Files in cases where a child died or nearly died as a result of abuse or neglect that have been released, under court order, by the Kentucky Cabinet for Health and Family Services have been heavily edited.
The records are the reviews carried out by the cabinet to assess how its child-protection workers performed in these horrific cases and what, if any, changes could be made to prevent future deaths.
Despite the heavy editing, a picture of failed communication is coming into focus as reporters sift through the 86 reviews from 2009 and 2010.
■ In the case of Amy Dye, the 9-year-old killed by her adoptive brother in February, a school nurse had written a letter listing six reports about suspected abuse or suspicious injuries of Amy. Only three of the reports are in the girl's file at the cabinet. When Amy was sent out of state, the cabinet didn't inform the school district she had moved.
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The superintendent of schools said the system often reports cases of abuse and neglect to the cabinet but doesn't get any feedback about what happened as a result of those reports.
■ Madaline Grace Reynolds died because she didn't have the medication she needed to treat her cystic fibrosis. The child-protection worker who looked into her case eight months before she died did not check with the pharmacy to see if her parents had filled her prescriptions.
In another case, when a 2-year-old was taken to a hospital with a suspicious fracture, the child-protection worker didn't interview key medical personnel, including the doctor.
In that same case, the cabinet failed to pursue information about previous incidents of child abuse involving the child's stepfather in another state. The reviews repeatedly note that case workers should do a better job interviewing key witnesses or following up on critical information.
■ The reviews also repeatedly comment on the need for a system of better communication with police, hospitals and parole officers to identify situations in which children are at high risk.
This pattern of failed communication only came to light because this newspaper and Louisville's Courier-Journal have aggressively pursued these records in court and Franklin Circuit Judge Phillip Shepherd has relentlessly pushed the cabinet to open the records in these cases.
Just yesterday, Shepherd said the cabinet's proposed guidelines on withholding information would almost certainly result in information being withheld that Kentucky law says should be open.
But the pattern of faulty communication doesn't stop there.
At a Tuesday hearing, legislators took the cabinet to task for failing to inform them about regulations that prevented it from investigating abuse by a sibling, such as in Amy Dye's case.
That's a "gaping hole" in the law that the legislature could have addressed years ago if it had known about it, Rep. Susan Westorm, D-Lexington, said.
Another lawmaker, Sen. Julie Denton, R-Louisville, called for the resignation of Cabinet Secretary Janie Miller, saying "I'm tired of lies. I'm tired of deception. I'm tired of the tap-dance routine. I'm tired of the shroud of secrecy."
We don't know if Miller should resign; we do know that her resignation alone would not solve this systemic problem.
The cabinet's missed connections pre-dated Miller and will survive beyond her tenure without a thorough, public airing of these problems and a transparent plan to change the culture at the cabinet and provide the resources frontline child-protection workers need to do their jobs.
The cabinet has raised legitimate concerns about protecting the confidentiality of its clients, the people who report suspected abuse and the minor siblings of the children involved. The challenge is to deal with those concerns in an open forum, not use them to draw a shroud of secrecy around the cabinet's work.
The cabinet, indeed the entire executive branch, has shown it won't fully address these issues without the hot, bright light of outside pressure. The courts have acted responsibly and forcefully. Now, the legislature must take up the painstaking and painful job of examining the cabinet's work, finding the missed connections and fixing them.