Los Angeles County missed many chances to save Anthony Avalos

Anthony Avalos
Anthony Avalos: Los Angeles Times

In July 2018, ten-year-old Anthony Avalos arrived at the Emergency Room with fatal bleeding in his brain. His emaciated and battered body succumbed the next day to years of deprivation and abuse. For four years, the Los Angeles Department of Children and Family Services (DCFS) had received 13 reports on suspected abuse of Anthony and his siblings. For part of that period, his family was actually under the supervision of DCFS.

Many commentators saw parallels between Anthony’s death and that of Gabriel Fernandez in 2013 in the same town of Palmdale, in the Antelope Valley section of Los Angeles County. Gabriel was tortured to death by his mother and stepfather after multiple reports to DCFS failed to result in his rescue from this lethal home.

But based on its review of the family’s case file, Los Angeles County’s Office of Child Protection (OCP) concluded that Anthony’s case was “very different” from Gabriel’s. OCP concluded that it could not say that Anthony might still be alive today if the agency had done things differently. In justifying this conclusion, OCP stressed that the family was not under DCFS supervision at the time of Anthony’s death and that it had been over a year since the last report was made to the child abuse hotline concerning the family.

But in his devastating article,  The horrific death of Anthony Avalos and the many missed chances to save him, investigative reporter Garrett Therolf shows that DCFS had many opportunities to save Anthony. It also reveals striking connections between Anthony’s case and Gabriel’s. The same private agency counselor had worked with both boys, and had been questioned in court about Gabriel. A caseworker who had been disciplined for his errors in the Fernandez case actually supervised the social worker who managed Anthony’s case.

Garrett Therolf was kind enough to share the DCFS case file with Child Welfare Monitor. In reviewing the file, we were struck by the many red flags that DCFS ignored and the crucial points where the agency could have intensified the surveillance of the family or removed the children to safety. In this post, we highlight our own observations from the case file, complemented by key information obtained from other sources (such as interviews and grand jury transcripts) by Therolf.

The First Calls: 2013 and 2014

Anthony Avalos first came to the attention of DCFS in February 2013, when he was only four years old and reported that his grandfather sexually abused him. The agency substantiated the abuse but did not set up any ongoing monitoring, relying on his mother, Heather Barron, to keep his grandfather away from him.

In May 2014 the family came to the attention of DCFS again when a caller alleged that Barron, who had four children at the time,  was  hitting the children with hoses and belts and locking them in their rooms for hours. An allegation of neglect (but not abuse) was substantiated.  Barron agreed to the opening of a voluntary case, which was open from May 20, 2014 to December 4, 2014. A social worker named Mark Millman was assigned to manage the case. 

Under DCFS Supervision: June-December 2014

In June, 2014 a PhD. psychologist who evaluated Barron concluded that she  “appeared to have poor parenting skills as shown by her lack of patience towards her two children that displayed energetic behavior….At this time…. the assessor believes that her capacity to provide suitable care for her children is severely limited by her poor parenting skills, poor judgment, and denial and lack of awareness of her mental health issues.”  The evaluator recommended a variety of services for Barron. She refused to participate in individual therapy–probably the most essential. But there is no indication that case manager Millman even read the report, let alone followed up to see if the services were provided or successfully completed. Barron did participate in in-home services to improve her parenting skills, which were provided by an agency called the Children’s Center of the Antelope Valley. 

Once services got under way, reports from the provider were not encouraging. A July 2014 progress report from the Children’s Center indicated that Barron was “having a difficult time maintaining her composure when the children misbehave.” In its August 2014 report, the agency reported that Barron was overwhelmed. The agency case manager recommended therapy for Ms. Barron but she again refused saying she was not interested in talking about the past. 

On October 9, 2014, a counselor at the Children’s Center called the hotline with concerns about the family.  The counselor had tried to discuss her concerns with Millman but he seemed to “blow it off.”  She reported that Barron, who had recently given birth to a fifth child, was “ very aggressive and angry and showed no nurturing to any of her children, even the infant.” She reported that she observed Barron yanking one child by the arm, yanking her daughter’s hair while brushing it, and calling the children names like “punk” and “bitch.” 

