by Sarah Font (Washington University in St. Louis) and Emily Putnam-Hornstein (University of North Carolina at Chapel Hill)
I am honored to publish this post by two of the leading academic researchers in child welfare. They are also the Principal Investigators of the Lives Cut Short project, which documents child abuse and neglect fatalities around the country.
Armani Evans. Zemar King. Leviathan Froust. These are just three of Wayne County’s children who have been killed by their caregivers in recent years. Wayne County is the home of Michigan’s largest city, Detroit.
As part of the Lives Cut Short project, which aims to document child abuse and neglect fatalities nationwide, we requested and reviewed the Wayne County Medical Examiner records for child deaths since 2022. At least 52 children died due to abuse or neglect in the last 3.5 years, accounting for more than 1 in 10 of all child deaths in the county. Nearly two-thirds of child maltreatment deaths involved children ages 3 years and under.
At least nine children under the age of 3 died of illicit drug poisonings – involving fentanyl, heroin, and methamphetamine.
Equally disturbing, more than half of the child maltreatment deaths – 27 – involved intentional injury rather than negligence: children who were shaken, stabbed, beaten, and smothered. Many young children’s deaths received no media attention – all that is known is that they were killed by homicide, with the injury description merely stating “found beaten.”
The 52 children who died of maltreatment in Wayne County are likely the tip of the iceberg – these deaths are challenging to identify due to limitations in the death investigation process, minimal release of information, and other factors.
What would prevent children from dying at the hands of caregivers and family members?
Wayne County recently announced an expanded partnership with RxKids to provide thousands in no-strings-attached cash to all new and expectant mothers in 6 cities within the county. The county’s $7.5 million investment adds to a statewide investment of $250 million in RxKids for 2025-2026 alone. The governor’s FY2026 budget recommendation further includes $27 million to provide “economic and concrete supports” with the goal of reducing or avoiding involvement with Child Protective Services.
The leaders of RxKids imply on their website and other materials that their cash transfers can produce a large decline in child maltreatment and reduce the need for CPS intervention. Fortunately, a rigorous evaluation of the program was conducted in Flint.
The punchline? No impact.
Such findings should come as little surprise when we take seriously the threats that children face. Neither drug addiction nor extreme violence seems likely to be ameliorated with short-term monthly checks. And many children died after CPS ignored clear warning signs. A wrongful death lawsuit filed on behalf of murdered Detroit toddler Chayce Allen reveals that relatives asked CPS to intervene on at least 13 occasions.
The likely reason so many kids are left to die in horrifying circumstances is that Michigan has a severe shortage of child protection caseworkers. Statewide vacancy rates are 20% and the problem is worse in Wayne County, which has 46 fewer caseworkers than intended, leading to high caseloads and turnover. High caseloads were one of the systemic problems that the state was expected to address as part of the Dwayne B. settlement – a case filed nearly two decades ago. Michigan seeks to exit court supervision as soon as this summer, despite their continued failure to adequately staff their system.
Before massive expansions of cash assistance – much of which is going to families who are not impoverished – perhaps the state should fulfill its existing obligations to kids.
Note: some deaths handled by the Wayne County Medical Examiner may stem from incidents occurring in surrounding counties (from which children were brought to and then died at a Wayne County hospital). Our data do not provide the location of the maltreatment incident.
Ten-year-old Begidu Morris died more than three years ago of horrific child abuse by his parents, who adopted him from Ethiopia. But there was no avalanche of media coverage of his death, no interviews with shocked neighbors saying they had no idea the child even existed. No pyramid of teddy bears and flowers outside his home. No arrests of those who tortured and murdered Begidu, and no demonstrations demanding justice. No anguished commentaries from experts on how we failed and what could be done to prevent such tragedies in the future. There is not even a picture of Begidu by which we can remember him. If not for a child fatality summary released by the Florida Department of Children and Families (DCF) two years after Begidu’s death, nobody outside the family, a few neighbors, and a small group of medical, social service, and law enforcement professionals would have known that it happened.
According to the DCF child fatality summary, Begidu Morris collapsed at home in Lee County, Florida, on March 17, 2022 and was transported to Golisano Children’s Hospital. He was diagnosed with subdural hematoma, hypothermia, cardiac arrest, acute respiratory failure, retinal hemorrhages, and metabolic acidosis.Begidu was placed on life support and died on March 22, 2022. Examination showed bruising to Begidu’s head and significant scarring to his buttocks. Begidu weighed 44 pounds, which was in the 0.1 percentile for his age. An autopsy determined that the cause of death was “complications of hypoxic ischemic encephalopathy due to craniocerebral trauma” and the manner of death was homicide.
