Why No One Saved Gabriel Fernandez

Gabriel Fernandez
Image: LATimes.com

On September 13, 2018, a Los Angeles County judge denied a motion to dismiss felony child abuse and falsification of records charges against four former child welfare caseworkers in the 2013 death of ten-year-old Gabriel Fernandez.  The charges, filed in 2016, marked the first time Los Angeles caseworkers were criminally charged for misconduct connected with their work, and is one of only a few similar cases nationwide.

If Gabriel’s case is one of the few child deaths to result in prosecution of state workers, the egregious nature of the state’s failure explains why. A brilliant article by investigative reporter Garret Therolf shows that for seventh months, evidence of Gabriel’s abuse steadily accumulated. Yet again and again, the Los Angeles Department of Child and Family Services (DCFS) failed to intervene. Some of the worst errors are listed below.

  • Gabriel’s mother had been the subject of at least four calls to the child abuse hotline, had abandoned one child, and had lost custody of a son a year older than Gabriel. Yet, this record was never reviewed by workers investigating multiple reports of suspicious injuries to Gabriel.
  • Each time investigators came to the home, they interviewed Gabriel and his siblings with his mother in the room, against agency policy and common sense. And each time they did so, he recanted his previous statements. Even after he came to school with his face full of bruises from being shot by his mother with a BB gun, he recanted and told the investigator the injuries were from playing tag with his siblings. In the face of visible evidence, the investigators repeatedly chose to believe the repeated recantations
  • Investigators never spoke with neighbors or school personnel (other than the teacher who reported the abuse) but according to Therolf the abuse was known widely among school staff.
  • A computer program had found Gabriel to be at “very high risk” of abuse, requiring that the case be “promoted,” usually involving asking a court to require services or foster care. But the investigator, backed up by her supervisor, referred Gabriel’s mother to voluntary family services. Gabriel’s mother Pearl Fernandez withdrew from these services after three visits.
  • During the brief period of voluntary services, Gabriel wrote several notes saying he wanted to kill himself. Gabriel’s therapist informed the caseworker and supervisor, but they took no action.
  • The therapist had grown concerned that Gabriel was being abused, but her supervisor told her not to call the hotline so as not to jeopardize the mother’s participation in the voluntary case.
  • After three visits, Pearl Fernandez asked for her voluntary case to be closed. The caseworker accepted her decision, stating that there were no safety or risk factors for the children. Contrary to policy, her supervisor signed off on the case closure without reading the file.
  • After the case was closed, a security guard at the welfare office saw Gabriel covered with cigarette burns and other marks and being yelled at by his mother. The called DCFS twice and got lost in the automated system. The 911 operator gave him the non emergency line, which he called. He was later told that a sheriff’s deputy had gone to the home and seen nothing wrong.
  • Gabriel’s teacher, who had lost hope of any rescue from DCFS, called the DCFS investigator one more time late in April when Gabriel showed up looking worse than she had ever seen him. One eye was blood-red, skin was peeling off his forehead, and other marks were on his face, neck and ear. Her call was never returned. Gabriel had only about a month left to live.

Investigators later learned that during the weeks before his death, Gabriel  was spending days and nights locked in a cabinet with a sock in his mouth, hands tied, a bandanna over his face, and handcuffs on his ankles. His solitude was interrupted by vicious beatings and torture sessions in which his siblings were required to participate. On May 22, Pearl and Aguirre tortured Gabriel a final time with a BB gun, pepper spray, coat hangers and a baseball bat. When they finally called 911, paramedics found two skull fractures, broken ribs, several teeth knocked out, BB gun pellet marks, cigarette burns on his feet and genitals, a skinned neck, and cat feces in his throat.

Therolf poses a key question regarding Gabriel’s death: “Was [the] failure …to protect Gabriel an isolated one—the fault of four employees so careless and neglectful that they allowed a child to suffer despite a series of glaring warning signs? Or was it a systemic one, the result of a department so ill-equipped to safeguard children that tragedies were bound to happen?”

While Therolf does not actually answer the question, his report offers a number of key findings and insights that point strongly in the direction of systemic factors as the prime contributors to the failure to protect Gabriel. Therolf found that many of the errors made by investigators, such as failure to interview children alone or to speak with witnesses outside the family, were prevalent in Los Angeles County. Sadly, many of the same failures were evident in the very recent case of Anthony Avalos, also in Los Angeles. And we also see similar failures , and in cases around the country, including Kansas, New York, and Oregon.

