There were warning signs that Michael Utley was a danger to his toddler son.
Utley had been charged with assaulting the mother of his child 18 months before the Gallatin County man attacked his live-in girlfriend and then shot and killed their 3-year-old son and himself in February 2009.
When the mother attempted to drive her "trashed" partner home from a local bar in September 2007, Utley slapped her hard enough to give her a black eye as 17-month-old Owen James Utley sat in the back seat.
A state adult-protection worker substantiated "partner abuse." But social workers never considered Owen's safety, according to an internal review of the boy's death conducted by the Cabinet for Health and Family Services, which handles child and adult protection in Kentucky.
Social workers should have formally assessed the "risk of harm" to Owen after the domestic violence episode, according to the internal review that focused on the handling of the case before the deaths.
That oversight was one of several problems related to domestic violence documented in internal reviews completed after children with whom the cabinet had previous contact died or were seriously harmed in 2009 and 2010.
A Lexington Herald-Leader analysis of the 85 reviews found that domestic violence in the family was mentioned in 48 of them and that an episode of domestic violence played a direct role in the injury or death of a child in five instances, including the death of Owen, who was killed shortly after his father had beaten his mother.
Among the shortcomings identified in the reviews:
■ Social workers don't always emphasize the safety of the child when domestic violence is discovered in a family.
■ Social workers sometimes fail to thoroughly assess whether domestic violence has occurred.
■ People living in some rural areas don't have convenient access to domestic violence shelters.
According to a 2011 report on deaths and near-deaths from child abuse and neglect in Kentucky, domestic violence was identified as a risk factor in 68 percent of cases from 2007 to 2011.
Another report released in January 2011 said studies have shown that there is an overlap of 30 percent to 60 percent between violence against children and violence against women in the same families.
In Kentucky, police must send the state a report of all incidents of domestic violence, and adult-protection workers are supposed to investigate those cases, although people are not required to accept the workers' help. Additionally, state regulations say that the cabinet must conduct an assessment to see whether a child is at risk of harm from domestic violence.
According to Jim Grace, assistant director of the cabinet's Division of Protection and Permanency, simultaneous child protection and domestic violence investigations are launched under a variety of circumstances, including if the child has been harmed, is prevented from leaving the premises by an abuser or is considered at risk of being harmed.
But cabinet officials conducting the fatality reviews said workers sometimes missed opportunities to protect children whose families experienced domestic violence.
For example, the cabinet's review of one 3-year-old's death raised questions about why the state found in a case involving the child's family that "there are no child-protection issues" even though a female relative told authorities, "I'm scared for my life and my child's life." The woman said she was being physically abused on a regular basis.
The review of Jeffrey B. Fields' death also questions whether a child-protection investigation should have been initiated after a report said, "Child has seen mother's paramour beat mommy up."
In the end, Jeffrey died in a traffic accident in 2010 when he was thrown from a car driven by a woman who was not his parent and who allegedly could not pass a drug test after the crash, according to the review of his death. There were previous reports of domestic violence in the child's family and the driver's family.
In an April 2009 case in Larue County, a child was taken to Hardin Memorial Hospital with 16 fractures and "multiple brain bleeds" and nearly died. A man in the child's home — his relationship to the mother was not made clear in documents — was criminally charged, and the cabinet found that the mother was neglectful for not protecting her child.
The review in that case noted that another child in the family was injured in 2007 during a domestic violence case involving the mother's previous boyfriend. That boyfriend assaulted the mother when she had an infant in her arms, cutting and bruising her and leaving a bruise and swelling on the baby's head.
The cabinet's review said staff should "continue to emphasize child safety and assessment" when conducting concurrent child-protection and adult-protection cases.
Grace said the cabinet is conducting training "on the dynamics of domestic violence and how it relates to a child's protection."
Once cabinet officials identify a systemic problem as a result of a fatality review, "there's the expectation that we would correct it," he said.
Shelters not always close
The death of Owen Utley also highlighted a lack of domestic violence shelters in rural portions of Kentucky.
After the initial 2007 report of domestic violence against Owen's mother, a social worker spoke with her about financial resources and alternative living arrangements that were available to her. But going to a shelter in her own community was not an option.
Ultimately, the cabinet's review said Michael Utley beat Owen's mother in February 2009 until she had two black eyes and cuts to her ear, and was missing chunks hair. When she ran to a neighbor's home for help, he killed the child and himself.
The "lack of shelter options in rural counties could be a deterrent to victims utilizing ... services," the review said.
