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Stephanie Villafuerte, Child Protection Ombudsman of Colorado at the Ralph L. Carr Colorado Judicial Center on February 24, 2020, in Denver. The ombudsman announced an initiative this week to reform the child fatality review system. (Kathryn Scott, Special to The Colorado Sun)

In the past five years, 146 children died in Colorado from abuse or neglect. You haven’t heard about almost any of them. 

The children are listed — not by name but by case number — on spreadsheets published online under Colorado law by the state human services department. Only a few of their deaths made the news, inspiring a round of outrage and calls for action. But the vast majority went unnoticed — part of a tally of child fatalities that has not subsided despite governor-appointed task forces, a statewide child abuse hotline and millions of public dollars to hire more caseworkers. 

One of them was a 4-month-old girl who died in June 2018 after she was propped up with a bottle and left alone for hours, then found cold with milk running out of her mouth and nose. An autopsy found methamphetamine residue in her hair. 

The family with four other young children had been reported to the child abuse hotline 13 times in the three years before the baby died. Adams County child protection workers never opened an investigation — not when callers said there were drug deals in the home, or that the children were in danger during two house fires, or that their grandmother was caring for them while holding a meth pipe.

The day the baby girl died, her older siblings said they hadn’t eaten all day. Law officers ordered them a pizza. 

A report on the baby’s death, by the state’s Child Fatality Review Team, found multiple problems with the way child welfare caseworkers handled previous calls about the family. It also criticized communication gaps between child welfare and law enforcement, and the lack of affordable childcare in the community. The baby’s mother relied on her brothers to watch her five children while she was at work, even though the men worked overnight shifts and needed to sleep during the day. 

The breakdowns leading to the baby’s death were familiar to members of the Colorado Department of Human Services’ Child Fatality Review Team — similar problems are repeated again and again in dozens of reports of deaths going back to 2012. Recommendations directed at child welfare agencies, schools, hospitals and law enforcement are written by the review team, yet there is no agency in Colorado responsible for making sure those corrections are made.

And that’s why the number of child fatalities is not decreasing, said the state’s Child Protection Ombudsman Stephanie Villafuerte, a former child abuse prosecutor who became the ombusdman in 2015. She announced an initiative this week to revamp the child fatality review process in Colorado, starting by reviewing every death due to abuse and neglect. The state team now reviews only about half of them. 

The baby girl in Adams County was one of 36 children who died because of abuse or neglect in 2018. That number was 35 in 2017 and in 2016 — jumping from 23 in 2015, according to documents reviewed by The Colorado Sun. Deaths last year are still under investigation, but preliminary work shows that 2019 numbers will not reach as high as the previous three years.

“Child fatality has become so common, we don’t even put a human face to it,” Villafuerte said, noting that the children who died since 2015 would have filled four school classrooms. 

“The thought that any child in our state can be brutalized to death is unconscionable,” she said. “The fact that hundreds are, defies logic.”

The cycle of public outrage repeats

After 7-year-old Caden McWilliams’ body was found encased in concrete in a storage unit around Christmas 2018, child advocates called for reforms. The little boy had stopped attending school and officials thought he was home-schooled. But no one checked on him.

No law has been enacted that would require child welfare authorities to check on children who abruptly leave school after official reports about abuse or neglect. 

In 2007, a 7-year-old Jefferson County boy named Chandler Grafner starved to death as he was kept in a closet. His death led former Gov. Bill Ritter to create in 2008 the “Child Welfare Action Committee,” which recommended, among other things, that Colorado have a child protection ombudsman. 

At the time, policymakers were outraged that 30 children had died of abuse and neglect in a three-year period. That’s fewer than the number of children who died in 2016, 2017 and 2018. 

And in 2013, following a Denver Post/9News project called “Failed to Death,” former Gov. John Hickenlooper announced $20 million in child welfare reforms, including the creation of a statewide child abuse hotline and a caseworker workload study. In the years since, calls to the hotline and the number of caseworkers have continued to increase, yet the number of child deaths has not declined.

To report suspected child abuse or neglect, call:
1-844-CO-4-KIDS (844-264-5437)

The cycle of public outrage repeats across the country. And part of the reason for the lack of substantial change is that the public is looking for a villian — almost always the child welfare division — and reforms to address the broader problem have fallen short, the ombudsman said. 

“We always do what I call ‘reactive public policy,’” Villafuerte said. “It is not effective if you are trying to erradicate or lessen child abuse fatalities.” 

Colorado has two state agencies that investigate child deaths. The Colorado Department of Public Health and Environment looks into trends and releases reports with aggregate data on specific topics, such as seatbelt safety or suicide. The state Department of Human Services oversees the Child Fatality Review Team, which includes caseworkers, pediatricians, lawmakers and others, and zeroes in on what the child welfare system could have done to prevent a death.