The CPS investigation
Begidu lived with his adoptive parents, Jack and Consuela Morris, and their biological son. Their two other biological children were in college and returned home for vacations. Begidu and his biological sister were adopted from Ethiopia by the Morrises, when he was about two years old. His sister’s adoption with the Morris family disrupted and she was re-adopted by another family in 2019. After Begidu’s death, the family quickly obtained a lawyer and was “minimally cooperative” with the CPS and police investigations.
The family’s three-bedroom home was described by the investigator as “pristine.” In addition to the master bedroom and the teenage sibling’s room, the third bedroom served as a guest room for the two adult siblings when they returned home from college. Begidu slept in a small closet, where investigators discovered a pile of urine-soaked clothing on a rollaway bed. The door to the closet was locked from the outside and was monitored by a camera. The closet had no ventilation and there were no toys or personal possessions indicating that a child lived there. Begidu’s adoptive parents claimed that he engaged in behaviors such as temper tantrums and fecal smearing.
The CPS investigation concluded that “[a]lthough it was not able to be determined with certainty who inflicted the injury/injuries that led to this child’s death, it can be concluded that the parents either participated in the abuse that led to the child’s injuries and subsequent death, or they participated in concealing the horrific abuse and neglect that he suffered.” It found the parents Jack and Consuelo Morris responsible for Begidu’s death and for “bizarre punishments,” internal injuries, physical injuries, medical neglect, “failure to thrive/malnutrition/dehydration,” failure to protect, and inadequate supervision.
Deaths due to child abuse or neglect are the tip of the huge iceberg of child maltreatment, most of which remains unseen by the public. All of these deaths should be examined, not only to determine whether maltreatment occurred and who was responsible, but also to identify systemic issues that might suggest policy changes to protect other children. Yet, the investigation summary I received showed a complete lack of curiosity and interest by DCF in drawing lessons from this terrible case and making them available to the public.
Isolation is a common element of severe and chronic child abuse cases. Begidu was clearly isolated. He had not visited a medical provider in three years. Most neighbors were unaware that the child even existed. And perhaps most important, he was not attending school–at least not in person. The Investigation Summary contains three different statements about Begidu’s and his adoptive brother’s schooling, stating in one place that the brother was enrolled in Lee County Schools and Begidu was not, in another place that both were homeschooled, and in two different places that each was enrolled in “virtual school.” DCF did not respond to my request to know which statement was correct. Yet this is crucial information.
If Begidu was enrolled in school virtually, it would have been incumbent on the investigator to contact the school and ask about his attendance and any interactions with Begidu and his family. This would be important in establishing if there was any negligence on the part of school staff or any need for policy changes. If Begidu was not in school at all, the question would be whether the state was aware he was being homeschooled. Homeschooling parents in Florida must provide one-time notice to the local superintendent, maintain a portfolio of their children’s work, and turn in an annual assessment by standardized test or portfolio evaluation. We need to know if Begidu’s parents complied with these requirements, and how he fell through the cracks if they did not.
With the lack of protective educators to respond to Begidu’s plight, DCF should have wanted to know if there were any opportunities for his situation to be brought to the attention of other protective adults. While the Morris family had no history with CPS in Florida or in Michigan, where they adopted Begidu, there may have been an occasion when the abuse in this home could have come to light. Begidu’s sister was re-adopted by another family in Florida in 2019. One cannot help wondering if the sister was the previous target of abuse in the home, thus leading to her adoption by another family. In his medical chart from a primary care visit in 2018 or 2019, there was a note that Begidu said he was “going to be just like his sister.” (These may be the only words of Begidu’s to be recorded).
Fully 19 lines of text about Begidu’s sister are redacted from the Investigation Summary, which says only that she lives in another state and had no contact with Begidu or the Morris family. It is likely that the redacted information concerned the circumstances behind the disruption of the sister’s adoption. Did the sister report any concerning treatment to her new adoptive parents? Did anyone involved in the second adoption have information that should have been reported and investigated? Was a coverup part of the new adoption arrangement? Unfortunately, DCF denied my request for this information. DCF appears to have no interest in learning from Begidu’s death and sharing the implications of what they have learned with the wider community in the interests of protecting children in the future.
