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Policy violations in Colorado social-services system found amid deaths of 43 children

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In the past five years, 43 Colorado children died from abuse or neglect after entering the child welfare program. Every one of those deaths was marked by a policy violation or sparked concern in the way the case was handled by county social workers.

Investigations completed by the Colorado Department of Human Services since 2007 indicate that social workers in 18 counties repeatedly failed to complete basic functions — such as interviews or follow-ups on assessments — in 43 cases where a child later died from abuse or neglect.

In 40 percent of those deaths — 17 children — county social workers failed to start or did not accept an assessment after a referral warranted an investigation for abuse or neglect.

The state department opens an investigation whenever a child’s death is a result of abuse or neglect and there was contact with the county child welfare system during the two years before the child’s death, said spokeswoman Liz McDonough.

Before 2011, an investigation was opened if a child entered the system five years before the death.

Human Services’ latest investigation will be into the death of 3-year-old Caleb Pacheco, whose body was found tucked underneath a Sterling mobile home last week. His mother, Juanita Kinzie, 24, is in custody and faces one count of first-degree murder in her son’s death.

In 2011, 21 child-fatality reports were launched in Colorado. Two have been completed. Reports become public after they are finished and if they show policy violations or concerns. The Denver Post obtained all 43 public reports completed in the past five years.

Most of the reports included multiple referrals and assessments.

According to The Post’s findings:

  • There were 27 instances in which county social workers failed to contact, interview or follow up with victims, caregivers, reporting parties or other adults involved in an referral.
  • There were 32 instances in which social workers did not document unsafe conditions, prior incidents or other concerns in their assessments.
  • There were 33 occasions during which assessments were not started in a timely manner, were completed incorrectly or left open beyond the allotted time frame.
  • In five cases, social workers failed to account for other children or caregivers living in the home, and communication difficulties across county departments and other systems — such as law enforcement — hindered an investigation in five cases.
  • One of the reports was on 7-year-old Chandler Grafner, who was starved by his foster parents, Jon Phillips and Sarah Berry, in 2007.

    In December, a federal judge ruled that the Denver social workers who were involved with his case were not immune from a lawsuit filed by the boy’s relatives. Phillips was sentenced to life in Chandler’s death and Berry to 48 years.

    Caleb’s family members say they last saw the boy in January 2011. During the year he was missing, the boy’s family said they called social services in three counties more than 70 times.

    Human Services cannot release details about Caleb’s case or confirm whether his family contacted county departments because the investigation into the boy’s death is ongoing, and a Logan County judge issued a gag order in the case, McDonough said.

    Dr. Kim Bundy-Fazioli, an associate professor at Colorado State University’s School of Social Work, said the family’s claims about unanswered calls for help are a concern.

    “When families aren’t making progress, there is a lot of chaos, and it can be overwhelming for case workers and service providers,” Bundy-Fazioli said.

    “You never know who to interview or who to trust, but it’s not an excuse not to intervene.”

    Bundy-Fazioli also was concerned about decreased funding for county programs and increased caseloads for overwhelmed social workers, who often have to make judgment calls on high-priority cases and investigations.

    Each of Colorado’s 64 county departments are being asked to do more with less, said Becky Miller Updike, ombudsman with the Office of Colorado’s Child Protection. Often, families in the most dire situations are also more transient, making it harder to track children through school systems and other county departments.

    “We have to cut back dollars from our counties every year, causing us to ask them to do more with less,” Miller Updike said.

    Jordan Steffen

    Mile High Mamas
    Author: Mile High Mamas

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    • comment avatar Michael R January 29, 2012

      This is total and complete incompetence of the highest level. What in the world are these County Welfare case workers doing with their time, if not investigating neglect and abuse? Heads should roll over these totally unfit and incapable of doing the job buffoons, starting at the top in administration right down to the lackey case worker not doing what they are being paid to do. Of course, the union would not allow this to happen.

