The Colorado Human Services Directors Association in an Oct. 19 warned the problems “are crippling our work and putting the safety of children and families at risk.”

“I’m most worried about child safety and something falling through the cracks,” said Dan Makelky, director of the Douglas County Department of Human Services who, as president of the county directors association, authored the letter. “I don’t think there is a choice. This has to get fixed. We need some urgency from the state.”

Among the most crucial functions of the computer system is the role it plays in assessing the risk a child faces when allegations of abuse are made. The system processes information from child protective staffers investigating alleged abuse to help guide decisions on whether to remove a child from a troubled home.

But the rollout of the new system has generated so many issues, the state’s help tech desk has been besieged by more than 3,000 requests for help from county child protective workers. Since the upgraded system went operational this past summer, it has crashed repeatedly without any alerts to county officials, Makelky said. When it is up and running, the system does not properly assess the level of danger for abused children, he added.

“Our workers rely on that system to look at the prior history of a family,” Makelky said. “And if the system goes down, they’re flying blind in terms of making critical decisions about a child’s safety.”

The county association’s letter was sent to Reggie Bicha, executive director of the Colorado Department of Human Services, and Suma Nallapati, Colorado’s secretary of technology and the state’s chief information officer.

Bicha and Nallapati responded to the complaints of the county association last Thursday, two days after The Denver Post asked state officials about the computer upgrade complaints. In to the county association, the two state officials said they “are moving expeditiously” to address the persistent problems.

The state is coming up with workarounds while some of the bigger issues get fixed, said David McCurdy, the chief technological officer in the governor’s office of information technology. He stressed that the modernization to the computer system eventually will yield benefits that reduce red tape that has burdened child protective staffers for years. Future updates planned in 2019 also will help create a more seamless experience, he added.

“Change is always a painful thing, but the state will be in a much better place as the system gets fixed,” he said.

When the new system went live in late July, staffers of the statewide child abuse hotline for several weeks lost their ability to process information in the computer system, Makelky’s letter states. The state never told county officials their hotline workers were shut out of the system, prompting widespread chaos.

The upgraded computer system is performing so poorly that child protective staffers spend, on average, an hour longer to complete assessments that determine whether a child should be removed from their home and placed in foster care, according to recent data. In more complex assessments, the delays drag on for days or weeks due to the technological issues, said Julie Krow, El Paso County’s executive director of human services.

Krow added that the upgraded system doesn’t always correctly score assessments.

“Sometimes neglect gets scored as an abuse case or abuse as a neglect case,” Krow said. “If one county does a risk assessment, and the family shows up in another county, the new county workers might rely on the system to make faulty decisions about that family or child. High risk shows up as moderate risk at times, which could potentially end up with a child being harmed.”

The Statewide Automated Child Welfare Information System, more commonly referred to as Trails, is used by about 6,000 public officials. It integrates with 11 other state systems that track child abuse and neglect cases, provider licenses, children and youth in the youth corrections system, foster and adoptive services and data required to gauge program effectiveness and adherence with government safety standards. State and county officials refer to the computer system as the backbone to Colorado’s child-protective system.

County child protection staff and supervisors say they have sometimes had to identify in the computer system potential witnesses of child abuse as clients needing services for abusive tendencies. Such entries are vexing because they end up labeling innocent people as child abusers, which could impact future employment since employers often check the computer system when making sensitive hires.

The modernization to Trails was a key part of Gov. John Hickenlooper’s reforms he promised after investigative reports in 2012 from The Denver Post and 9News. The newspaper and 9News partnered to review the cases of 72 children whose families or caregivers were known to the state’s child protective system before their death and found a lack of coordination between county and state officials, funding inequities across the state, lax state standards and overburdened child protective workers.

In the wake of the newspaper’s reports, Hickenlooper pledged that he would hire more child-protective staff and make other fixes. His promises included a technological upgrade he said would give a boost to child protective workers. They would be armed with mobile and computer tablets that would allow them to make in-the-field decisions that would protect the state’s most vulnerable children, the state said.

Beginning in 2015, Hickenlooper began putting resources toward modernizing the Trails child protective computer system, which was first put to use in Colorado in 2001. Federal authorities agreed that the state could use federal aid to pay half the upgrade costs. Each year, since then the state has continued to press the modernization project.

County officials say that when the upgraded system went live this year, they were swamped with complaints from their child protective staff. The main contractor the state hired to overhaul Trails, CGI Technologies and Solutions Inc. of Fairfax, Va., has resisted fixing problems because CGI contends those fixes aren’t part of the original scope of work, according to the letter from the county association.

Contract documents show the state originally planned to pay CGI nearly $10 million for its portion of the Trails upgrades. Those documents show the state repeatedly amended CGI’s contracts to raise the price the state owed CGI to more than $18 million, nearly double the original amount.

“What counties desire now is an urgency of action mirroring their own and a high-level awareness of the very real consequences caused by this latest release of Modernized Trails,” the Colorado Human Services Directors Association said in a report accompanying the Oct. 19 letter. “Most importantly, counties are concerned about the risk to child safety when the new Modernized Trails system cannot be trusted as presently released.”

A Sept. 18 memo from Minna Castillo Cohen, the director of the Colorado Department of Human Services’ office of children youth and families, acknowledged “55 bugs” in the modernized Trails system had been discovered, but said progress was being made on those issues.

The letter from the county association said that memo’s accounting downplayed the problems and differed from the 171 issues the state admitted a week earlier had been identified.

“In this informational memo, eight weeks after the release of Modernized Trails, the state acknowledged problems but listed no plan of action,” the county association says.

“The rollout of the project has been met with frustration from users as well as supervisors, managers and directors and has compounded the challenges and shortcomings of a nearly 20-year-old system,” the county association’s letter states.

Children who are beaten, starved or abandoned are likely to suffer emotional trauma so severe that it can impair the way their bodies and brains grow up — and, if never addressed, cause lifelong health problems.

But in Colorado, specific treatment for such emotional distress is rare, leaving these children vulnerable to being misdiagnosed as mentally ill or hyperactive when, in reality, they are exhibiting post-traumatic stress disorders, experts say.

As a result, these children are more likely to develop long-term depression and even illnesses such as cancer and heart disease. Some are given drugs they may not need.

“What has really emerged out of the science of the last 15 years is the evidence that when you abuse and neglect a child, it actually changes the way their brain is organized,” said Bryan Samuels, who oversees the U.S. Department of Health and Human Service’s programs for at-risk kids.