Whatever the flaws of the investigation were in terms of uncovering systemic issues, DCF ultimately found Begidu’s parents to be responsible for Begidu’s death and the horrific abuse and neglect that preceded it. But shockingly, the agency decided not to remove Begidu’s adoptive brother from the home. According to the case summary, the teenager reported feeling safe in the home, and “sources familiar with the child” reported no concerns for his safety. (One wonders who these sources were and what they knew about Begidu’s abuse.) The investigator also noted that the teen “appeared physically healthy, was enrolled in virtual school, and was visible in the community, including attending a Mixed Martial Arts program several times weekly. He had his own fully furnished bedroom, and he was allowed to have relationships with others outside the home, including his adult siblings who were away at college.” It is clear that this decision did not come easily. According to the investigation summary, “[W]hile it is concerning that [Begidu’s sibling] remains in the home, it should be noted that he does not share the same vulnerabilities that were present with his younger sibling.” This is quite a statement. Apparently, this child was considered “safe” in the home of where his brother suffered unspeakable abuse and died, because he himself was not ill-treated. There was not even a services case opened to make sure that he received therapy for the trauma he has endured.
The criminal investigation
Three years after Begidu’s death, the police have made no arrests in the case. The DCF Investigation Summary states that CPS was involved in multiple meetings, including with the State Attorney’s Office (SAO) and that
“[u]ltimately no action was taken by the SAO as the perpetrator of abuse could not be determined based on the information that was available at the time of their staffing. There were two individuals (the mother and [the brother]) in the home capable of causing the head trauma to the child; the individual responsible for the abuse could not be determined.
The lack of charges is almost incredible. If they could not have charged anyone with the actual homicide, it is hard not to understand how the parents could not have been charged with multiple counts of child abuse, charges that surely exist in Florida as they do in other states. It is hard not to ask the question, as one child advocate put it, could this happen if Begidu were White? The State’s Attorney denied my request for the investigation records on the grounds that “there is still an active investigation.” But it is hard to believe that the police are still seriously working on this case.
Adoptions and Severe Abuse
Begidu’s story has similarities with the stories of other children adopted from overseas or from foster care. Few readers could have forgotten the six Hart children, adopted from foster care in Texas, who were starved, beaten, and eventually killed in a 2018 murder-suicide by one of their adoptive mothers. In 2013, a Washington State couple were convicted and sentenced to decades in prison in the death of their Ethiopian adopted daughter, Hanna Williams, who died of hypothermia in 2011 after being forced to sleep outside in the rain. Her malnourished body was covered with bruises and scratches and her brother testified that their adoptive parents beat them and deprived them of food. A Pittsburgh couple was sentenced in 2014 for endangering the welfare of two children they adopted from Ethiopia through withholding food from their six-year-old son and causing abusive head trauma to their 18-month-old daughter. In a dispiriting echo of Begidu’s case, the adoptive mother was sentenced to six to 12 months in jail with daily work release to enable her to go home and care for her biological children. The mother who re-adopted these children saw this sentence as “an indication that the court viewed adopted children as different, since it decided that a woman who abused her adopted kids could be trusted with her biological children.” In 2021, a woman in Washington was charged with second-degree criminal maltreatment for beating and starving a 12-year-old boy that she and her husband adopted from Ethiopia. The prosecution decided to drop the case, as reported by KUOW, stating that the boy had “suffered mental health challenges which will prevent him from testifying.” The child had been re-adopted by one of his schoolteachers, who saw his abuse and came to an agreement with his parents–a possible hint to what may have happened with Begidu’s sister.
The vast majority of adoptive families provide loving homes, and a study from the Netherlands suggests that adoptive families are less likely to maltreat their children than birth families. Nevertheless, observers have noted clusters of cases of severe abuse of adopted children. Such a cluster was noted in the State of Washington at the time of Hanna Williams’ death. A committee led by Washington’s child welfare agency and children’s ombudsman in 2012 published a Severe Abuse of Adopted Children Committee Report, which discussed 15 cases of adopted children who had suffered abuse at the hands of their adoptive families. There was a common pattern of concerning parenting practices in these cases, including physical confinement, withholding food, isolation (including withdrawal from school), forcing the child to remain outside the home; and disparaging remarks about the child. The committee observed that these cases tend to occur “when an adoptive family is ill-prepared or ill matched with a child that suffers from unidentified and/or untreated trauma, abuse, and/or neglect.” The analysis suggests that families may respond to their adopted children’s difficult behaviors caused by past trauma by using punishments like sending a child to bed without dinner, which in turn triggers further behaviors, leading to a vicious cycle of behaviors and punishments culminating in egregious abuse.