The social worker assigned to investigate the new allegations was not concerned.  He observed  that Barron and her children were ”interacting positively” and “that mother and children had secure attachment as seen by their interaction.” Barron’s admission that she hit the children with a belt and used hot sauce to punish them for talking back did not seem to bother him.  It appears that he was influenced heavily by Millman, who expressed no concern for the family. He reported that Ms. Barron “has her hands full and is doing her best….…She does cuss and yell but [is] doing all she can to provide appropriate care.”

The automated risk assessment performed as part of every investigation showed a high risk of abuse and neglect and recommended promotion to a court case. The investigator overrode this recommendation,  stating that the children were already involved in a voluntary case and getting services. And somehow, despite the mother’s own admission, the investigator closed the referral as “inconclusive” for physical abuse, as well as emotional abuse and general neglect.

Another Children’s Center therapist called DCFS on November 5, 2014, alleging she overheard one child say “She’s bad because she whips our ass.” The caller said that Barron continued to get frustrated easily. She quoted Barron as telling one of the children, ‘Don’t think, because she is here, I won’t whip your ass.’” This referral was “evaluated out” with no explanation.

Case Closed: December 2014

The voluntary case was closed on December 4, 2014 with the following comments: “The mother has been compliant with services and receptive to outside resources. Although the family has received two new referrals, the allegations were assessed unfounded/ inconclusive. Mother has agreed to continuing counseling for the children.” The agency arranged for the family to receive this counseling through a new agency,  Hathaway Sycamores Counseling.  There  was no indication that the mother had made any progress in addressing her parenting issues.  Nor was there a rationale given for directing the counseling toward the children rather than the mother.

Hathaway-Sycamores was the same agency that worked with Gabriel Fernandez, as mentioned above. As Therolf reveals, Anthony was even assigned to the same counselor, Barbara Dixon, who worked with Gabriel. Dixon testified in court that she had observed extensive injuries to Gabriel but did not report them to the hotline, despite being a mandatory reporter. The fact that she still had her job is mind-boggling. According to Therolf, “her case notes show that she counseled [Gabriel] to listen to his mother more attentively and to finish his homework.”

Kareen Leiva Enters the Picture: 2015

As Therolf describes, Barron met Kareem Leiva in 2015 and began a relationship that would last several years and result in Barron’s seventh child. Within months, the father of Anthony’s two-year-old brother reported to police that Leiva was abusing his son. There was no DCFS investigation but DCFS did open a court case involving that child and his parents, resulting in regular visits to the home by a social worker, Mindy Wrasse.

On June 12, 2015, the same father went to the police again after an agency-supervised visit with his son, reporting that his son had bruises on his arm and face. The social worker observing the visit had confirmed the bruising and reported that the child repeatedly said “Mommy is mean” during the visit. The father reported that the child seemed to have bruises at every visit. Ms. Barron reported the two-year-old fell in the shower, and the toddler reportedly confirmed the report. A two-year-old’s ability to confirm this verbally–and to take a shower on his own–shows suspicious precocity for his age. Despite the other siblings giving two different accounts of the bruising, the referral was ruled unfounded on the grounds that all of the children had similar stories. Additionally, the risk of maltreatment was found to be high and the recommendation was to promote to a case. But this recommendation was overriden because there was already an open case involving the two-year-old and his mother. That case closed in October 2016, leaving no DCFS personnel in contact with the family.

The Children Beg for Help: September 2015

On September 18, 2015, the hotline received a call, revealed by Therolf to be from the principal of Anthony’s school, recounting disturbing reports by Anthony of his treatment at home. A similar call came in from a sheriff’s deputy the next day. According to Therolf’s investigation, the children were visiting their uncle, David Barron, and told him about the horrific treatment they received from Barron and her boyfriend, Karim Leiva. David Barron refused to allow his sister to pick up the children and called the police instead. Anthony and his two oldest siblings described to the deputy who responded a litany of horrific punishments by Barron and Leiva.  They reported Barron made them. squat against the wall for long periods of time, a torture she called the “Captain’s Chair.” They also described beatings,  food deprivation, being locked in their rooms, and Leiva’s hanging Anthony’s brother from the stairs.  