The systemic factors that cause these failures fall into two major categories–resource constraints and ideological factors.

Resource Constraints

Child welfare involves a balancing act between too much intervention  or “erring on the side of child safety” as Therolf puts it and too little or “erring on the side of family preservation.”  Striking this critical balance requires a combination of  knowledge, skill, and time. In other words, as Therolf puts it, “it requires a highly trained workforce with the resources to carry out a thorough investigation in every case.” Therolf rightly contends that most agencies don’t have these resources. One has only to read the constant stream of news reports of overwhelming caseloads and poor training of child welfare workers around the country. All of this reflects the unwillingness of taxpayers and legislatures to provide what is needed to protect children. Inadequate funds mean caseloads are too high and salaries are too low, both resulting in low standards for caseworkers.

More funding and could buy both lower caseloads and higher salaries, which are necessary to obtain more qualified investigative workers. After reading so many similar stories, and recalling my own rudimentary training as a Child Protective Services (CPS) worker I am beginning to think that ultimately CPS Investigation should be a specialty in Masters in Social Work Programs. Students would learn advanced interviewing skills and how to assess the truthfulness of children and adults rather than, for example, believing children when they recant allegations with their parents in the room.  Alternatively, CPS Investigations could be folded into the growing field of Forensic Social Work. In any case, a Masters-level specialization could be required in order to be a CPS worker, also adding a needed level of prestige to an important, difficult and hard-to-fill  job.

Ideological Constraints

Inadequate resources might result in a random distribution of agency errors between those that involve too much intervention and those that involve too little. But the dominance of a particular ideology may skew the errors in one direction or another. And Garrett Therolf alludes to the rise of an ideology prioritizing family preservation nationwide and particularly in California during the years preceding Gabriel’s death. This ideology contributed to the decline in foster care numbers around the nation and particularly in Los Angeles, where Therolf reports the number of children in foster care fell from about 50,000 in 1998 to 19,000 in 2013. Much of this decline occurred during the tenure of DCFS administrator David Sanders, who later went on to lead Casey Family Programs, a foundation worth over two billion that has played an outsize role in national child welfare policy. The same year that Sanders took over at Casey, it declared a new goal to reduce the number of children in foster care by half by 2020.

Therolf was right to point a finger at Casey Family Programs. In my post about the death of two children by child abuse in Kansas, I wrote about how Casey leverages its massive wealth to affect policy directly, bypassing the voting public. It provides financial and technical assistance to state and local agencies, conducts research, develops publications, and provides testimony to promote its views to public officials around the country. Through its wealth in an underfunded field, Casey has been able to directly influence policy at the federal, state, and local levels.

Therolf points out that opinions on child welfare often cut across traditional political groupings. While Casey tends to support progressive causes, its emphasis on family preservation is often shared by conservatives who desire to reduce the government’s incursions on parental authority and at the same time to reduce spending. Working together, Casey and the George W.  Bush administration created a waiver policy that allowed child welfare agencies to direct unused foster care funds toward family preservation services–a policy change which created an incentive to reduce the use of foster care. Therolf links this incentive to the drastic decline in the Los Angeles County foster care rolls between 1998 and 2013, stating that “When Gabriel came to the attention of DCFS, the chances of an abused child being placed in foster care were “lower than they’d been in many years.”

Perhaps all of the factors that led up to Gabriel’s death can be summed up by a striking statement by the supervisor on Gabriel’s case, who is currently standing trial in Gabriel’s death. He told Therolf that he had  “concluded long ago that some of the children who depended on the department would inevitably be injured, if not killed.” He expressed frustration that administration and the public expected him to prevent all such deaths. This is not an acceptable attitude. It is true that a child welfare agency cannot prevent deaths among children who are unknown to the agency. But to expect that children will die under the agency’s watch–that is a low expectation indeed. We must do better by our most vulnerable children.