“It actually shapes the architecture of the brain.”

The science isn’t all that hard to understand. It has much to do with hormone levels that can rise dangerously during abuse.

High levels of the hormone cortisol, for example, affect impulse control and memory. Heightened stress also can damage the prefrontal cortex, the region of the brain that regulates focus, self-control and decisionmaking.

Unfortunately, hormone levels can remain high even after abuse victims are removed from bad situations.

That means fixing these broken children often requires more than putting them into a stable environment.

Doctors need to evaluate their physical development while counselors review the patterns and severity of past abuse to develop a long-term combination of psychological and medical care. Instead, many simply are treated as bad kids.

Emotional challenges

Dominique Mallard, 21, of Aurora said she felt that nobody understood her emotional challenges through much of her time in Colorado’s child protection system.

At 16, she and her 4-year-old brother were removed from her home because of unsafe conditions. She ended up cycling from foster home to foster home and in and out of treatment centers — 13 placements in all.

Along the way, she was separated from her brother, complicating her issues. She has since seen him just once, and only briefly, in a chance encounter in a discount department store. He waved at her from afar, too timid to approach.

“I feel that the system, they twist things up to where they don’t make sense,” she said.

In one treatment center, she was prescribed five mood-stabilizing medications, which she believes weren’t needed and which she has stopped taking now that she is an adult.

It wasn’t until her last placement that a therapist finally worked to understand her and the pain she had been through.

“It wasn’t until then that they actually looked at the problem instead of focusing on the behavior,” Mallard said. “In foster care, they label you as a horrible child. They never look at why you do what you do.”

Looking at the why — including the type of abuse, and when and how it occurred — is crucial because different kinds of abuse can have different impacts, experts say. The child’s age and the frequency of abuse can also play roles.

Children in the worst situations grow up more likely than their peers to abuse drugs and alcohol; contract sexually transmitted diseases; suffer from obesity, and heart and lung disease; and even commit suicide.

The more complex the abuse, the more likely the negative impact will follow a child into adulthood, according to an ongoing study by Kaiser Permanente and the Centers for Disease Control and Prevention that has been tracking the mental and physical health of more than 9,000 survivors since 1995.

Abused and neglected kids are 11 times more likely than their peers to get arrested for criminal activity as juveniles, according to another study by the U.S. Department of Health and Human Services.

And the problems persist: As adults, they are nearly three times more likely to get arrested for violent and criminal activity.

The cycle of abuse is hard to break. Nearly one-third of the victims will abuse their own children, statistics show.

Several of the children who died of abuse and neglect in Colorado since 2007 had parents who grew up in the child welfare system.

Anthony Angel and Brandi Strawn — whose 5-month-old baby, Antonio Angel, was shaken to death — had troubled childhoods and spent time in foster homes, state records show.

Anthony Angel now faces criminal charges in Pueblo County for allegedly killing Antonio while in a rage. His trial is pending.

More robust systems

That cycle and the sobering statistics have prompted Colorado officials to look to other states, such as Illinois, that have more robust systems in place for determining the traumatic impact children suffer.

In Illinois, minors entering the protective system get an initial survey and within 45 days receive a comprehensive assessment conducted with a licensed clinician that determines the level and frequency of their abuse.

Caseworkers use the information to create detailed treatment plans that differ from child to child. The plans are rigorously reviewed for effectiveness.

“The screenings and assessments allowed us to get to the children sooner,” said Samuels, who overhauled the Illinois system more than 10 years ago when he was its director. “They ended up having less problems in the long run. They had reduced level of trauma. They functioned better.”

Colorado wants to see similar success stories, but it has a way to go.

“The directive I have is to get trauma-informed care implemented systemwide and departmentwide,” said Dr. Lisa Clements, director of behavioral health in the Colorado Department of Human Services.

This year the state received a grant from the federal Substance Abuse & Mental Health Services Administration that will help eight counties test and craft assessment tools for abused and neglected children.

Colorado, along with the rest of the states in the nation, will have to meet new federal mandates enacted by Congress in 2011 requiring them to come up with plans for screening and treating trauma-related symptoms.

Some areas in Colorado are starting to forge ahead. The federal agency that Samuels heads provided a $3.2 million grant for the Kempe Center, which treats abused kids, to work with Denver child protective officials to develop a program similar to Illinois’.

“We are going to be putting trauma front and center in everything we do, creating an understanding of trauma so that when we work with families and children, we are working with the underlying causes of what’s going on with them,” said Nachshon Zohari, the administrator for mental health for Denver’s Department of Child Welfare.

A new kind of treatment

Children who are misdiagnosed with behavior problems are often prescribed psychotropic drugs that do more harm than good, said Dr. Gary McClelland, a leading behavior specialist and professor at Northwestern University.

“You do a great disservice to children if what you are treating is a manifestation of trauma but you are treating it as a mental disorder,” he said. “The treatment is quite different for trauma than what you would do for a mental disorder. You want to develop skills for that child that got interrupted when they got traumatized.”

Lately, scientists have expanded their focus on treatment into the brain itself.

Dr. Bruce Perry, a senior fellow at the ChildTrauma Academy in Houston, has used brain-scanning technology, including imaging produced by the Denver clinic CereScan, as part of a broad treatment designed to determine not just what’s wrong with a traumatized child in complex cases but also how best to try to repair the damage.

He said research shows that the neurological abnormalities that abused children develop, if left unchecked, will turn into health concerns as the child ages through adulthood.

In the 1990s, Perry and his team conducted a pilot study that assessed both the emotional and neural development of 400 children as soon as they entered the child welfare system.

The two-year pilot cost $1.5 million, but, Perry said, it ultimately saved money because children who got the upfront assessment were in care for a shorter amount of time.

And because they were able to identify which children had the most intractable emotional problems, “We were able to place higher-risk kids in a higher level of care,” which meant fewer moves and placements for those children.

Research showed the potential savings would have amounted to $25 million annually if the program had been spread throughout Texas, where Perry works, but no money was made available for implementation.

Mount Saint Vincent Home in Denver is one of the first treatment centers in Colorado to put some of Perry’s work into practice.

“What we used to do as a treatment center, we assigned every kid a therapist and every kid got the same package of therapy, which, most of the time, was talk or play therapy,” said Kirk Ward, Mount Saint Vincent Home’s clinical director. “Now, we conduct an assessment on all kids who come in, based on their history and the observation of the child and interviewing caretakers.”