The Washington committee made multiple recommendations for avoiding such tragedies in the future, including better oversight of child-placing agencies, strengthening the assessment of prospective adoptive families, and improved training for parents and adoption professionals, and post-adoption support services for families. Some of these recommendations required legislation and other required agency action, and it is not clear whether any of them were implemented.
The trial of Larry and Carri Williams for the death of their adopted daughter, Hannah, was a major event in Washington, with Seattle-area Ethiopians attending proceedings every day, “almost as a vigil” as the Seattle Times described it. But with no arrests in Begidu’s case and no media coverage until two years later, Florida’s Ethiopian community may not even be aware of it. Holding Begidu’s adoptive parents accountable won’t bring him back, but the lack of any meaningful response to his death is an offense to all child victims of abuse and neglect and those who care about them. The only thing that can be done now is to hold his torturers and murderers responsible and learn from his suffering to prevent other children from sharing it.
This blog was published on the website of Lives Cut Short on January 6, 2025.
On January 17, 2020, eight-year-old Thomas Valva died of hypothermia in the freezing garage at the home of his father and his father’s live-in fiancée. It soon came out that school staff had made multiple calls to the state child abuse hotline during the 16 months before Thomas’ death, describing how he and his brother were starved, beaten and forced to sleep in a garage and urinate upon themselves. Almost four years after Thomas’ death, a Suffolk County grand jury issued a report explaining that it had been denied access to records from the child protection system (CPS) concerning ten investigations prior to his death because they were “unfounded.” At no point did the state or the county explain how they had missed this case of chronic abuse, share plans for ensuring the same errors would not occur in the future, or hold any employee accountable for leaving Thomas in the hands of his abusers.
In September 2017, during a bitter divorce battle between Michael Valva and Justyna Zubko-Valva, a judge gave Michael Valva temporary custody of Thomas and his two brothers. The boys joined a household that included their father, his fiancée, Angela Pollina, and her three daughters. As described in the grand jury report, Michael Valva removed six-year-old Thomas, and his older brother Anthony, from their specialized school in Manhattan and enrolled them in a Suffolk County elementary school. Both boys had been diagnosed with autism and were described as “high functioning.”
Repeated calls for Help
According to the grand jury report, Thomas and his brother were the subject of at least ten reports to New York’s child maltreatment hotline between September 2018 and Thomas’ death in January 2020. All of these reports were “unfounded” by Suffolk County CPS ; “unfounded” means that the investigator found no credible evidence of alleged abuse or maltreatment. But the New York Daily News obtained records of at least 20 calls by school staff about Thomas and Anthony during that period. We don’t know how many of these additional calls were investigated or screened out at the hotline as not warranting investigation. (Except where otherwise noted, all case details are based on the grand jury report.)
In January 2018, about four months after moving to their father’s home, Thomas and Anthony began to complain to school staff that they were hungry, reporting that they were denied breakfast as punishment. The staff alerted the CPS worker who was already investigating allegations against both parents, but it was not clear whether the boys’ hunger was addressed in the investigation.1 In September 2018, Thomas and Anthony returned to school looking very thin and both were now wearing pullups, despite having used the toilet without problem the previous year. School staff observed the children eating food from the trash and the floor. It was then that a school staff member made the first call to the state hotline that was documented in the grand jury report. The nine calls that followed during the next 14 months reported that the boys were hungry, had suspicious bruising including a black eye, were coming to school in urine-soiled clothing and shoes, and reported sleeping in an unheated garage, where they urinated upon themselves and were hosed down in the morning.
School staff made four calls in March 2019 in a concerted effort to get a response. But the effort seems to have backfired. When the staff called Suffolk County CPS to follow up, they were told that their multiple reports had “canceled each other out.” In April 2019, a staff member confronted a county CPS representative at the school. According to staff reports, the CPS representative responded that without broken bones, there was nothing they could do. The last report was made in November 2019 describing bruises on both children’s faces and their continuing complaints of hunger.
