Madaline Grace Reynolds needed medicine to treat her cystic fibrosis, but her parents seemed more interested in getting their own prescriptions filled, a tipster told a Kentucky child-protection worker in November 2008.
Madaline's parents always picked up their own pills, including pain pills, but sometimes went months without getting medicine needed by the 20-month-old Lincoln County toddler, according to a state report.
After Madaline died July 24, 2009, an autopsy showed that there was no medication in her system and that her airways were blocked, according to a review of her death by the Cabinet for Health and Family Services.
The review noted some other troubling facts. The child-protection worker who had looked into the report eight months before that Madaline might not be getting her medicine did not check with the pharmacy to see whether her prescriptions had been filled. The worker also failed to ask the parents to show her the toddler's medication, according to the review.
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The case highlights shortcomings often identified when the state assessed how its child-protection workers performed in 86 cases in which children died or nearly died as a result of abuse or neglect in 2009 and 2010.
The reviews repeatedly noted, for instance, that caseworkers needed to do a better job interviewing key people other than parents or caregivers to assess whether a child was in danger.
They also noted a number of other problems and issues, including the need for a better system to identify cases in which children could be at high risk; difficulties in getting drug tests for poor parents; and the need to improve communication with other agencies, such as police, hospitals, and probation and parole officers.
The cabinet is required to do an internal review any time a child with whom it has had contact dies or nearly dies because of abuse or neglect.
The cabinet turned over heavily redacted versions of 86 reviews last week to comply with a Nov. 3 court order. The Lexington Herald-Leader and The (Louisville) Courier-Journal had sued to get the documents under the Kentucky Open Records Act and now have asked a judge to order the cabinet to release unaltered versions of the reviews.
The documents provide a rare glimpse into the challenges and failures of the state's child-protection system.
For example, the cabinet's review of the near-death of a 2-year-old Northern Kentucky girl uncovered crucial shortcomings in a previous investigation involving the toddler.
When the girl was taken to a Northern Kentucky hospital in April 2010 with a suspicious fracture, the child-protection worker assigned to the case did not interview key hospital personnel — including the doctor — and failed to do a timely investigation, the review found. The cabinet also failed to follow up on information that showed the child's stepfather had previous incidents of child abuse in North Carolina, according to the review.
About a month later, on May 21, 2010, the girl was taken to St. Elizabeth Hospital with a blood alcohol level of 0.259, three times the legal driving limit. Her stepfather, Raymond Jackson, encouraged her to drink tea spiked with gin, according to the review.
X-rays taken at the hospital showed other injuries, including a healing rib fracture, possibly new fractures, and bruising and swelling around the girl's face.
The girl — whose name was removed from the report — survived, but Jackson was sentenced to seven years in prison, according to court documents and media reports.
The state's review of the case also concluded that the initial investigation, which hadn't concluded by the time of the second incident, took too long.
"The worker initially assigned failed to make diligent efforts to contact the family, medical professionals and collateral at the onset of that investigation," the internal report found.
The worker did not make face-to-face contact with the family until six days after the report was received. However, the worker did document that she tried to contact the family and make home visits on several occasions.
The cabinet began doing internal reviews in 1988. They are supposed to create opportunities to improve the system of protecting vulnerable children by assessing what could have been done better in a particular case.
However, a Herald-Leader analysis of the reviews shows inconsistencies in how they are done and the recommendations they produce.
In the cases of Madaline Reynolds and the 2-year-old Northern Kentucky girl, cabinet employees seemingly did a thorough investigation of what happened, and the review team looked for ways to ensure that similar incidents never happened again.
In several other cases, however, employees who conducted reviews produced only one-page reports with few details of what happened and no assessment of potential policy changes or training needs that might prevent another child from being killed or badly hurt.
For example, in the case of the death of a 4-month-old boy — whose full name was not provided in the documents — the internal review is a one-page summary that mostly includes information about the incident surrounding his death.
His parents withdrew oxygen without the consent of his doctor and did not provide follow-up medical care after surgery for a bowel problem.
