grafner’s death in 2007, then-Gov. Bill Ritter, a Democrat, created an expert panel to study child welfare. Grafner, who starved to death, had been trapped in a linen closet with no food or water and only a litter box to go to the bathroom, even as school officials called child welfare authorities.
The committee worked for two years, , including a caseworker-training academy now open in Parker. But two of the biggest reforms died in a political battle that pitted county commissioners against state officials and child advocates.
The panel of child welfare experts wanted a statewide hot line to report child abuse, a central place to screen calls. And they wanted a regionalized system, where rural counties would combine resources and expertise.
“We looked at the urgency of this because of the well-being of children, who one or another seemed to be falling through the cracks in the most fatal ways,” said Ritter, who called the “turf issue” with counties one of the most contentious of his tenure. It was “terribly frustrating,” he said, that his child welfare task force could not get statewide data because each county has its own authority.
Former Gov. Bill Owens, a Republican who held the office before Ritter, recalled the same problem.
“We have a real challenge because authority is so diffused,” he said. “Where you would think that a governor and a state have the responsibility and authority, in many cases they don’t. While many of our counties have very strong departments of social services, regrettably, some do not, and it’s very hard to establish statewide accountability and structure when there are such huge variations.”
Hickenlooper stopped short of calling for less county control, but said he might consider it in a few years if his administration’s reforms don’t work.
Hickenlooper’s key effort is a state scoring system, created by the new director of the Colorado Department of Human Services, that rates counties’ handling of child abuse investigations and He hopes public pressure will encourage county departments to improve their work, given the state has limited authority over them.
“We are always going to be one step removed because the counties are going to have that ultimate control,” Hickenlooper said. “Now the only way that I can see that the state can begin to exert serious authority … is through transparency.”
It’s one reform in a list of overhauls announced by Human Services director Reggie Bicha, who took over the department in January. He also has called for clearer and more consistent procedures across all counties.
“We are trying to shift a huge ocean liner in our child welfare culture in Colorado,” Bicha said. “I want us to turn the boat in a better direction for kids and families.”
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About 30 kids, on average, die of abuse and neglect in Colorado each year, putting the state among the top half nationally in per-capita death rates. Since 2007, 175 children have died of abuse and neglect in Colorado.
“It’s all of our fault,” said Skip Barber, executive director of the Colorado Association of Family and Children’s Agencies, a group of not-for-profit advocacy agencies.
More often than not, child abusers are the children’s own parents, a relative or their mother’s boyfriend. Those are the people to blame.
But the blame stretches further, experts said.
“Children don’t vote. They don’t have a strong enough advocacy,” said Tracey Feild, director of the child welfare strategy group at the . “There is an assumption that abused and neglected children are only ‘those’ people.”
Clearly, though, even when people plead for help, that is not always enough.
The El Paso County caseworker who listened to the baby monitor audio recordings of 2-year-old Alize Vick said there wasn’t enough evidence to remove Alize from the foster home. The worker was reassigned to another county job, and the county revamped its practices so it could, among other things, react faster to help children in danger. The foster mother, Cuneo, is serving a 32-year prison sentence.
The girl’s neighbor who had recorded the abuse, Mary Ann Hartman, would tell a state Senate committee that El Paso County ignored her.
“I believe that preconceived ideas and attitudes can run through an institution like a virus,” she said. “I was met with skepticism and disrespect.”
She had written a letter, called and met authorities — but could not get their attention, Hartman said.
“I was in total disbelief … I was trying to save a little girl, and they would not believe me,” she said. “I kept telling them, she is going to kill the little girl. She will kill her, and they still did not believe me.”
Jennifer Brown: 303-954-1593 or jenbrown@denverpost.com; Christopher N. Osher: 303-954-1747 or cosher@denverpost.com; Jordan Steffen: 303-954-1794 or jsteffen@denverpost.com
Child fatality reviews
When a child who was part of the child welfare system dies of abuse or neglect in Colorado, county and state officials complete a child fatality review.
Those reports were the basis for many of the findings in this series of stories.
Caseworkers, county child protection supervisors and state officials review each fatal case — including any referrals involving the family before the child was born — to create a detailed history of involvement in the system. The review team identifies any risk factors that were present for the child or the family before the death.
The review determines whether there were any concerns or policy violations in the way caseworkers investigated claims of child abuse or neglect, said Ruby Richards, child protection manager for the state.
But the parameters for when and how a report is completed have fluctuated.
In 2011, state officials excluded an unknown number of children’s deaths from ever being reviewed by decreasing the amount of time within the child welfare system — from within the last five years to within the last two years — necessary to trigger a review.
Also, beginning in 2012, reports have provided fewer details about the child and the child’s family’s history with the department, Richards said. Instead of a narrative style, information is provided in a list, check-box format.
The reports also list fewer violations of state regulations, noting the violations only if officials determine they are “systematic” concerns.
“Pointing out an isolated issue doesn’t seem fair,” Richards said, explaining the policy change.
During a case review, a report might pass from the county department to the state and back to the county as many as four times. If the county department disagrees with the state’s findings, it is noted in the report. But corrective actions — other than additional training, review and supervision — are seldom included.