Instead of trying to get kids to talk about what has happened to them — an approach many therapists now agree doesn’t make sense at an age when verbalizing anything can be challenging — Ward’s staff emphasizes repetitive tasks, along with music, art and dance, which “activate the brain.”

Some of those who end up caring for children from abusive homes are pushing for brain scans to craft treatments even though such scans are controversial. The cost is also high, about $3,450 per child, and Medicaid, which insures foster children, typically won’t cover that.

Inner turmoil.

Grant Oakes displays his grandson’s brain scan. Oakes became the legal guardian of the boy when he was 10 months old after the child’s mother used drugs and was abused by her partner in front of the child. When he reached his teens, the child began using pot, skipping school and threatening suicide. A donation from a friend allowed Oakes to pay for the brain scans that he said helped diagnose the child as struggling with a bipolar disorder. (Craig F. Walker, The Denver Post)

Grant Oakes became the legal guardian of his 10-month-old grandson after the child’s mother used drugs and was abused by her partner in front of the child. When he reached his teens, the child began using marijuana, skipping school and eventually threatening suicide.

A donation from a friend allowed Oakes to pay for the brain scans that he said helped diagnose the child as struggling with a bipolar disorder. Now on mood-stabilizing medication, the child has improved, though challenges remain, including issues of substance abuse, Oakes said.

“I love this kid, but we went through hell and back,” Oakes said. “If we would do these scans and get people help much earlier, then there would be so much money saved in the court system and in doctor visits, not to mention avoiding the grief that people go through.”

Christopher N. Osher: 303-954-1747, cosher@denverpost.com or and Jennifer Brown: 303-954-1593, jenbrown@denverpost.com or

Snowie Buehler’s memories of her 9-month-old granddaughter have been replaced by nightmares. Three years have passed, but Buehler still dreams of screaming and crying, trying to claw her way out of the trash bin.

“I miss her so much,” she said recently. “I don’t understand how someone can take somebody else’s life.”

It was Iyana’s misfortune to live in Pueblo, which had among Colorado’s lowest spending on specialized services aimed at helping troubled families struggling with child abuse and neglect issues. A Denver Post review found that for fiscal years 2007-11, Pueblo ranked 10th out of the state’s 10 most-populous counties in such spending per eligible child, a victim of an antiquated funding system Colorado is seeking to fix.

Buehler takes her share of responsibility for her granddaughter’s death on July 3, 2009. She knows she was the person who, exhausted one night, left Iyana in the care of other relatives, .

But she also blames Pueblo County’s child protection workers. They were the ones, she says, who never listened to her pleas for child care assistance when she took Iyana into her home after the girl’s parents were deemed unfit to care for her.

The fact that Boulder County, where the average household makes $64,839 per year, receives twice as much money for core services per eligible child as Pueblo, where the average household makes $40,699, infuriated her.

“That just doesn’t make any sense,” she said. “You would think the poorer counties would get more help than the richer counties, so to speak. We need it. It doesn’t matter what county you live in, if you need it, you need it.”

Since Colorado started providing what is called “core service” aid in 1994, funding inequities have troubled the program, according to interviews with state and county officials and a review of funding data.

Some counties aggressively sought the money, while others did not, creating a system that left parts of the state underfunded. Those disparities have grown even more pronounced over the years as counties grew and needs increased.

As a result, for nearly two decades, children like Iyana, living in counties that receive less of the money, had less access to core services, such as intensive family therapies, economic assistance, crisis intervention and parenting classes.

County child protection agencies rely on the money to help head off foster care placements and pave the way for children to return home from foster care.

This year, the Colorado Department of Human Services is trying to fix the disparities by factoring in demographics and the number of children eligible for service when money is distributed.

State and county officials will review the changes next summer. If they are made permanent, counties that have enjoyed greater allocations of core service aid will have to send some of it to counties with smaller allocations.

“It’s critical that we be fair and equitable,” said Melinda Cox, the administrator of the core service program for the state. “Every child and every family in the state deserves it. It’s the least we can do for Colorado families: provide equal access throughout the state for appropriate services.”

A review of funding data from fiscal year 2011 shows just how disparate the funding was.

Among the 10 most populous counties in Colorado, the average spent per eligible child on core services was $997.

Pueblo spent an average of $825, Boulder $1,711 and Denver $1,200.

In Boulder, where state data shows foster care cases have plunged by more than 60 percent in the last three years, the core service spending helped bolster a robust effort aimed at preventing children from sinking deeper into the child welfare system.

Certain troubled families there can expect daily checks by child protective workers, far more than are done in other areas of the state.

“Our basic premise is that when you provide access to food, access to medical care, access to safe and stable housing, when they are maximized to the greatest degree possible, you can move into other family issues, such as domestic violence or mental health issues or unemployment issues or substance abuse issues,” said Frank Alexander, the director of Boulder County’s Housing and Human Services.

The core service spending differences are especially pronounced in some of the state’s less-populated counties. Lake County pushed its average spending on core services per eligible child to more than $10,000.

In fiscal 2011, Lake County used some of the money to hire a counselor to work in the school district to address the needs of troubled families and children. Last year, the school counselor was replaced by a new county worker, funded by core dollars, who works with families struggling with abuse and neglect issues.

That worker acts as a go-between for those families and food-stamp programs, housing officials, mental health providers, probation officers and other providers.

“Now they all come together for common treatment plans so that there are not a million different approaches,” said Jeri Lee , the director of the Lake County Department of Human Services. “It consolidates services and creates more cooperation and collaboration on behalf of the families.”

State officials will limit the percentage of aid a county could gain or lose to prevent counties such as Lake from having to cut staff due to the distribution change. Still, significant change will occur if the reforms move forward.

For instance, Denver lost more than $700,000 in core aid this fiscal year. Boulder lost about $250,000. Pueblo gained nearly $250,000.

“In the recent past, people have been raising questions on how effective we are throughout the state, and how we are using our resources,” said Jose Mondragon, the director of Pueblo County’s Department of Social Services. “The process is driving us toward being more fair and equitable for counties, and, most importantly, helping the people in need.”

While the shift will take money from Boulder, county director Alexander sees the change as necessary for the greater good of children throughout the state.

“It is hard to lose core dollars through this particular process,” Alexander said. “But we don’t see it as penalizing us. It allows those counties that haven’t had access to core services to access them now.”