Social workers had received a referral Feb. 19, 2010, about the parents not taking the child to medical appointments and possibly not providing care. The child died seven days later, but there is no description of the Feb. 19 investigation in the internal review. It says only that the investigation was not concluded at the time of the child's death.
Terry Brooks, executive director of Kentucky Youth Advocates, a non-profit that advocates for children, said the state should consider standardizing the types of information included in internal reviews.
"Good decision-making in any enterprise is based on data," Brooks said. "If the reports met standards and common protocols, you could use those reports to learn lessons to make changes. If the reports are a random collection of stories, you may be meeting the letter of the law but you are missing the intent."
Cabinet officials have said the internal reviews released Monday have produced meaningful changes.
For example, allegations of abuse of children younger than 4 are now deemed high-priority, the cabinet has said. Also, experienced staff must have frequent consultations with front-line workers during such investigations.
Jill Midkiff, a spokeswoman for the cabinet, said there might be inconsistencies in the reports because not every internal review finds a need for change.
"If there are no recommendations made, there will be no recommendations documented on the internal review," Midkiff said.
She said that the cabinet repeatedly has addressed the importance of thorough investigations and interviewing people through "standards of practice, consultation, case review, training and supervisory discussions."
The cabinet also has improved training during the past year for child-protection workers dealing with caregivers who have substance-abuse issues. Most recently, the cabinet conducted drug training seminars in all nine service regions, Midkiff said.
In the internal reviews, caseworkers repeatedly asked for more training on dealing with substance-abuse issues and more direction on cabinet policies about when to test a parent for drugs.
Too much to do
Others familiar with the state's child-protection system said that too often, caseworkers have too much to do, too little support and not enough training.
Jordan Wildermuth, executive director of the Kentucky chapter of the National Association of Social Workers, said front-line child-protection workers in Kentucky have higher caseloads than recommended, are not paid well and are not required to have a degree in social work or to be licensed.
The relatively low pay and stress drive a high turnover rate among caseworkers, he said. That means less experienced caseworkers looking into reports of children being abused or neglected.
Gene Clark, family court judge for Clay, Jackson and Leslie counties, said caseworkers get too little support and are "absolutely, totally overworked."
"I would rob gas stations before I would be a social worker," Clark said.
Federal statistics show that child protection workers in other states face even bigger caseloads.
A 2010 report from a division of the U.S. Department of Health and Human Services said Kentucky had 32 completed reports per investigative caseworker, one of the lowest numbers in the 41 states that reported.
The numbers in states surrounding Kentucky were much higher: Indiana, 135; Illinois, 85; Missouri, 118; Tennessee, 73; and Virginia, 94, according to the publication, called "Child Maltreatment 2010."
The situations that child-protection workers must assess and investigate can be immensely complex, involving substance abuse, mental health issues, domestic violence, poverty and other factors, experts said.
Many caseworkers are relatively young and might not have the educational backgrounds to help them sort through such situations, said Robert Walker, an associate professor at the University of Kentucky and a researcher at UK's Center on Drug and Alcohol Research.
Child-welfare workers also have to juggle the dual mandates of protecting children and reuniting families, said Walker, a licensed clinical social worker. Many mistakes workers make might come from not knowing which side of that fence to come down on, he said.
"These are conflicting goals in many cases," he said.
'Smothered to death'
After the death of Madaline Reynolds, the toddler in Lincoln County who died of complications from cystic fibrosis, her three sisters were placed with a relative. But the state had to remove the children from that home because it was unsanitary and there was another relative staying there who had been charged with having sex with a minor.
Social workers did not visit the relative's home before placing the children there, the internal review of Madaline's case found.
Madaline's parents were never charged in her death, said Bill Demrow, who was the coroner at the time.
The conditions at the Crab Orchard mobile home where the girl lived were some of the worst he had seen in his three decades as coroner, said Demrow, who left the job later that year.
Windows were missing and there were holes in the floor. There were no beds, and the place was hot and dirty. The other children in the house had lice.
Demrow said it angers him that the little girl died because she didn't get her medicine.
"That's all in the world it would have taken" to keep her alive, he said. "Literally, the child sat there and smothered to death."