When the DCFS investigator met with Anthony, he told her  “Heather is my old mom. This is my new house. I am part of the Barron family now. I’m never going to see Heather again. She locks us up in our rooms and makes us starving.”

But sadly, the agency that was responsible for Anthony’s safety did not allow him to stay in his safe “new home.”  The investigator spoke with three staff members of Hathaway-Sycamores, the agency providing home-based services to the mother. The three reported that they were “constantly in the home” and that the mother did not hit the children.  They said the children did not seem frightened, never talked of abuse, and there were no locks on the doors. The contrast with the reports of the Children’s Center a year earlier is striking. Given what came out after Anthony’s death, it is clear that the providers from the Children’s Center were much more discerning. Or perhaps Hathaway-Sycamores was in the grips of an ideology that values family preservation over child safety–a belief system that has led to many other children being abandoned to a horrible fate. In any case, it is incredible that DCFS was still using this agency after its role in Gabriel’s death.

Heartbreakingly, Ms. Barron was allowed to take the children home from her brother’s house. Not surprisingly, they recanted all the allegations once deprived of the protection of their aunt and uncle. Instead, they said their aunt and uncle told them to make these allegations. The wholesale retraction is suspicious because of the similarity and unusual nature of the allegations and the young age of the children, as well as the number of previous reports of abuse. It doesn’t take a genius to realize that the children may have been frightened into recanting their allegations. But the investigator decided that the aunt and uncle were manipulating the children and had instigated the allegations. (Therolf reports that she was new to the job and testified in court that she was unaware that survivors of abuse often retract their accounts.). The allegations were found to be “inconclusive “and the referral was closed with a disposition of “situation stabilized.” 

One last chance of rescue missed: April 2016

 On April 28, 2016, DCFS received another report, which Therolf learned came from a domestic violence center staffer who was working with Barron. Two of Anthony’s brothers had bruises on their faces. Barron said they had been in a fight, but the boys told the reporter that Karim Leiva made them fight each other. They also reported being locked in their rooms and deprived of food for long periods of time. Barron stated that Leiva had not been in the home since the previous September. In interviews with the investigator, Anthony, his sister, and the five year-old brother all denied the allegations. Anthony and his sister denied that Leiva was in the house or even that they knew him–a denial which should have raised serious concerns to the investigator. Wrasse, the social worker who was monitoring the open case involving Anthony’s brother, said the children definitely knew who Leiva was–and she thought he was coming regularly to the house. The investigator of the previous report also declared definitely that the children knew Leiva.

Despite all these inconsistencies, the allegations were all judged “unfounded” or “inconclusive,” and the disposition was “situation stabilized.” The risk assessment showed a high risk of abuse or neglect and a recommendation to “promote” the case. But the recommendation was disregarded because there was already a social worker on the scene–the same worker who was sure Leiva was coming into the home regularly. Her involvement ended in October 16, and then the children were totally on their own.

There were no more allegations until it was too late for Anthony. At some point, Ms. Barron cut ties with her brother and sister-in–law and moved Anthony to a school that did not know his history. Nobody was left to protect him. It is nevertheless surprising that no  reports came from the children’s schools–a fact that deserves further investigation. According to Therolf, Anthony’s teacher noticed that he was “often nervous about something.” Such nervousness is not normal and should have triggered a response. But that is an issue for another post.

June 2018: Anthony’s suffering ends

Anthony’s fate was sealed when he told his his mother that he liked boys and girls. Leiva overheard this conversation.  The following night, his siblings later reported, Leiva picked up Anthony by his feet and slammed his head on the floor repeatedly. The next morning, Barron called 911, saying Anthony  had fallen. He was taken to the hospital and died the next day.

Anthony’s siblings initially denied any abuse, but as soon as they were questioned by an expert forensic interviewer, they revealed all the horrors that were occurring in the home. As punishment for minor transgressions, they were made to kneel on rice with weights in their hands, were kept awake all night (with water thrown into their faces by Barron or Leiva if they fell asleep), and were whipped with a belt or extension cord on the buttocks or soles of their feet. Anthony was singled out of special punishment. Leiva would pick him up by the feet and slam him on the floor head-first, as he did the night before Anthony died. By dying, Anthony saved his siblings from this nightmare home. They were removed from the home Barron and Leiva , who have been charged with first-degree murder for Anthony’s death.