The $57.5 million in core service money counties spent in fiscal year 2011 made up just about 15 percent of the $375 million Colorado spent on child protection issues. About 29 percent of that amount was spent on placements of children outside their own homes in foster care or group homes. Just three years ago, those out-of-home placements happened more often, and they cost more than 33 percent of the state’s child welfare spending.

Colorado officials want to make sure that as those spending priorities continue to shift, they distribute the child protection money throughout the state effectively.

In an effort to prod Colorado’s system toward one that supports keeping children in the least restrictive settings possible, a system that uses foster care and group homes only as a last resort, the Colorado Department of Human Services has set aside $24,000 to pay a consultant, Larry Brown, the former executive deputy commissioner of New York’s children and family services, to review all of Colorado’s spending on child protection.

Two questions Brown is probing, according to Lloyd Malone, the director of child welfare in Colorado: “Does our formula incentivize the best way to serve families? Is it even antithetical to it?”

Brown said he is just starting his review and is reaching out to state and county officials. Any changes will require several years, he added. One change already is in the works. Federal officials this year approved a waiver for Colorado so the state can shift federal money that previously had to pay the room and board of foster children, whose numbers are on the decline, to family-support services, where need is on the rise.

It was only after Iyana’s death that the child protective system offered Buehler any help through child-care subsidies for her other two grandchildren, Elijha 8, and Abcde, 6.

“Everyone knew the circumstances,” Buehler recalled. “They knew we needed help, and they refused to help us. That’s all I wanted, day care. ‘Could you help us with day care? There’s day care right down the street.’ That’s all I asked for. That’s all I wanted.”

Iyana didn’t last a month after Buehler got custody of her. Exhausted one night and facing an early-morning shift the next day, July 4, 2009, at the Denny’s where she worked as a cook, Buehler sent her granddaughter over to her son’s mobile home for a night.

Kevin Buehler, 22, is serving 32 years in prison for killing 9-month-old Iyana Perez.

Her husband’s son from a previous marriage, Kevin Buehler, was staying in the trailer that night too. Snowie Buehler knew he had been convicted of assault for choking his sister. But to her, he was family, once a blond little boy who used to come to her house begging to play with her children.

There were three blows to Iyana’s head. His semen was found on her dress, which was in the trailer. He was sentenced to 32 years in prison for the killing.

“Who hurts a 9-month-old child?,” Snowie Buehler said. “What kind of person kills her and throws her in a trash can? You don’t think your husband’s family would do that to you.”

State officials who reviewed the circumstances of Iyana’s death found that the Pueblo County Department of Social Services should have looked “at the issues of financial support, child care, emotional support, how this family would manage caring for all three children, what services they would need, and to identify any gaps.”

Dawn Rivas, the primary child protective caseworker for Iyana, was promoted after Iyana’s death to a position as regional training specialist with the Colorado Department of Human Services in charge of training child protective staff in the southeastern counties of Baca, Bent, Crowley, Custer, El Paso, Fremont, Huerfano, Kiowa, Las Animas, Otero, Prowers, Pueblo and Teller counties.

“What I said when I heard that was ‘Good luck to those kids,’ ” Buehler said.

“I am not a fan of social services,” she said. “They could have helped me. They could have helped her. They could have helped these other two. Obviously, we were a family in need, and they could have helped, and they didn’t.”

Rivas declined comment. Her former boss, Tim Hart, one of two child welfare administrators in Pueblo County, said improvements have been made since 2009, the year Iyana died.

“There has been a significant change statewide in practice,” Hart said. “And some of that is where the allocation formula struggles. There is a shift from out-of-home placement to program services that are more flexible to support families in different scenarios.”

The family’s struggles continue. In October 2011, Elijha showed up at school with a scratch across his chest. His teacher told his grandmother she had to report the scratch to police. Snowie Buehler was charged with child abuse, but she said child protection workers tell her she remains the best option for Elijha and Abcde. Prosecutors dismissed the child abuse charge in July.

She says she loves the slender boy with cropped hair, the glasses and the serious demeanor who helps her program her computer. She says she loves his sister, who laughed on a recent sunny day as she ran to the car to lug stuffed toy after stuffed toy to the picnic blanket.

Later that night, with the children lined up on the couch, slurping on popsicles and watching cartoons, Buehler remembered an infant who hardly ever cried.

“I should have quit my job. My husband should have quit his job. My son should have stayed home. My daughter should have been better.”

We’re all to blame, she said, the family as well as society.

“None of us protected this child,” she said. “We all did what we thought we could do, but we didn’t protect her.”

Christopher N. Osher: 303-954-1747, cosher@denverpost.com or

Police and child protection workers in Colorado endanger the lives of abused and neglected children by failing to work together despite state laws meant to ensure collaboration, a review of state child death records shows.

Colorado law requires county human service agencies to have written agreements with all local law enforcement detailing how they will cooperate to save children and investigate their deaths. But when asked by The Denver Post to produce them, 16 percent of the counties could not.

Even if every county had an agreement in place, that wouldn’t resolve the distrust that can exist between police officials and child caseworkers.

“We work in an an industry of punishment, and they work in an industry of helping,” said Sgt. Jim Gerhardt of the Thornton Police Department. “They actually go well together. If you don’t understand that, you will get officers resenting the touchy-feely social workers, and you will have the social service workers thinking cops are Nazi Gestapo.”

After died at the hands of her mother’s boyfriend, concluded that a breakdown in communication between law enforcement and the El Paso County Department of Human Services played a role.

Human Services had helped Tamyrii’s mother, Tanesa, get her own apartment after her boyfriend was accused of sexual assault on 4-year-old Tamyrii.

Randall promised to stay away from the boyfriend, Tristan Price, but the month after moving into her apartment, the two got into a domestic dispute. Randall was evicted and landed in a shelter.

She eventually moved back in with Price.

The state review noted that Colorado Springs police did not tell child protection workers about that domestic dispute, even though social services was still monitoring the family.

Tristan Price was sentenced to 25 years in prison for killing , 4. Price was the boyfriend of Tamyrii’s mother, Tanesa.

Price killed Tamyrii about six months later, on Sept. 26, 2008, with force that nearly tore her liver in two. The coroner found eight broken ribs, three of which likely had been broken weeks earlier. Price pleaded guilty and was sentenced to 25 years in prison.

noted that the El Paso County Department of Human Services did not have the required memorandum of understanding, or MOU, with the Colorado Springs Police Department.

Such an agreement now exists, and it includes a recommendation that might have helped Tamyrii: a joint review and investigation between child welfare workers and Colorado Springs police when there is domestic violence in a child’s home.