Thomas’ Deathand the Response
On January 17, 2020, the Suffolk County Police Department learned that Thomas had been pronounced dead. The cause was determined to be hypothermia. Video surveillance from the garage the night before Thomas’ death shows Thomas and Anthony shivering in the garage. The low temperature that evening was 19 degrees Fahrenheit. At the time of his death, Thomas’ body temperature was recorded at 76 degrees. Michael Valva and Angela Pollina have been convicted of “depraved indifference murder” and sentenced to 25 years to life. Justyna Zubka-Valva has sued Suffolk County for $200 million in Thomas’ death.
In the wake of the tragedy, the grand jury was empaneled to identify any failures in CPS conduct and practices, determining whether anyone should be found criminally liable, and potentially making recommendations to improve CPS practices to ensure that future children would be better protected. When the grand jury finally issued its report in April, 2024, its central conclusion was that its ability to investigate the case was “severely hampered” by the law governing the disclosure of reports declared by CPS to be “unfounded.” Under that law, these records are sealed and can be provided only for very restricted purposes to a short list of people and agencies under specific circumstances. Thus the grand jury had no access to any information about any of the CPS investigations that occurred in response to calls from the school.2
We know that reviewers in both Suffolk County DSS and New York State’s OCFS did have access to the complete records of the case. New York law requires local departments of social services to investigate all fatalities from maltreatment. The state’s Office of Children and Family Services is required to review each local fatality investigation and issue its own report within six months of the local investigation. Unfortunately, neither the state and county legislatures, the grand jury nor the public had access to these two reviews. The local reviews are never released to the public. OCFS posts its fatality reviews on its website (with names and identifying information redacted), but only when it is determined that “disclosure would not harm the child’s siblings or other children in the household.” An earlier post by Lives Cut Short discusses this process and shows that about a quarter of these reports on child deaths in 2022 appear to be withheld on these grounds, including most of the cases that had been covered in the media. Not surprisingly, the grand jury confirmed that the OCFS report on Thomas’ death was withheld on these grounds.
The Costs of Secrecy
The grand jury’s central recommendation was that the state’s law must be changed to expand access to this information–but only to grand juries and district attorneys prosecuting cases. Actually, a much broader change is needed. At a minimum, the “best interests” determination must be eliminated and all of the OCFS child fatality reviews, with appropriate redactions, must be shared with the public. As described in a Lives Cut Short report on state disclosure policies, several other states share such case reviews. These include Pennsylvania (which posts case reviews on all child maltreatment fatalities and near fatalities); Florida, Oregon and Washington (which post case reviews on the deaths of children in families with which the agency had contact within a year); and Colorado, (where cases are posted if the agency has dealt with the family in the past five years). In addition, Arizona and Wisconsin post summaries of all child maltreatment fatalities and near fatalities including a brief description of prior agency requirement.
The public should have access to the full agency file involving its interactions with a family in which a child later dies of abuse or neglect. That includes records of all reports received and agency responses, including decisions not to investigate. These files should be redacted to remove the names of those who reported abuse and of other children in the family, though the names of Thomas’ brothers have long been known through media reports. Laws in Florida and Arizona require the release of redacted case files upon request in cases where a child dies of maltreatment.
The limits of the grand jury’s recommendation may stem from its limited view of why the changes are needed. The grand jury stated that the privacy protections enshrined in the law “have had the unintended consequence of shielding an entire agency, its leadership, and its hundreds of employees, from criminal investigation and prosecution.” Accountability is certainly necessary. Newsday has reported that three Suffolk County CPS employees that “played key roles” in the investigations of Valva and Pollina were promoted after Thomas’ death. But we don’t need transparency just for the purposes of holding people accountable. Individuals are not always at fault in these cases, and even if they are, there may be systemic flaws as well. Knowing the entire case history is critical to enable legislators, advocates and the public to identify the flaws in the system that caused it to fail.
Without access to the full agency record, It is difficult to understand how so many reports over 14 months could have resulted in no findings of abuse or neglect. The number of reports, the serious nature of the concerns expressed, and the repetition of similar concerns regarding two boys, do make it difficult to understand how all of these reports were screened out or unfounded. Suffolk County officials provided a clue when they stated in a recent press conference that CPS staff may have been biased in favor of Michael Valva because he was a police officer. But other flaws in policy or practice, such as high caseloads, untrained or unqualified staff, an extremely parent-centered culture, or even criminal misconduct by CPS workers or supervisors, may have been present as well.