    • comment avatar Mark B January 29, 2012

      Maybe if state social workers weren’t over burdened with cases these tragedies could be avoided. I’m sure any additional investigation would find that county social services are under funded and grossly understaffed. The case load a social worker must manage is impossible. Don’t point the finger at the social workers, blame needs to be placed on the system as a whole.

    • comment avatar John A January 29, 2012

      The state didn’t fail these kids, their parents did.

    • comment avatar DL B January 29, 2012

      If I read the article correctly, there were an additional 19 deaths in 2011 that are not included in the 43 deaths because the cases aren’t concluded. So there are at least 62 deaths of children in the last 5 years plus any more deaths that occurred in previous years but are not concluded. 62 deaths are more than one dead child per month in Colorado.

      The system was warned that these 62+ children were in danger or they wouldn’t have been in the system. It is time for children to be removed first and then the parents in question can try to prove they can provide a safe home for the kids. When drugs are involved, maybe there should be a zero-tolerance policy and the children are taken away forever. Usually, I believe in second chances but these children are dead! They had no second chance.

      Is anyone else sick of reading about kids dying because of terrible parents and a social services system that doesn’t seem to care enough to act?

    • comment avatar Colorado Mom January 29, 2012

      Remove any immunity from lawsuit for all paid government workers. Civil lawsuits including access to their personal belongings: houses, cars, electronics, bank accounts, retirement accounts, etc. to pay judgments for the deaths of these helpless children.
      I know the problem. I’ve dealt with it. They look for every excuse to find a way NOT to investigate. Our pediatrician has been up in arms and made the calls to social services himself. THEY BLEW OFF THE CHILDREN’S DOCTOR !!!!!!!!!!!

    • comment avatar Zinka T January 29, 2012

      The child protection department of social-services is broken and we know that. One child’s death is too many. Are the case workers over loaded of course they are but does that mean they don’t go out and do their job? So what if they have to stay late to complete a case, it could save a child’s life. I have been to the Pueblo office and I sat for 2 1/2 hours before I was told to come back the next day, while I was sitting there I seen a couple of case workers take 6 breaks, never pick up the phone, the person at the front desk took messages for almost all calls, police officers came and went dropping off papers, the court clerk came in several times with papers that were put in basket that was so full I thought it was going to fall over. All I wanted was to find out what rights I had to get visitation with my granddaughter. If there are going to budget cuts, cut from the top down or make the top working mangement or supervisors, weed out those who aren’t producing and get people who will produce. Like many places there are good people and bad people, in this case it is costing children their lives.
      While I believe the whole social services system need a complete reform this department needs something right now, today. Don’t ask me how to fix because I don’t know all I know babies are killed and it has to be stopped.

    • comment avatar Jeremiah January 29, 2012

      First of all, I feel terrible about the death of young Caleb. This goes w/o saying!

      I also watched on the news the large/extended family during the evening memorial and many of the family were railing against the State and the DSS.

      Where was the family, the multitude of aunts and uncles, grandmother… everyone else when Caleb was alive?

      They were all blaming the state for the death of Caleb. How about blaming the meth ridden mother, their own relative? And… where was the family through all of this? 🙄

      Non-existent! ❗

      People better stop blaming others and the government and begin to take responsibility for their own actions! 😉

      Caleb… Rest in Peace.

    • comment avatar Alfred January 29, 2012

      Part of the problem is the confidentiality of the Children’s Code, Title 19 of the Colorado Revised Statutes. I live in Larimer County, and DHS here has been accused by some in the community for years about wrongful conduct. But one would think from the glowing reports to the Larimer County Commissioners that they are the best in Colorado. However the fact is that the Citizens Review Panel, that is supposed to provide oversight, is compromised by insiders and cronies, much like the Commission on Judicial Performance in the Eighth Judicial District, which encompassed Larimer and Jackson Counties. Hence NO COMPLAINT AGAINST DHS IN LARIMER IS EVER FOUND TO HAVE MERIT!