DCFS had many chances to save Anthony but it wasted them all. This gifted, sensitive, and loving child was condemned to years of suffering ending only with his death. OCP was set up to protect children in the wake of Gabriel Fernandez’s death. It’s sad that this office ended up basically whitewashing Anthony’s. Now we are waiting for their report on why four-year-old Noah Cuatro was killed when DCFS disregarded an order to remove him from his home. Based on the Avalos report, the chances of a thorough investigation by OCP are slim.

Yet another child abandoned by another state: Two-year-old Jordan Belliveau dead at his mother’s hands in Florida

Juliet Warren (left) with her foster child, Jordan Belliveau. The 2-year-old toddler went missing for more than two days and was then found dead late Tuesday. His 21-year-old mother, Charisse Stinson, now faces a charge of first-degree murder in the death of her child. [Photo Courtesy the Warren Family]
Jordan Belliveau, Jr. with his foster mother: Tampa Bay Times
On September 4, 2018, the body of two-year-old Jordan Belliveau was found in a wooded area in Largo, Florida. Two days before, his mother Charisse Stinson told police she was assaulted by a stranger and that her son was missing when she recovered consciousness. She later admitted that she had fabricated this account and in fact had caused the injuries that caused Jordan’s death.

Jordan had been removed from his parents in October 2016 and reunited with Stinson in May 2018. At the time of his death, Jordan was under court-ordered “protective supervision” by a nonprofit agency under subcontract with the Florida Department of Children and Families (DCF). There was also an open investigation of allegations of ongoing domestic violence between Stinson and Jordan’s father, Jordan Belliveau, Sr. DCF convened a special review team to determine why Jordan killed despite being under supervision by the system that was supposed to protect him. The team’s report was issued earlier this month.

To understand the case, one must grasp the particularly fragmented nature of child welfare in Pinellas County, Florida, in which three crucial functions usually vested in one agency are split between three different agencies. The Sheriff’s Department handles child abuse investigations, a private agency called Directions for Living manages in-home service cases under contract with Eckerd Connects, which in turn has a contract with DCF, and the State Attorney’s Office represents DCF in court.

The first call concerning Jordan and his parents came in to the child abuse hotline on October 2016, when Jordan was three months old. Jordan and his parents were living in the home of his paternal grandmother, and the caller was concerned about drugs, gang activity and firearms in the home. The allegations were verified and an emergency hearing was called. Ms. Stinson was ordered to relocate immediately and was referred to a program providing housing and support services to young mothers. However, she  refused to cooperate with the program and was rejected. A second hearing was convened on the same day (November 1, 2016) and Jordan was placed in foster care. In order to get Jordan back, the parents had to comply with a case plan which required each of them to obtain stable housing and income, comply with a “biopsychosocial assessment,” and follow the recommendations of the assessment. Ms. Stinson was also required to obtain counseling.

In January 2017, Jordan was placed with the foster family that would keep him until he was returned to his mother 16 months later. It was in this home, as his foster mother reported in a heartbreaking statement after his death, Jordan learned to roll, crawl, walk and talk and flourished in a supportive community of church members, foster families, and Coast Guard families.

While Jordan was thriving in foster care, an escalating series of violent incidents was reported between his parents. Each parent was in turn arrested for violence against the other but each case was dropped because the other parent did not press charges. Despite these incidents, Ms. Stinson was granted unsupervised visits with her son starting June 18, 2017. During the first unsupervised visit, Ms. Stinson allowed Mr. Belliveau to attend despite the fact that his visits were still required to be supervised. At this visit, which took place at a Burger King, members of a rival gang arrived and a fight ensued. Holding Jordan in her arms, Ms. Stinson struck at a woman who was fighting with Mr.Belliveau. Attempting to hit back, the woman hit Jordan in the mouth, inflicting lacerations. This incident was reported to the child abuse hotline, along with allegations that Mr. Belliveau was selling cocaine and marijuana from their home and that both parents used these drugs. Both parents refused to be tested for drugs. The investigation concluded with a finding of inadequate supervision and failure to protect Jordan by both parents.