An Absurd Response to Thomas’ Death
On July 9, 2020, the Suffolk County Legislature enacted the CPS Transformation Act, which was designed to prevent future tragedies. It seems to have been based on a cursory external review by a legislative task force, which apparently did not have access to the internal DSS review. Four years later, Suffolk County officials announced “comprehensive changes” to CPS in response to Thomas Valva’s death. Strangely, several of the changes that were cited were completely irrelevant to the conditions that resulted in Thomas Valva’s death. These included changing the process of removing a child from a family by instituting “blind removals,” returning adult protective services to the Child and Family Services Division of DSS, and a new mobile “panic button” for employees who find themselves in danger.
The most bizarre of these reforms was the adoption of “blind removals” by Suffolk County. The blind removal process, pioneered in neighboring Nassau County, NY, was created in response to concerns about racial bias leading to the removal of Black children at a disproportionate rate compared to their share of the population. It requires each child removal to be approved by a panel that does not have access to demographic and identifying information on the child and family. The policy gained national attention due to a 2018 TED Talk citing numbers that were later shown to be wrong. The only academic study found no impact for the process; but New York State had already required all counties to develop a blind removal process by October 14, 2020.
County officials at the press conference attempted to connect blind removals with preventing future tragedies by stating that the policy “eliminates the type of “biased decision-making” that kept 8-year-old Thomas Valva in the custody of his police officer father before his death.” But Thomas was never found to be abused and therefore not considered for removal. Moreover, Suffolk County adopted blind removals in response to a state mandate, not Thomas’ death.
Thomas Valva suffered and died because CPS ignored his cries for help and the repeated warnings of staff at his school. Almost five years after Thomas Valva’s death, the public still does not know why the system set up to protect abused and neglected children failed both him and his brother. In New York and around the country, we need transparency around child fatalities and near fatalities when public agencies were involved with the family and could have stepped in.
In February, 2018, Suffolk County CPS “indicated” (found some credible evidence of maltreatment) a case against Thomas’ mother for “inadequate guardianship” and against his father for “inadequate guardianship,” “excessive corporal punishment,” and other charges. These cases apparently stemmed from allegations that Thomas’ parents made against each other and are not further described in the grand jury report. ↩︎
It is possible that the grand jury was misinformed that ten reports were investigated and unfounded, The report cites only two visits from CPS workers to the school. Moreover, the grand jury’s report that a CPS worker said the four reports made in one week canceled each other out suggests that they were not investigated at all. If some of these reports were screened out or not investigated, the grand jury should have been informed of this fact and given information about why these reports were screened out. ↩︎
This post was prepared for and originally appeared on the website of Lives Cut Short, a project to document and analyze child maltreatment fatalities in the United States. See my interview with KUTV about this post here.
On October 10, the Utah Department of Children and Family Services (DCFS) finally released a statement summarizing its involvement with Gavin Peterson, who died on July 9, 2024 at the age of 12. Gavin’s father, stepmother, and older brother are awaiting trial on reckless child abuse homicide, among other charges. The much-awaited “CAPTA statement” from DCFS (named for the federal law requiring that states have a policy to disclose “information and findings” about child maltreatment fatalities and near fatalities) provided some new information but raised new questions, especially when contrasted with media accounts.
The DCFS statement begins with a disclaimer. Gavin came from a “two-household family” and was residing with his biological father, Shane Peterson, and father’s long-term girlfriend, Nichole Scott, at the time of his death. The agency explains that although it “worked with each household at several points in Gavin’s life as early as 2013,” the statement includes only “information relevant to Gavin in the household where his death occurred.” It is not clear from this disclaimer what information was withheld from the public, either because it was from the other household or because DCFS decided it was not “relevant to Gavin.”
Some of that information can be pieced together from media coverage. Gavin’s mother, Melanie Peterson, told a reporter at KSL TV that she lost custody of all four of herchildren in 2014 or 2015. Court documents obtained by the reporter showed that two-year–old Gavin was found unsupervised outside of his home in 2014, and that in the same year Melanie pleaded guilty to allowing a child to be exposed to illegal drugs or drug paraphernalia. Melanie told the reporter that she never regained custody of her children from the courts, but that Shane Peterson unofficially returned her third child to her in 2018 and her second child in 2019. (Her first child was apparently Tyler, who is charged in Gavin’s death, and Gavin was the fourth child.)
