It would be unfair, however, to blame any one agency or individual, cautioned Dr. Andrew Sirotnak, director of the Kempe Child Protection Team at Children's Hospital.

"You see a dead child, a child abuse fatality, hear about a history of abuse and neglect, and you want to assume the system failed. And that may not be the case, because you don't know the whole story," said Sirotnak, a member of child death review teams for Denver and the state. "It's a lot more complicated than that."

A recent case in Brighton illustrates some of the complexities. Kevin Henn's second-grade teacher never saw any signs of physical or emotional abuse in the bright, happy 8-year-old, and his family had no prior social services contact. But after Kevin was critically injured in his home, officers noted old injuries and bruises all over his body.

Kevin remains on life support with a massive head injury. His stepmother, Gail Henn, 30, has been charged with child abuse resulting in serious bodily injury.

"We certainly have cases where the family had no contact with social services, and a child ends up dead. Who should have known there?" said Diana Goldberg, executive director of Sungate, an Arapahoe County child advocacy organization.

"Often, by the time it gets to social services, there were lots of people who knew there was a problem," she said. "Lots of people who could have, would have, should have done things differently."

Colorado reported 91 child-abuse or neglect deaths from 1998 to 2000, and at least 24 of those families, or 38 percent, had prior contact with social services, department documents show. The national average is about 12 percent, according to the National Child Abuse and Neglect Data System.

A draft of an internal assessment by the state Department of Human Services obtained by the Rocky Mountain News said the number of Colorado deaths was too small to pinpoint the impact of child welfare practices. But reviews of abuse deaths where child protection services had been provided to the family within the previous two years did reveal some recurrent issues, the report noted.

The department's State and County Child Fatality Review Team observed that "caseworkers often minimize the significance of a history of family violence and previous abuse/neglect reports when making case decisions, including screening, assessment and services."

Susan Ludwig, a child protection specialist with state Human Services, said that statement had been removed from later versions of the report because it could not be substantiated. The final report is not yet available.

Goldberg said that, in her experience, caseworkers don't downplay family violence. But they might have problems obtaining a family's past history when families move from county to county or state to state.

"The caseworkers don't get access to the information, and they don't know about it," Goldberg said. "And the family's certainly not going to tell you."

The draft report also cited the need for improved communication between local agencies, adding: "The retrospective reviews have sometimes shown that one agency knew pertinent risk or family functioning information but failed to communicate the information effectively to other agencies."

In 1998, the state reported 28 deaths from child abuse, neglect or a combination. At least eight of those families had previous social services contact for reports of abuse or neglect, and five of them had a caseworker assigned to the family at the time the child was killed, Ludwig said.

In the case of one child who was killed, an earlier report of abuse or neglect was investigated and deemed unfounded.

"When you have that scenario with a previous referral and later lethal abuse, it certainly raises concern," Ludwig said.

The earlier report might have been about neglect as opposed to abuse, or the fatal abuse or neglect might have occurred at the hands of another person, rather than the child's main caretaker, she said.

"Had circumstances changed for the family? Was there something that didn't come to the attention of the department in previous involvement? Things might have been OK at the time of intervention but went downhill quite quickly after that," Ludwig said.

Social services removed children from the home in just over 9 percent of substantiated abuse or neglect reports in 1999 and again in 2000, for a total of 1,359 children, the report shows. But it also notes that problems with the way verified abuse/neglect cases are reported means that placements actually occur at up to four times that rate.

In Denver, half of the child homicide victims from 1997 to 2000 were known to social services, according to the Denver Child Fatality Review Committee report.

Child advocates say caseworkers need more support and lighter caseloads to prevent burnout and turnover. And they say the community needs to address the conditions that give rise to families where kids die, such as poverty, homelessness, unemployment, substance abuse, lack of education and lack of affordable day care.

"For many people, it's emotionally and philosophically easier to point fingers," Goldberg said, "than to look at it as a communitywide problem that we're all responsible for."

March 11, 2002