A panel investigating the death of a 10-year-old Florida girl whose body was found in the back of her adoptive father's truck said a lack of commonsense and communication among child welfare officials played a role in the tragedy.
"A child has died, and a child didn't need to die," said panelist David Lawrence, a former Miami Herald publisher. "We could have done a hell of a lot better than we did."
The three-person panel recommended that the state Department of Children and Families immediately review the qualifications of case managers, child protective investigators and psychologists contracting with the state, warning in the 14-page report "there is no substitute for critical thinking." The panel also suggested that the state establish a more concise and immediate information-sharing system and review its state abuse hotline procedures.
The investigation revealed that child welfare officials repeatedly missed signs that the girl, Nubia Docter, and her twin brother Victor were being abused by their adoptive parents.
Nubia's partially decomposed body was found in the back of her father's pickup truck along a busy interstate on Valentine's Day. Victor was found in the front seat, soaked in toxic chemicals, and is now recovering from serious burns. Their adoptive parents, Jorge and Carmen Barahona have been charged with first-degree murder in Nubia's death.
A child protective investigator visited the home on Feb. 10, one day before Nubia's death, after the state received a call to its abuse hotline that the twins were being bound and locked in a bathroom. She never saw the twins, but marked on a safety questionnaire they weren't likely "in immediate danger or serious harm," even though she didn't know where they were. She spent four days looking for the twins but never called police.
Many of the panel's recommendations match the findings of other commissions in Florida foster-child deaths in recent years. Case workers didn't talk to teachers and medical professionals. Critical information was missing from case files. Abuse allegations were treated with little sense of urgency. In short _ no one was ultimately responsible for Nubia and Victor.
Jim Sewell served on the panel that investigated the girl's death. He also chaired a team that investigated the death of 7-year-old foster child Gabriel Myers, who hung himself while on a powerful combination of psychotropic medications in 2009.
"It's like deja vu all over again. Some of the same things in Gabriel's case, where there was systemic failure, failed Nubia," Sewell said. "I think mediocrity in responding to needs of the children is the bane of child welfare. We've seen too frequently people just get the job done and that's not enough when it comes to children."
The panel recommended a single, concise place where relevant information is consistently updated so case workers, judges, doctors and school officials can access it. Currently, case files are unwieldy mounds of documents with missing data.
"We know there were pieces of information that if ever brought together and listened to gave us a very good chance of ... a stunningly different outcome in this case," said Lawrence, a child advocate. "We think there is a fundamental problem of failure to listen, failure of common sense. We've seen numerous issues where the child was not the first priority."
Nubia's teacher and principal testified before a judge in 2007 that the child stole food and was afraid of her adoptive mother, Carmen Barahona. One teacher said Nubia alleged that Carmen hit her. But that information never made it to a psychologist, who recommended in 2008 that the Barahonas be allowed to adopt the twins. A judge later approved the adoption.
Nubia also told a psychologist she had considered suicide and feared something terrible was going to happen to her, but little was done.
Records show the case manager didn't even talk to the twins in a majority of visits while they were foster children in the Barahonas' home over four years, nor did the caseworker consistently visit them every 30 days.
The Barahonas were repeatedly told the twins badly needed dental care, but child welfare officials never did anything about it. In 2004, a nurse had warned that Nubia was missing important doctors' appointments and questioned whether the Barahonas were appropriate foster parents.
"Much of the documentation was incomplete or inadequate and it was difficult for this panel as well as staff concerned with quality assurance to reconstruct what actually occurred, who was or should have been involved and the results of any action taken," according to the report.
The panel also recommended that DCF review its state abuse hotline procedures. The hotline call regarding the twins, for example, was flagged to be followed up within 24 hours instead of immediately.
The panel said DCF officials should work better with law enforcement when children are missing.
"The performance of our staff and community partners is completely unacceptable," said Pete Digre, DCF's assistant secretary of operation. "Nubia did not receive the care, and prompt and urgent attention that each of us would have given our own children. As such we failed miserably.
The panel also asked DCF to review it's contract with Our Kids, a private company that receives about $100 million a year to manage foster care in Miami-Dade and Monroe counties, saying the investigation raised concerns about "the quality of some services delivered by Our Kids and its subcontractors."
A spokesman for Our Kids said many of the panel's recommendations have already been implemented with new technology designed to improve information-sharing since the time Nubia and Victor were in foster care.
"We must insist on pursuing perfection, especially when it comes to protecting (kid's) lives," the spokesman said.