That team reviews deaths, near-deaths and egregious incidents of child abuse when the family had been reported to the child abuse hotline at least once in the previous three years, and when the county child abuse agency where the incident occurred has substantied that the death or near-death was the result of child abuse. The criteria mean that fewer than half of child deaths by abuse and neglect are reviewed.

In 2019, for example, 109 fatal, near-fatal or egregious incidents were investigated by counties as potential child abuse, but about one-third were “unsubstantiated” for abuse or neglect. And among those that were substantiated, only a portion had prior involvement with child welfare and met the criteria for review by the state team. 

“We’re looking at 50% of the evidence right now, and that’s not enough to solve a problem that is this big,” Villafuerte said.

Child abuse is a public-health issue

In each of the past several years, about 60% of child fatalities from abuse or neglect happened in families that had already been reported to child welfare authorities, according to a Colorado Sun review of state data. In many of those cases, the fatality review team pointed out ways that county child welfare departments could have stepped in sooner.

Following the death of the 4-month-old baby in Adams County, after 13 prior referrals to child welfare, the team wrote: “It appeared that the county responded or reacted to each individual report of concern separately rather than looking at or taking into consideration the family’s pattern of chronic neglect.” 

Such findings typically are reviewed by the county department, but the review team’s recommendations to improve other community agencies — hospitals, law officers, schools — often go nowhere after they are documented by the fatality review team, the ombudsman said. 

Stephanie Villafuerte, Child Protection Ombudsman of Colorado at the Ralph L. Carr Colorado Judicial Center on February 24, 2020, in Denver. (Kathryn Scott, Special to The Colorado Sun)

In one case, a 4-year-old girl was brought to the emergency room three times with bone fractures before she was beaten so severely that she died. The review of her death found that a caseworker pushed the emergency department physician to make a finding of child abuse, but the doctor declined. As a result, the Child Fatality Review Team recommended that emergency department physicians in Colorado receive child abuse training. 

But there is no mechanism in Colorado law to implement that recommendation, whether through the Colorado Hospital Association or the local chapter of the American Academy of Pediatrics. 

“There is no entity responsible today for taking those recommendations, implementing them or monitoring them,” the ombudsman said. “That is the crux of our concern here.”

Villafuerte’s point is echoed by officials at the Colorado Department of Human Services, which since 2012 has been required to submit an annual child fatality report to the state legislature. The reports have noted that struggling families need childcare funding and help ending domestic violence, as well as substance abuse and mental health treatment.

“These types of incidents are a much bigger issue than just child welfare,” said Marc Mackert, director of the department’s administrative review division who sometimes sits on the Colorado Fatality Review Team. “It really is a public health, society issue that we need to look at more broadly.”

Compared to many other states, Colorado has a higher percentage of child deaths that occured in families already known to child welfare, in part because its statewide hotline has generated so many tips and put parents on the child welfare department’s radar, Mackert said. The hotline — 1-844-CO-4-KIDS — has received more than 1 million calls in the past five years, leading to about 274,000 assessments for child abuse or neglect. 

But when callers report vague information that doesn’t meet the threshold to assign a caseworker, counties are correct in “screening out” the call, Mackert said. 

A public awareness campaign about the hotline has resulted in an uptick of calls, which is a good thing. But now Colorado needs to harness that public awareness to treat child abuse as a public-health issue, one that requires support from multiple systems — from schools to health care to nonprofits, state child welfare officials and the ombudsman said. 

“In every child fatality review that I have sat in on for literally the last 15 years, inevitably, this was also a child that went to school, it was a child who had neighbors, who also had a dentist,” Villafuerte said. “Yes, human services agencies should be held accountable. But what we really are missing is that broader review.”

Babies, and those who can’t speak for themselves, are most in danger

Of the 273 children who died of abuse or neglect in Colorado from 2010-18, 200 of them — or three-quarters — were age 3 or younger. And 114 were babies. 

The percentages are similar nationwide, evidence that the most vulnerable children are those who are seen by few people outside of their family, and those who don’t have the vocabulary to articulate what is going on in their home.

“Kids that age don’t have the capacity for self-protection,” Mackert said. 

One of the 35 Colorado children who died in 2017 was 6 years old, but was unable to communicate any abuse he may have suffered. The Broomfield boy was paralyzed at age 2 in a car accident that killed his mother and was being raised by his father. Evidence suggested that the ventilator that kept the boy alive “had been purposely turned off for several minutes preceding the child’s demise,” according to a Colorado Fatality Review Team report. 

In the two years before the boy died, child welfare officials in three counties received a total of eight reports that the child’s father was not capable of taking care of him or was ignoring medical advice. 

On the state’s child fatality notification page, the boy is referred to only as case 17-108. 

Editor’s note: This story was produced in partnership with 9News. 

Jennifer Brown writes about mental health, the child welfare system, the disability community and homelessness for The Colorado Sun. As a former Montana 4-H kid, she also loves writing about agriculture and ranching. Brown previously...