In the next court hearing on the family case, the magistrate in charge of the case was not informed that this was a gang-related incident, that Ms. Stinson was involved, or that Jordan was injured. There was no mention of the  need to screen both parents for drug use.

According to Florida statute, DCF was required to file a petition for termination of parental rights within 60 days of November 1, 2017, when Jordan had been in foster care for 12 months. Yet no such petition was filed. At the hearing on January 8, 2018, the court found “compelling reason not to consider termination” because Ms.  Stinson was “partially compliant” with her case plan tasks because she had completed an assessment and was wrongly reported to be in counseling.

During a court hearing on April 23, 2018, Ms. Stinson’s attorney reported that she had completed the counseling mandated by her case plan, but no documentation was provided. As a matter of fact, Ms. Stinson had been terminated from counseling for the second time a week before the hearing. The Guardian ad Litem (GAL appointed to represent Jordan’s interests in court) objected to reunification because there was no documentation that Stinson was going to counseling and it appears that the case management agency objected as well. Without requiring documentation,  Magistrate Jennifer Sue Paullin ordered reunification and gave all parties 20 days to object based on new information. No objection was filed.

The court order, obtained by the Tampa Bay Times, states: “No evidence was presented to show that the circumstances that caused the out-of-home placement have not been remedied to the extent that the return of the child to the mother’s care with an in-home safety plan … will not be detrimental to the child’s safety.”.

On April 25, 2018, in anticipation of Jordan’s return to Ms. Stinson, the latter was referred to an in-home reunification program that provided twice-weekly visits from a licensed clinician. Ms. Stinson missed three or her five scheduled visits prior to reunification, which went ahead as scheduled on May 21, 2018. She missed seven of 11 visits following reunification and was unsuccessfully discharged from the program due to failure to participate

In a court hearing on June 11, 2018,  the court granted reunification to Mr. Belliveau, allowing him to join the family. Ms. Stinson had already missed several appointments with the clinician but the case management agency and government attorney reported that both parents were compliant with services.

On July 14, 2018, police responded to the parents’ residence to find Ms. Stinson bleeding and bruised and reporting that she had been punched by Belliveau. Mr. Belliveau was arrested after threatening to kill Ms. Stinson and “a lot of ….cops.” The child abuse hotline was not notified of this incident until three weeks later, on August 4. Despite the escalating violence and threats, the ensuing investigation did not find Jordan to be in danger warranting removal, but it was still open at the time of Jordan’s death.

On August 17, 2018, the agency filed an amended case plan with the court, including domestic violence services for Belliveau (as a perpetrator) and Ms. Stinson (as a victim). On August 24, Ms. Stinson refused to allow the GAL into the house. The investigator contacted the case manager for the first time on August 29, more than three weeks after the investigation began. The case manager said she normally visited once a week but admitted that he sometimes had trouble  reaching Ms. Stinson. On August 31, the case manager completed a home visit and explained to the parents that they needed to participate in services in order to retain custody of Jordan. Less than 24 hours later, Ms. Stinson reported Jordan missing.

Charisse Stinson has been charged with first degree murder for hitting Jordan, causing him to hit his head and have a seizure. Police report she did not seek medical treatment immediately and Jordan died. She then allegedly dumped his body in a wooded area and lied to police about a stranger kidnapping him, resulting in an Amber Alert and days of searching before Jordan’s body was found.

The special review team made six findings about the system’s  failures to save Jordan:.