El Paso County officials said that in addition to creating the cooperative agreement, they’ve made other improvements.

Now, key child protection workers work out of police stations, said Karen Logan, the child welfare intake manager in El Paso County. Police come to weekly child protective meetings. She attends quarterly meetings with the Colorado Springs police.

“We’ve always had a relationship with law enforcement agencies in this county,” she said. “From time to time, depending on staff changes, it might have been strained, but it was never nonexistent.”

State legislators, recognizing cooperation is critical in protecting children, passed a law in 1988 requiring written agreements between county human service agencies and every law enforcement agency in the county. The agreements are supposed to detail exactly how they will cooperate to ensure kids are safe and that any child deaths are properly investigated.

And yet, when The Post requested copies of those memorandums of understanding, 10 of Colorado’s 64 counties never produced the documents. Of those counties that did, seven drafted them after The Post’s request. Six others hadn’t updated them since the early 1990s.

A third of the memorandums of understanding didn’t have any signatures that would indicate whether police officials or child welfare workers ever read the documents.

Betty Donovan, director of Gilpin County’s Department of Human Services, said she has a 15-year-old, outdated agreement with the Black Hawk Police Department — one she said was so poorly drafted that it was useless. That’s better than what her agency has in place with the sheriff’s department or Central City police, she said.

Written documents don’t even exist for those law enforcement agencies.

“As far as a formal agreement, one that would be the best one, I don’t have a good one right now, which I know I have failed in,” Donovan said.

The agreements that do exist also differed markedly in the breadth of topics covered. Law enforcement officials in Ouray and San Miguel counties haven’t updated their cooperative agreements since 1995, the year they signed the three-page agreements.

In contrast, Denver’s child protection team in 2008 negotiated a detailed, 42-page pact with the Denver Police Department, the Denver District Attorney’s office and Denver Health Medical Center.

Allan Gerstle, the director of social services for Ouray and San Miguel, said state law doesn’t require the agreements to be updated or signed.

“You don’t do something you don’t have to do unless it’s statutory,” he said, adding that the counties he oversees are sparsely populated, so collegial relationships already exist between police and his workers.

“I know the cops, and they know me,” Gerstle said. “They call me at home. They know my caseworker. They call her at home. We don’t have an issue.”

Theodore Cross, a research professor at the children and family research center at the University of Illinois, said the written agreements do matter.

He reviewed 4,539 child-maltreatment cases across 36 states and found that communities with written agreements between law enforcement and child welfare agencies were nearly twice as likely to have conducted police investigations into allegations of child abuse and neglect than other areas.

“When you have so many different professionals involved and when the cases are so complicated and when the stakes are so high, it’s a well-established principle: the necessity for coordination in professional circles,” Cross said.

The Colorado Department of Human Services, however, does not monitor how law enforcement agencies and child protection workers interact or whether those agreements are actually in place.

Reggie Bicha, executive director of the Colorado Department of Human Services, said he wants the signed agreements but, more importantly, wants them to be well thought out. He said he has refrained from ordering all counties to immediately put them in place to ensure they aren’t just going through the motions.

THINKING AHEAD.

Reggie Bicha, executive director for the Colorado Department of Human Services , says he wants counties to have signed agreements between police agencies and child protection services – but, more importantly, he wants them to be well thought out. (Craig F. Walker, The Denver Post)

“We absolutely are talking to counties about our entire array of child protective services, so where does an MOU — because the state says you have to have an MOU — become more important to me than ‘Are your cases done on time?’ ” Bicha said. “We’re trying to balance a whole bunch of things right now to improve our system.”

Colorado was put on notice a decade ago that a lack of cooperation between police and child protection workers was an issue.

and found that conflicts between county child protection staff and law enforcement officers were one of several issues hampering efforts to protect abused and neglected children.

That review found “particularly crucial” the need for police to inform human services workers of a child’s death so that child protection workers and police can work together to “determine the safety of the remaining children and family members.”

Yet years later, problems persist.

Just last year, the Colorado State Patrol did not alert any county human services agency that a mother and her boyfriend had been charged with child abuse resulting in death and child abuse resulting in significant bodily injury after 4-year-old was killed in a single-car rollover crash, a state human services review of his death found.

Child protection workers in Summit County, where the wreck happened, and El Paso County, where the family lived, were not told that Charles’ siblings — ages 6 months, 3, 6 and 8 — were not wearing seatbelts or in a child seat at the time of the wreck.

Gerhardt, now detailed to the North Metro Task Force, a multijurisdictional drug unit, said such communication failures are common. He recalled conducting a training session in another state where child welfare workers complained police never returned their calls. It turned out they were using pager numbers because they were never told police had switched to cellphones.

He knows firsthand what a difference cooperation can make. Within six months of pushing his own staff in Thornton to work more closely with social services, the number of cases police referred to child protection workers was up by 70 percent.

Of the 59 abuse and neglect deaths reviewed by the state since 2007, the Colorado Department of Human Services found 13 instances where authorities failed to communicate, including a lack of cooperation during death investigations and a failure by police to alert caseworkers about children in danger. Other times, child protection workers failed to do the simple task of doing a criminal-background check on those accused of abuse.

Experts believe law officers had contact with most children who die of abuse and neglect.

WATCHING OUT FOR KIDS.

Lori Moriarty, a former commander of the North Metro Task Force, leads a meeting at the National Alliance for Drug Endangered Children office in Westminster. (Craig F. Walker, The Denver Post)

“If you look closely at all the child maltreatment deaths in Colorado, you would find out that law enforcement likely had some kind of contact with the family well before the death, and you will find that a lack of collaboration likely was a significant factor in not saving that child’s life,” said Lori Moriarty, the former commander of the North Metro Task Force.

After a career in law enforcement, Moriarty went on to work as vice president of the nonprofit National Alliance for Drug Endangered Children, a position that allows her to train police officers and child protection workers on the importance of coordinating efforts. She has also adopted two children whose mother was a drug addict.

She remembers the incident that changed her life: a 2002 drug raid of a Thornton house by officers equipped with oxygen tanks and respirators to protect them from the noxious fumes of a meth lab. Inside they encountered a barely clothed 14-month-old boy. The raid made front-page news.

Moriarty then delved into the statistics and found that in one year, 137 children had been left behind after arrests by the task force.

Of those children, half were known to child protection services before the drug raids. Of those, only 12 percent were receiving ongoing services, anything from foster care to parenting classes.