DCFS’ statement provides a chronology of abuse and neglect reports and agency responses, which are summarized below along with our commentary in italics.
May 28, 2019
The first report of abuse in Shane Peterson’s home is received. DCFS investigates and finds that Nichole Scott had physically abused another child in the home. The Peterson family accepts voluntary in-home services. After a month of services, DCFS concludes the safety concerns have been resolved and closes the case.
The “other child” was clearly Gavin’s sister Mayloni Peterson, now 19. She told KSL TV that she was abused even more severely than Gavin at the time, and was even punished for his actions. She described being beaten, tied to her bed, fed only once or twice a day, forced to perform labor in the household and at her grandmother’s house. She reported that Scott once shaved off all her hair as punishment for combing her hair without permission and strangled her in the car following a failed attempt to run away. On Saturday, May 25, 2019, Mayloni told her father that she accidentally broke a sprinkler while mowing the lawn. Her father took her to her mother’s house without warning and left her there, possibly saving her life. Melanie Peterson reported that Mayloni was malnourished and “with all her hair buzzed off.” After hearing what her daughter had been through, Melanie made a report to DCFS after the Memorial Day holiday–clearly the May 28, 2019 report. (Mayloni mentioned a report that was made by her school in March; it is not clear whether that report was omitted by DCFS because it was “not relevant to Gavin.”)
February 27, 2020
DCFS receives a call reporting abuse of Gavin in “another household.” DCFS finds Gavin to be a victim of abuse and files a court petition. On May 27, the court orders both households to participate in DCFS in-home services.
Melanie Peterson told KSL TV that she took a picture of an emaciated Gavin in February 2020. It would be the last time she saw him. She alleges that Nichole and Shane Peterson found out about the photo and made a false allegation about her, thereby ending her visitation rights pending a judgment by DCFS. That “false complaint” was likely the February 27, 2020 report, which resulted in an open case for both households.
August 24, 2020
While the two households are receiving in-home services, DCFS receives a call reporting concerns about Gavin’s treatment in his father’s home. The information does not “meet the criteria required by Utah state law to open an investigation,” but the intake worker shares the information with the in-home caseworker.
May 21, 2021
The “Peterson family” successfully completes” in-home services, and the judge closes the case. No information is provided about what these services were.
September 2, 2022
DCFS receives a report from “someone concerned about Gavin’s well-being, after observing some of his behaviors.” The hotline worker decides the report does not meet the legal criteria for opening an investigation. A supervisor approves this decision.
This report most likely came from Gavin’s school, and his “behaviors” included eating food from the trash. Cafeteria worker Rachel Reynolds told KSL TV that she suspected Gavin was hungry even before the school’s COVID-19-era free meal program ended in August 2022 and Gavin began taking leftovers from the trash. Her colleague Jan Davis said that she and a coworker began paying for Gavin’s lunch. That ended when Nichole Scott demanded they stop buying his lunch. But the workers continued to “sneak food” to him, according to Reynolds.
March 28, 2023
DCFS receives a report regarding physical neglect of Gavin and opens an investigation. Two days later, DCFS receives another report, which is added to the open investigation. Gavin is interviewed at school without his parents and does not disclose abuse. On May 8, 2023, DCFS receives a third report alleging physical abuse of Gavin. The investigator visits the home for a second time, interviews the adults and interviews Gavin outside the presence of the alleged abusers. The case is closed on May 15 with no finding of abuse or neglect.
These three reports likely came from the school.The school district reported the school made “multiple calls” about Gavin, and Rachel Reynolds said that at least four calls were made by cafeteria workers and the principal. Reynolds personally observed the nurse and school principal call DCFS when she brought Gavin to the nurse with fingers that looked swollen and infected from picking. Jan Davis mentioned that Gavin came to school with a chipped tooth shortly after Nichole Scott learned that cafeteria staff were feeding Gavin. Perhaps that accounted for the abuse allegation.
In August 2023, Gavin was withdrawn from school for schooling at home. There are no more reports until July 29, 2024. Utah has no policy in place for monitoring children withdrawn from school following allegations of abuse or neglect,
July 9, 2024
DCF receives a report that Gavin is in the emergency room with injuries that appeared to be the result of abuse or neglect. He dies the same day.