      If DHS continues to have nobody but themselves to police themselves, we’ll continue to have these problems. We’ll continue to have adoptable kids wrongfully taken from families, while un-adoptable kids are left to squander, hence these poor 43. People may not want to believe, but that is another issue in itself. The worst atrocities are committed in plain view, because people refuse to believe. 43 child deaths should help to open your eyes. Hopefully…

      I’ve been an activist in Fort Collins on this cause since 2005. Some other activists have been at this for well over a decade. How did they come about to be activists? They were foster parents in the system. I’ve seen more than one child adopted or fostered out, where they have family members available to take care of the child. WHY? Follow the money on adoptions and fostering…

    • comment avatar Kristi H January 29, 2012

      The state did fail these children, 43 deaths in 5 years and in each case there was a policy violation in the way the case was handled by social workers, that is an inexcusable failure. Of course we to have failed the children, by allowing funding to be stripped away from the only safety net these innocent children have. There have always been and will always be parents who abuse and neglect their children. I believe we as a society have a moral obligation to protect those who are to small and vulnerable to protect themselves.

    • comment avatar DL B January 29, 2012

      Previous stories covered the efforts of Caleb’s Aunt Yolanda. Caleb was living with her at one point and she wanted to keep him. Social Services made her give him back to his druggie mother. Yolanda kept trying for over a year to locate him and made over 70 calls to social services in 3 different counties. Don’t blame this good woman for the failings of his mother and the authorities who did nothing. It took a Facebook Page quote about Caleb being missing to get the police involved. The family was ignored by everyone until then.

    • comment avatar Barney January 29, 2012

      My wife and I got out of foster parenting because of the treatment we received from Denver and Adams County HHS. We were treated worse than the biological parents. We were threatened with child neglect if we didn’t drop what we were doing and bring the kiddos to several last minute scheduled visits with the biological parent(s). We had other obligations and for the county to consistently tell us we have 45 minutes to an hour to bring a kiddo in or we would be in hot water as they said on more than one occasion.

      When you treat well respected foster parents like 4th class citizens – you will have well respected foster parents get out of being foster parents and you will get 4th class citizens to be foster parents.

      If counties would treat foster parents with respect and passion, I’m sure there would be better foster parents in the system caring for the children and less of these deaths and investigations.
      Not all case workers treated us bad. Those that treated us with respect were the minority. The culture at HHS departments must change and it should start with showing respect, compassion and support for the foster parents.

    • comment avatar rickey kalinowski January 30, 2012

      we have become minimal ist to the point that these kids bare the brunt!! the days of compasion ended when we started letting the government take over never never think they know whats best for thet are FOOLS!!!

    • comment avatar Kerri January 30, 2012

      Weld County DHS took my sister’s children from her because one of them at age 7 told a daycare worker that her mom’s husband was physically and sexually abusing her. They lived with me for a year, their mom was charged with failing to protect. The step-dad did nothing he was supposed to do in his treatment plan. The detective on the case was certain he had perpetrated against the little girl, yet no charges have been brought as it’s her word against his. They gave the kids back to her even though I warned them that I feared she was still in contact with the step-dad and that she would run off with him. They knew she was still in contact with him because the police had phone records, and she lied and said oh no, I never talk to him even though they had evidence to the contrary. She did all her classes and they gave the kids back, and lo and behold they disappeared. I have spent months trying to contact them and have been petitioning the courts, calling DHS and nobody will help, they say the case is “closed” I am beside myself with worry, as the step-dad is a monster and my sister is an idiot. I pray the girls don’t end up as one of these statistics, but there’s nothing I can do, and it’s driving me crazy. I am so angry at DHS for giving the kids back when they knew she was a risk. Anyone have any ideas for me about how to do anything about this?

    • comment avatar Josette E. Fifer April 26, 2013

      I wonder why these things happen. Lack of education, support, funding?I guess primarily parents should be blame for this but social services are also partly to be blame. We have read and heard a lot of issues about this and i think it’s time government do something about it.

    • comment avatar Gail C. Jackson May 21, 2013

      Abuse, neglect and all other unfortunate events happening in social services have been in the news for a lot of years now and it has never been stopped. I really don’t understand why things like this happen. I think there should be a conscientious effort between all parties involved to put an end to all of this.

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