Child protection staffers told her they couldn’t intervene in more cases because they were unable to determine whether drug use and violence were harming the children.

“We were like, ‘We could tell you that every time,’ ” she said. “We have that piece, so why are we not sharing this information. … Why can’t we start thinking about the futures of these children?”

Christopher N. Osher: 303-954-1747 or cosher@denverpost.com

The bruises on ‘s face, arms and shoulders were yellow and faded.

During a substance abuse class, ‘ mother appeared drunk when she said she didn’t want her son anymore. She did, however, pass a drug test.

was missing school. When he did make it to class, someone at the school said he was dirty and smelly, but that wasn’t much information to go on.

Those are some of the reasons child welfare workers chose not to fully investigate those reports that the children lived in dangerous homes.

Within a year of those calls, Zoe had been beaten to death, , and .

Of the 72 children who have died since 2007 after their families or caregivers came to the attention of social services, 13 had every call made to child welfare workers screened out, or left unassigned and uninvestigated.

The calls were the only warnings caseworkers would get before the children wound up dead.

An additional 21 deaths were in families where caseworkers investigated at least one allegation but also screened out at least one complaint.

In eight of the deaths, the decision not to investigate violated state policies on when to open a case, according to a Denver Post review.

In Zoe’s case, the bruises should have been enough evidence to investigate whether she was abused. In other cases, and , according to the state reviews of the children’s deaths.

. But in practice, counties have wide discretion in determining whether a call has enough information and the right details to warrant further investigation. Those decisions are seldom examined by state officials.

“It almost has to be a crisis before the state is aware of a child’s situation,” said Debbie Stafford, a former state representative who has worked to improve practices and transparency into decisions about child welfare cases.

A troubling policy change

For child welfare advocates who favor a more consistent approach in how cases are evaluated, a policy change this year is troubling.

Until this year, state rules required an automatic child abuse investigation after social services received a third call about a family within a three-year period. The so-called “third-referral” rule had been in place since Gov. Bill Owens’ administration.

In April, . The state determined that implementation of the rule was inconsistent across Colorado’s county-run child welfare system.

Now, there is no limit on the number of screen-outs allowed per family.

“Right off the bat, there were inconsistencies about how it’s done because there were two different schools of thought about what the rule meant,” said Ruby Richards, child protection manager for the state .

The one-sentence rule said child welfare workers “must assign for investigation (those) reports that are the third in two years, if the first two were not assigned for assessment.”

A study by the state department of human services showed that in 2011 there were 7,039 third referrals of abuse or neglect that should have automatically been investigated under the policy. Fewer than half — 47 percent — were investigated.

County departments said the rule was not only confusing, but time-consuming, forcing caseworkers to use limited resources when they could have focused on more serious cases.

“It was sending workers out on things that really didn’t meet the criteria for abuse or neglect and invading in families’ privacy to raise their children when we really didn’t have the authority to do that,” Richards said.

Youlon D. Savage, chairman of the State Board of Human Services, said a heavy push for the rule change came from the three county commissioners serving on the board — Stephen Johnson in Larimer, David Long in Weld and Sam Pace in Saguache.

“It didn’t make sense to make a county worker go out on something that was obviously a frivolous call,” Johnson said. “My perspective is that picking a certain number of calls arbitrarily, without any knowledge of the case, is not really protecting kids.”

REAL Colorado, part of the lobbying group Colorado Counties Inc., suggested the rule change to state officials. The revision requires child protection workers to only examine prior contacts with the family when deciding whether to open the third referral.

Giving caseworkers more flexibility

One ongoing concern for caseworkers trying to decide whether to open a child welfare case — and in Colorado they get about 80,000 calls reporting abuse or neglect every year — has been the inability to intervene in a family without launching a full investigation.

State officials hope a new approach called “differential response” will allow caseworkers more flexibility and prevent certain low- to moderate-risk cases from getting screened out.

In contrast to a traditional investigation in which caseworkers have to speak with the alleged victim away from the suspected abuser, caseworkers can meet with whole families.

“It’s a very different approach to engage with the family and to identify with the family what the concerns are,” Richards said.

Five Colorado counties are using the differential response method as part of a pilot program.

“It is a great opportunity for Colorado,” said Angela Lytle, division manger of , one of the pilots. “It’s based on the premise that if we engage families much quicker and on a deeper level, resolution can be reached and sustained.”

About 75 to 80 percent of the families that Arapahoe County serves are in the low- to moderate-risk level, Lytle said.

Legislation was passed this year to begin implementing differential response into other counties in 2013, but child welfare advocates are concerned it is too early to tell whether the approach is the best fit for Colorado’s state-supervised, county-run system.

“Differential response has its place, but I also think that it needs to be limited in duration and there needs to be a high level of supervision so we aren’t creating more resistant families,” said Stephanie Villafuerte, director of the Rocky Mountain Children’s Law Center.

State officials said they don’t believe differential response would have saved any of the 72 children who have died in Colorado since 2007 after the children’s families or caregivers came to the attention of child welfare services.

They noted that caseworkers in Arapahoe County chose to use differential response in handling the case of and , who ultimately died in a fire while their mother left them alone to party with her friends.

Still, the method provides one more option to consider individual circumstances within a family’s situation, one of the most crucial and difficult tasks in child welfare, Richards said.

“You get one situation, one time,” she said.

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

Many of Colorado’s child abuse workers are inexperienced and overwhelmed, and at times fail to take basic steps to protect children: interviewing parents, properly assessing a dangerous home or checking a child’s body for obvious signs of abuse, a Denver Post analysis of state data found.

Caseworkers failed to follow state policy at least half of the time when asked to protect a child who later died of abuse or neglect, Colorado fatality reports show. Their mistakes ranged from paperwork problems to not visiting a child within the time required, or at all, and dismissing — without proper investigation — abuse allegations prior to the child’s death.

The job of a caseworker is tough — .

A survey of more than 500 of Colorado’s child protective workers who had participated in training sessions found 59 percent suffered from high or very high levels of “compassion fatigue,” causing burnout, poor performance and turnover, the 2011 application said. Those caseworkers, it said, can suffer from “anger, fear, anxiety, hopelessness and helplessness.”

“We gave them an unmanageable, thankless job,” said Skip Barber, executive director of the Colorado Association of Family and Children’s Agencies, a group of not-for-profit advocacy agencies. “If a caseworker makes a mistake, it’s front-page news. The system was set up to fail.”