The police investigation into Gavin’s death has revealed that Gavin was abused for years, was kept locked in an uncarpeted room without bedding or blankets while adults monitored him with multiple cameras, and was often beaten or starved, sometimes given only bread and mustard to eat. Nichole Scott, Shane Peterson, and Tyler Peterson were arrested and charged with child abuse homicide, aggravated child abuse, and endangerment of a child, and are awaiting trial. Gavin’s treatment can be defined as torture, a type of child abuse that some have observed may be increasing in Utah and around the country. These cases often include confinement, starvation, beating, and isolation.
Unanswered Questions
Utah’s report on Gavin Peterson’s death, when compared with the media accounts from Gavin’s mother, sister, and school staff, raises more questions than it answers.
The May 28, 2019 report: The allegations that Mayloni made to her mother, who presumably included them in her May 28, 2019 report, concerned multiple reports of physical abuse, confinement, and forced labor. Both children should have had a physical exam and a forensic interview. How is it possible that allegations of this magnitude (that turned out to be true) resulted in a case that was closed in a month and that was also described as “voluntary”?
The February 2020 report: This report about the abuse of Gavin in another household is clearly the “false allegation” stemming from his mother’s photograph of an emaciated Gavin. How did that result in a substantiation against her for abuse? The case was open for more than a year during the height of the COVID-19 pandemic. Were the visits virtual? Does that explain why the caseworker observed nothing of concern? Why did Melanie never get her visitation rights back after the case was closed?
The August 24, 2020 report: What concerns were raised and why did they not meet the criteria to open an investigation? Was this report really shared with the in-home worker and did that worker try to determine whether they were true?
The September 2022 report: How was this report, obviously from the school and conveying that Gavin was seeking food in the trash, not judged to meet the legal criteria for an investigation, even by a supervisor?
The reports in March and May of 2023: Why did the investigation conducted from March to May 2023 fail to find the abuse of Gavin, which was so obvious to school personnel? Wasn’t Gavin very thin? Shouldn’t he have received a physical examination? If he denied the abuse, was the investigator unaware that is what scared children do? Was there any discussion of taking him to a Child Advocacy Center for a forensic interview?
Key Takeaways
The first major takeaway of this report is that Utah’s CAPTA report does not tell us whether DCFS did all that it could do to protect Gavin. The information shared in the report complies with state policy, which in turn complies with the very vague requirements of federal law. But much more detail is needed including documentation of the reasoning behind rejecting certain reports as worthy of investigation, the entire record of each investigation including interviews and documents, and a report of every interaction with the family during the in-home case. A few states post “critical incident reviews” for some death and near fatality cases. But such reviews are expensive, not all cases get reviewed, and internal reviewers may be biased on behalf of the agency. The only way to ensure accountability and inform needed changes is to release the full case file on the family, with certain names redacted,1 for at least the five years preceding the fatal or near fatal event.
The second major takeaway is that in spite of the lack of detail, the information provided strongly suggests that the problems in this home were longstanding and there were many opportunities for DCFS to discover them. It appears that systemic issues prevented the diagnosis of issues that should have been obvious. A former DCFS caseworker told KUTV that she left the agency “after struggling with overwhelming caseloads and a culture of simply ‘checking boxes.” She explained that while cases demanding immediate action are usually addressed, other cases showing red flags are dismissed too soon as “safe enough.” She placed primary blame on the legislature for not allocating adequate resources, saying that workers want to do their jobs, but they are being placed in impossible situations. “It’s unfair to put them in these situations where they don’t have the time to produce quality work, or if they do decide to put in the time, they’re sacrificing so much.”
The third major takeaway is that Gavin’s fate was sealed once he was withdrawn from school and the reports stopped coming in. In its Make Homeschool Safe Act, the Coalition for Responsible Home Education proposes that a child cannot be withdrawn from school for homeschooling within three years of being investigated for abuse or neglect, regardless of the outcome, unless there is a risk assessment by social services or child welfare that finds that the child will not be endangered by being schooled at home, and the home educator agrees to a monthly risk assessment for the next 12 months.
Gavin Peterson was failed by the agency that was meant to protect him, A few children suffering similar torture have been lucky enough to escape to safety, like the boy who escaped from the home of parenting youtuber Ruby Franke and saved himself and his sister from likely death. But most children in these situations have no recourse unless the people being paid to protect them have the time, training, support and resources to investigate fully and respond appropriately. To ensure that happens, the public must have access to the complete records of cases in which the system has failed.
For example, the names of children and people who reported maltreatment. ↩︎
Child Welfare Monitor 