 

 

Abuse death of Anthony Avalos after 16 reports: the public needs to know why

Anthony Avalos
Image: Los Angeles Times

On June 21, the suffering ended for ten-year-old Anthony Avalos when his tortured body finally succumbed to years of abuse. The ten year old had severe head injuries and cigarette burns all over his body when his mother found him unresponsive and called 911. Anthony died the next morning. Despite sixteen reports to the Los Angeles Department of Child and Family Services (DCFS) or the police, the agencies tasked with protecting Anthony never rescued him from the adults that had abused him for years. Without a new law requiring public disclosure of the details of such cases, the public will never know how Anthony’s peril was missed or what changes are needed to protect future children from his horrible fate.

School administrators, a teacher, a counselor, family members and others called police or the child abuse hotline at least 16 times since 2013 to report abuse of Anthony or one of his six siblings, as revealed in a devastating article by respected investigative reporter Garrett Therolf published by the Los Angeles Times. DCFS received twelve reports between 2013 and 2015, according to its director, Bobby Cagle.

According to these reports, “Anthony or his six siblings were denied food and water, sexually abused, beaten and bruised, dangled upside-down from a staircase, forced to crouch for hours, locked in small spaces with no access to the bathroom, forced to fight each other, and forced to eat from the trash.”

Most of the allegations concerned Anthony. Among the alleged abusers were his mother, Heather Barron, her boyfriend, Karim Leiva, and another family member who was left in charge of the children and was accused of sexual abuse.

According to the sources, only some of the investigations resulted in a finding of child abuse. And even when abuse was found, the children were only once placed with an uncle and aunt, from whom they were soon removed and brought back to their mother over protests from the relatives, according to the aunt. She reports that she started making calls to DCFS in 2015 when she noticed injuries the children said were inflicted by Leiva.

Anthony’s father, a Mexican citizen, reported that Anthony asked to live with him but his mother refused. Aware that Anthony was being treated badly, he repeatedly gave case workers his contact information in Mexico. But he never heard back.

Instead of placing Anthony with his father or aunt and uncle, DCFS workers opened at least two cases to help Anthony’s mother improve her parenting while the children remained in the home. But these cases where closed without any resolution of the safety threat to these vulnerable children.

These horror stories of deaths of children after multiple serious allegations to police and child welfare agencies never seem to end.   The first step in preventing more tragedies is to conduct a detailed case review to identify the critical decision points where an opportunity was missed. It is likely that DCFS has already begun such an internal review. But it will be shared only with the county Board of Supervisors, which will hold it close.

This state secrecy is not unique to Los Angeles. Only a few states provide for the release of information about agency interactions with children who died of abuse or neglect. Texas’ Office of Child Safety posts reviews of fatalities but only when a child died of abuse or neglect during an open case. Florida requires an immediate investigation of a child’s death if the family was involved with CPS in the past year and posts the review if the child was found to have died of abuse or neglect.  In Washington, the Children’s Administration (CA) conducts a review (by experts with no prior involvement in the case) when the death or near-fatality of a child was suspected to be caused by child abuse or neglect, and the child had any history with the CA at the time of death or in the year prior. These reviews must be completed within 180 days and posted on the agency’s website.

The Washington legislation, which requires reviews for families having history with child welfare within the past two years, is the broadest and most useful requirement. However, the universe of cases covered should be increased to include families that had contact with the child welfare agency within the past five years at a minimum. The last report on Anthony’s family was made in April 2016, more than two years before Anthony’s death, according to a statement by Bobby Cagle, the DCFS Director.  After the sixth abuse report concerning Yonatan Aguilar (also in Los Angeles County), Yonatan was locked in a closed for over four years until he was found dead in 2016.

Reviews should also be required for cases of children who suffer severe injuries due to abuse or neglect as well as cases of chronic severe maltreatment that was allowed to continue despite reports to CPS. These would include another Los Angeles County case recently in the news when a jury awarded $45 billion to a girl who suffered two years of sexual abuse after child welfare workers left her in a home with an a accused molester. We need to know how these errors happen as well.

A requirement that all states conduct and post such reviews of children who died should also be added as an amendment to the Child Abuse Prevention and Treatment Act, which is expected to be reauthorized in 2018. When an agency egregiously abdicates its responsibility to protect children, the public must know how and why it happened. Only then can they hold their government accountable for making the changes necessary to prevent such tragedies in the future.

This post was updated on July 27, 2018.