  1. The decision to reunify Jordan with his parents was apparently driven by the parents’ perceived compliance to case plan tasks rather than behavioral change. Case decisions were solely based on addressing the reasons Jordan came into care. which related to gang and drug activity in the home where he was living. Although other concerns came to light during the life of the case, like substance abuse, domestic violence and mental health issues among the parents, these factors were not added to the case plan or considered in the decision to reunify Jordan with his parents. Ms. Stinson herself requested anger management training during a meeting in 2016 but this was never included in her case plan or provided. Moreover the court was kept in the dark about many of these concerns. “On multiple occasions, Ms. Stinson provided false information to the court,” which the case management agency and government attorney did not correct.
  2. Following Jordan’s reunification with his parents, staff failed to follow policy and procedures to ensure child well-being, such as making weekly visits. Moreover, they did not notify the court or take any action based on the mother’s lack of compliance with post-reunification services.
  3. When a new report was made to CPS, the investigator “failed to identify the active …threats occurring within the household that were significant, immediate, and clearly observable.” These included: ongoing and escalating violence between the parents, the father’s threat to kill the mother, and his gang membership and access to weapons, among others. In a major understatement, the Special Review Team opined that “Given the circumstances, a modification of Justin’s placement should have been considered.”
  4. There was a “noted lack of communication and collaboration” between investigative staff located in the Sheriff’s Department and case management staff during the August 2018 child abuse investigation. The investigator did not talk to the case manager for over three weeks after opening the investigation.
  5. There was a failure of communication and collaboration between all of the different entities involved in the case. There was a “lack of diligence in conducting multidisciplinary staffings at critical junctures of the case.” Neither the case management agency nor the state attorney provided accurate information to counter the false information provided by the mother to the court. Unbelievably, the case manager attended court hearings with no information about the mother’s participation in counseling, which was provided by the same agency.
  6. Assessments of both parents failed to consider the history and information provided by the parents and resulted in treatment plans that were ineffective to address behavioral change.

The review team did a good job of isolating the specific system failures that occurred in Jordan’s case but was not as successful identifying the systemic problems behind these failures. In this writer’s opinion, three major systemic factors contributed to the failure to protect Jordan:

  1. Lack of coordination and communication between agencies. This was the factor emphasized by the review team, which suggested that this issue was limited to Pinellas County. State Senator Lauren Book castigated the team for for this implication, arguing in a statement that the issue of “siloed communication” goes beyond the county and even beyond child welfare itself, citing the errors that predated the shooting at Marjorie Stoneman Douglas High School.
  2. Inadequate funding of child welfare services, leading to high caseloads and staff turnover.  The review team gave an offhand mention to the difficulty caused by high caseloads and turnover, both of which can be traced to inadequate funding but treated it as a given, rather than a problem to be rectified.
  3. The overemphasis on family reunification. In Florida and around the country, family reunification has been emphasized to the degree that children are often placed at risk. The Tampa Bay Times highlighted this  problem in its editorial entitled, Another child dead, another state failure. The death of a child following reunification is not a new story in Florida or around the country. If Florida law had been followed, Jordan’s parents’ rights should have been terminated before he was ever returned to them. A case manager who left Directions for Living shortly before Justin’s death told Florida’s News Channel 8 that the system “puts far too much weight on reuniting kids with unfit parents and makes it nearly impossible for caseworkers to terminate parental rights.” When asked why workers did not remove Jordan, she replied, “We are on quotas and we are told, ‘If there is any way to keep this kid in home do it.”

What is to be done to prevent future deaths like Jordan’s? It must begin, as the Tampa Bay Times editorial board asserts, with holding those involved accountable. This applies particularly to the magistrate on the case, who should have given the child rather than the parents the benefit of the doubt and held up reunification until she heard from the mother’s counselor. Second, child welfare must be funded adequately so that its staff are well-qualified and able to devote the time to handle cases correctly. Third, the silos must be broken down through improved policies and procedures that mandate data sharing and collaboration, but only adequate funding to enable reasonable caseloads will allow this to happen.

Finally, Florida and other states must rectify the balance between a child’s safety and the value of family reunification. Agencies must recognize that some parents who are suffering from the consequences of intergenerational trauma and dysfunction cannot change–at least within a timeline that is appropriate for a developing child.  This decision must be made early, with the input of qualified staff, high-quality evaluations, and laws and policies that put the child first.

As Justin’s foster parents put it, “Ultimately, we hope that our painful loss will result (in) a fundamental re-examination of the entire system, of how foster care works, of the reunification process. Jordan deserves that, and the other children in the system deserve that.”

Charisse Stinson is awaiting trial on charges of first degree murder and lying to police. She gave birth to another child in December and Belliveau has been determined to be the father. Both parents have filed court documents requesting the child be handed over to Belliveau, who has been arrested twice since Jordan’s death.

 

 

 

 

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 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.