And it is failing. Seventy-two kids whose families or caregivers were known to the child welfare system in Colorado have died in the last six years. Child protection workers failed to note unsafe living conditions, concerns about caregivers and previous contacts with the child welfare system before children were killed, according to 59 state child fatality reviews released to The Post.

While investigating reports of abuse or neglect, child protection workers did not talk in 10 cases to the person accused of the abuse and did not talk in nine cases to other contacts such as doctors and teachers.

In addition to failing to properly investigate claims of abuse or neglect, child protection workers struggle to correctly write . The Post’s analysis found caseworkers did this wrong 24 times out of 59 cases where children ended up dead.

“When you have a young, inexperienced staff, their ability to make good decisions is not huge,” said Tracey Feild, director of the child welfare strategy group for the Annie E. Casey Foundation.

Caseworkers’ safety assessments of a family can mean the difference between life and death.

HEARTBEATS.

Janet Gallegos visits the grave of her granddaughter, at Mount Olivet Cemetery in Wheat Ridge on August 1, 2012. It would be Neveah’s eighth birthday. Janet said, “I’m trying, spiritually, to let go of her in peace. I miss her she would be 8 years old today. I’m sad I can’t be with her anymore.” (Craig F. Walker, The Denver Post)

Take, for example, the failed case of .

Miriam Gallegos defended her boyfriend, Angel Ray Montoya, after he was accused of sexually assaulting Neveah. The Denver County Department of Human Services asked Gallegos to take parenting classes. She did, and then promised Neveah wouldn’t go near him.

So child protection workers closed the case.

But Janet Gallegos had a feeling her 3-year-old granddaughter was in danger.

“We asked and asked and asked them, ‘Please protect Neveah. Do a follow-up,'” she said of her pleas to caseworkers. “They didn’t do anything to help.”

Nine months after caseworkers closed their case on Neveah, .

“She didn’t protect Neveah,” Gallegos sobbed into a tissue as she sat in the garden she and Neveah planted. “I would have protected her.”

Denver County officials would not discuss their decision not to intervene before Neveah was murdered, but .

Angel Ray Montoya and Miriam Gallegos. Montoya was sentenced to life in prison without parole for murdering Neveah Gallegos. Miriam Gallegos pleaded guilty to child abuse resulting in death and was sentenced to 12 years in prison.

When Colorado officials have uncovered deficiencies in the system, change has come slowly.

The state human services department, after reviewing child deaths for five years, found in 2002 that child protective workers were doing a poor job assessing the safety risks of children living in allegedly abusive homes.

Eight years after the release of that report — in 2010 — the state department checked whether those charged with protecting children were doing a better job.

In 2010 and 2011, reviews in 33 counties found that casework was still inadequate. Just 41 percent of the time, caseworkers accurately conducted a safety assessment.

And when caseworkers decided a safety plan was needed, the plans were sufficient only 24 percent of the time.

Over-the-shoulder training was ordered after the 2010 study, and state officials are working on a new standardized form for caseworkers to follow. Inexperienced caseworkers shadow staffers with more experience in counties that still aren’t meeting standards, said Marc Mackert, the director of the state Department of Human Services’ administrative review division.

The additional training is making a difference, but not enough follow-up reviews have been done to determine whether significant improvements are taking place, he said.

Colorado has made improvements to caseworker training in recent years, opening an academy in January 2010.

New caseworkers — who are required to have a bachelor’s degree in sociology, psychology or another behavioral science — now must attend 210 hours of training at the academy in Douglas County.

In class, they learn how to fill out forms used to determine whether a child’s safety is in jeopardy, how to tell what qualifies as imminent danger and even how to ask parents open-ended questions. For example, instead of asking, “Do you hit your kids?”, try “Tell me about the hardest part of your day,” the teacher recommends.

“The people in there — they don’t realize what they are getting into,” said Art Atwell, who was a caseworker for 20 years and now is the state’s director of children and family training. “Until you get out there and it’s pulling at your heartstrings, you don’t know.”

A grimmer story surfaces

Colorado does not know how many children its caseworkers are tasked with protecting at a time; it is one of 11 states that does not report this to the federal government. The state has no requirements about how much caseworkers are paid; that’s up to each county. And Colorado does not track how long caseworkers stay in their careers, although typical burnout is about four years, according to interviews.

After numerous requests under the Colorado Open Records Act, the state released data it had never previously gathered showing the average workload for caseworkers in the 10 largest counties. Child welfare worker caseloads vary from 8.4 cases per worker at a time in Pueblo County to 13.6 in El Paso County, according to the data.

Smaller, rural counties told The Post that their caseworkers probably manage 12 to 15 families at once, and starting salaries range from $30,000 to about $40,000 per year.

But interviews with caseworkers revealed a grimmer story.

Amy Hinkle, an ambitious new college graduate, lasted one year. She earned $28,000, worked 60-hour weeks and once returned from four days off to find her voicemail jammed with 99 messages.

But that wasn’t what made her quit.

“Every single day, I wanted to give those kids the time and attention they deserved,” said the 23-year-old, who now works for an adoption agency. “It would become hard to turn the focus back to the children.”

Hinkle said she had 25 foster kids to keep track of at once, but many days, before she could check on them, she had to deal with biological parents who showed up intoxicated for supervised visits or missed their court-ordered therapy, and she had to deal with the paperwork that resulted from those problems.

“I just wanted to just crawl in a hole and die after a year,” said Hinkle, who worked for an El Paso County caseworker agency that contracts with the county. “It’s a very emotional and tiring job.”

The average caseload tallied by the state does not include rural or medium-sized counties, but does include contract workers, including Hinkle.

Nationwide, the average tenure for child welfare workers is about two years, according to a 2003 report from the U.S. Government Accountability Office. Caseworkers interviewed for that study said they spent 50 to 80 percent of their time doing paperwork.

“Is the work doable?” said Renee Rivera, executive director of the Colorado chapter of the National Association of Social Workers. “They go in because they care about kids, they want to help kids and help families and help society fix this problem, and they get just overloaded.”

recommends caseloads never climb higher than 12 to 17 children per worker.

State officials told The Post that workloads aren’t a problem.

“There is no clear number or science that you can get to that says, ‘Here is the magic number that the caseload ratio should be: 10 families to one worker or five families to one worker or 50 families to one worker,” said Reggie Bicha, director of the Colorado Department of Human Services. “We can get that information and analyze it, but then compare it to what?”

That recommendation was not followed.