Sherry Currens, executive director of the Kentucky Domestic Violence Association, said there are 15 regional shelters with a total of 466 beds, which are nearly always full. All 120 counties are served by a shelter, but some residents have to travel farther than others, Currens said.
It's unlikely that shelters could expand their services without additional funding, she said, and domestic violence shelters in Kentucky got less state funding per resident in 2011 than in 1996.
Beyond the problems noted in the fatality reviews, there are other gaps, domestic violence victim advocates said.
Currens said she knows of instances when adult-protection workers have dropped a case after child-protection workers got involved. But both kinds of workers are needed to help the non-offending parent figure out "how to deal with the threat to the children," she said.
Coordination between advocates and cabinet workers has at times been lacking, advocates said.
Darlene Thomas, executive director of the Lexington-based Bluegrass Domestic Violence Program, said advocates are sometimes not told by cabinet workers about domestic violence incidents. In other cases, advocates who contract with the cabinet to provide victim services don't have enough staff to attend team meetings about the family.
Lisa Holmes, the director of a domestic violence shelter in Elizabethtown, was concerned recently that she couldn't immediately get an answer at an intake line for the local child-protection office.
Holmes said she was "scared to death" for the safety of a child whose mother decided to leave the shelter.
Police had brought the mother to the SpringHaven shelter after "her boyfriend told her that the best way to handle his anger was to beat her 3-year-old child. So he picked her up and threw her, and she has a bruise on her face," Holmes said, referring to the child.
Holmes was trying to confirm that the boyfriend was in jail and that the mother and child would be safe if they returned home.
Holmes said she thought it would help "if we were quicker and better at adjudicating domestic violence cases and women had the support of CPS (child protection workers) instead of being afraid of them."
Advocates and child-protection workers are sometimes at odds about the best way to keep safe a child who has been exposed to domestic violence.
Members of Currens' group are concerned that the cabinet sometimes unfairly recommends that judges remove children from a domestic violence victim's custody under the theory that the victim is failing to protect the child.
As a matter of policy, the cabinet does not recommend removal of any child from a parent's home unless there is risk to the child's physical safety or well-being, cabinet spokeswoman Anya Weber said. Recommendations are presented to the court, where the ultimate decision is made related to removal of the child, Weber said.
Thomas, the Lexington-based domestic violence advocate, said children should be protected from a parent who is a batterer. But she and other advocates said every attempt should be made to allow the child to remain with the non-offending parent.
The 2009 near-death of a 2-month-old girl demonstrates the difficult decisions that child-protection workers must sometimes make in cases of domestic violence.
A state review of the case noted that the cabinet substantiated neglect by the child's mother due to a "history of engaging in abusive relationships," not following through once she was granted domestic violence protection orders, and not being cooperative in previous law enforcement interventions involving domestic violence with the child's alleged abuser.
According to the review, the unidentified child was taken to the University of Kentucky Hospital in 2009 with a traumatic brain injury after her mother's paramour admitted to shaking her and handling her roughly.
There are at least two legislative proposals this year to create task forces that would study the effect of domestic violence on Kentucky's children and come up with proposed laws for the 2013 General Assembly.
The sponsor of one proposal, Democratic state Rep. Joni Jenkins of Shively, said she worked in a domestic violence shelter for 10 years. She said expanding the services of domestic violence shelters would be beneficial.
"No kid gets beat in shelters. No kid gets neglected in shelters," she said.
Meanwhile, Sen. Mike Wilson, R-Bowling Green, and Rep. Johnny Bell, D-Glasgow, have introduced bills that would require the cabinet to assess the needs of children and custodial parents who have been exposed to domestic violence and to provide prevention services to help the child live at home. So far, neither bill has been considered by a legislative committee.
Other states have found success in having police, child-protection workers and domestic violence advocates working together on a team.
In Fresno, Calif., police Sgt. Daniel Macias is a member of the Children Exposed to Domestic Violence Team, which operates with a $200,000-a-year federal grant. The team's social workers and advocates, along with police detectives, investigate and provide services after domestic violence cases in which children are present, Macias said.
The team follows up with adult victims, Macias said, and "with the children, which are really the key to trying to stop the cycle of violence."
In Kentucky, Thomas said she would like to see collaborative efforts between the cabinet, which investigates allegations of abuse, and agencies that provide services for spouse-abuse victims to make sure families "have all available supports."
Having domestic violence advocates attend cabinet team meetings about individual families would help, she said.
But, Thomas said, "it all comes down to resources."