Subject of major scrutiny

Caseworkers’ decisions are the subject of major scrutiny, especially when a child dies.

Child fatalities are reviewed by a state panel, and caseworker errors are noted. The consequences for violating state policy most often are extra supervision and a review of regulations.

But it’s becoming more common across the country that relatives of dead or injured children take caseworkers to court.

In one Colorado case, watched across the country, two Denver County caseworkers were sued by the relatives of a boy who was purposefully starved to death by his mother’s ex-boyfriend and his new girlfriend. The civil case is ongoing.

“SUNSHINE” AND DARKNESS.

, born Chandler Ashton Norris, is buried in the Guardian Angel section at Mount Olivet Cemetery in Wheat Ridge. The 7-year-old boy starved to death trapped in a linen closet while in the care of Jon Phillips and Sarah Berry, who are in prison for murder and child abuse. Chandler’s story has been pointed to numerous times as an example of bungled casework. (Craig F. Walker, The Denver Post)

died in 2007, after spending much of the last year of his life in the bottom of a linen closet, 35 inches wide and less than 18 inches high.

.

Chandler’s story has been pointed to numerous times as an example of bungled casework. In all, there were eight referrals to child protection workers that alleged abuse and neglect.

. Supervisors at the child-abuse division did not assign any investigation, saying there were no allegations of abuse or neglect.

The next time they heard about Chandler, he was dead.

Caseworkers assigned to look after Chandler violated six state regulations, including failing to make “timely contact” with the boy after his school reported suspected abuse. Jefferson County and Denver County child welfare agencies failed to communicate with each other, and so while it appeared in a state computer system that one county was looking out for the boy, neither county was.

The supervisors who handled the case — and were sued by Chandler’s mother — are still working at Denver Human Services.

Jon Phillips and Sarah Berry are in prison for the murder and child abuse of Chandler Grafner.

Whether caseworkers are disciplined or fired for mishandling a case is a personnel matter and not usually public information. Denver County has fired caseworkers or given them “progressive discipline” plans over the years for violating state rules or county policy, said communications director Revekka Balancier.

Part of a supervisor’s job, she said, is to provide “support for dealing with something as disturbing and tragic as a fatality.”

“Having a fatality on a worker’s caseload is an extremely traumatic experience,” she said.

With the safety of dozens of kids on their conscience, caseworkers go alone to knock on the doors of hostile parents — to ask them what they feed their children and whether they hit them. They follow a checklist, ticking off questions and taking down answers on a state-standardized form. And they worry a kid in their care might die, a fear that keeps them up at night.

“It’s an incredibly tough job. You can look back and say caseworkers should have done this or that, but the reality is you are making decisions best you can in the moment,” said Julie Krow, a former Denver County caseworker who is now director of children, youth and families at the state Department of Human Services. “You have to walk away and hope that you made the very best decision.”

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

Mary Ann Hartman worried the little girl across the street was going to die.

A GRAVE FOR A LITTLE GIRL.

, left, whose body rests at Roselawn Cemetery in Pueblo, was killed at the age of 2 in October 2007 after her foster mother, Jules Cuneo, hurled her five feet, head-first into a coffee table. Based on the reports filed by her foster mother, Alize was extremely accident prone during the five months she lived with Cuneo. But a neighbor, Mary Ann Hartman, could hear what was going on inside the house through a baby monitor and began recording what prosecutors later described as the ongoing torture and abuse of Alize by Cuneo. The recording wouldn’t be enough. (Craig F. Walker, The Denver Post)

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 the children who died of abuse and neglect in the last six years in Colorado had families or caregivers known to child protection workers who could have saved them.

Those 72 children – many beaten, starved, suffocated or burned – 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.

Nine 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 in 2007 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.”

CAREGIVER.

Jules Cuneo, who was the foster mother for 2-year-old , is serving a 32-year prison sentence for the child’s death. (Handout)

No one at El Paso County took Mary Ann Hartman’s letter and baby monitor recording seriously enough.

, 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 ‘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.

Problems were “training issues”

Caseworkers assigned to Ciarea’s family violated several state regulations, including failing to interview key people after allegations of abuse prior to the . 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.

BEHIND CLOSED DOORS.

Maria Gardner stands in her room at the Denver Women’s Correctional Facility in Denver. Gardner poured gasoline over her five children then lit them on fire, killing 16-month-old and severely burning the other four on Jan. 28, 2008. In a plea agreement, she pleaded guilty to child abuse causing death and four counts of child abuse causing serious bodily injury. Gardner is now serving 85 years in prison. Gardner says the Department of Human Services should have done more. “They should have taken my children from my home, and they should have put me somewhere ” (Craig F. Walker, The Denver Post)

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 .

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.

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.

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.”

SAYING GOODBYE TO A BABY.

Torrey Brown Sr., 26, talks with his mother Corinthiah Brown and funeral director Jehn-ai Jackson at Caldwell-Kirk Mortuary in Denver on June 3, 2012. Brown was making service arrangements for his son, , above. The Commerce City Police Department found the remains of the 6-month-old infant May 31, 2012, at the Denver Arapahoe Disposal Site. Sharrieckia Page, 23, the baby’s mother, is charged with first-degree murder and child abuse resulting in death. Torrey Sr. says the Department of Human Services should have done more, “She talked about doing something before. Everybody took her serious but the Department of Human Services. She would call and make threats, ‘I’m going to choke him.'” (Craig F. Walker, The Denver Post)

In the case of little , 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.

Sharrieckia Page, 23, Torrey Brown’s mother, is charged with first-degree murder and child abuse resulting in death.

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.”

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 way 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.

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“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.

, created by the new director of the Colorado Department of Human Services, that rates counties’ handling of child abuse investigations. He hopes public pressure will encourage county departments to improve their work, even though county-by-county ratings do not appear on a state website that shows how the state stacks up against federal guidelines and past performance.

“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.”

Reggie Bicha, Executive Director for the Colorado Department of Human Services (Craig F. Walker, The Denver Post)

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.”

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 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.”

, 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
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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. Many of the findings in this series come from those reports.

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 provided fewer details about the child and the child’s family history with the department, Richards said. Instead of a narrative style, information was provided in a list format. The reports also listed fewer violations of state regulations, noting the violations only if officials determined they were “systemic” concerns.

“Pointing out an isolated issue doesn’t seem fair,” Richards said earlier this year.

In the course of a Denver Post investigation, state officials stopped the release of any other reports so that they could redo them in a format they say is more transparent.