Many of Colorado's child abuse workers are inexperienced and overwhelmed, and at times fail to take basic steps to protect children: interviewing parents, properly assessing a dangerous home or checking a child's body for obvious signs of abuse, a Denver Post analysis of state data found.
Caseworkers failed to follow state policy at least half of the time when asked to protect a child who later died of abuse or neglect, Colorado fatality reports show. Their mistakes ranged from paperwork problems to not visiting a child within the time required, or at all, and dismissing - without proper investigation - abuse allegations prior to the child's death.
The job of a caseworker is tough - so much so that in a federal grant application submitted last year, state officials said they fear many of the state's child protective workers are at the breaking point.
A survey of more than 500 of Colorado's child protective workers who had participated in training sessions found 59 percent suffered from high or very high levels of "compassion fatigue," causing burnout, poor performance and turnover, the 2011 application said. Those caseworkers, it said, can suffer from "anger, fear, anxiety, hopelessness and helplessness."
Intake caseworker Lilly Risch works at her desk at the Arapahoe County Department of Human Services, Aurora, CO, Wednesday, June 27, 2012. Today Risch is "protected," which means she can catch up on paper work and phone calls and will not be given any new cases. "We had a busy May - and paperwork isn't always the priority." As she sorts through her files of open cases she says she hope to close four today. She says, "I have too many open - probably '30ish.'" She looks at her computer and concludes, "40, I have a lot open that are ready to be closed."
"We gave them an unmanageable, thankless job," said Skip Barber, executive director of the Colorado Association of Family and Children's Agencies, a group of not-for-profit advocacy agencies. "If a caseworker makes a mistake, it's front-page news. The system was set up to fail."
And it is failing. Seventy-two kids whose families or caregivers were known to the child welfare system in Colorado have died in the last six years.
Child protection workers failed to note unsafe living conditions, concerns about caregivers and previous contacts with the child welfare system before children were killed, according to 59 state child fatality reviews released to The Post.
While investigating reports of abuse or neglect, child protection workers did not talk in 10 cases to the person accused of the abuse and did not talk in nine cases to other contacts such as doctors and teachers.
In addition to failing to properly investigate claims of abuse or neglect, child protection workers struggle to correctly write safety assessment plans meant to evaluate the risk of harm. The Post's analysis found caseworkers did this wrong 24 times out of 59 cases where children ended up dead.
"When you have a young, inexperienced staff, their ability to make good decisions is not huge," said Tracey Feild, director of the child welfare strategy group for the Annie E. Casey Foundation.
Caseworkers' safety assessments of a family can mean the difference between life and death.
Janet Gallegos visits the grave of her granddaughter, Neveah Gallegos at Mount Olivet Cemetery in Wheat Ridge on August 1, 2012. It would be Neveah's eighth birthday. Janet said, "I'm trying, spiritually, to let go of her in peace. I miss her she would be 8 years old today. I'm sad I can't be with her anymore."
Take, for example, the failed case of Neveah Gallegos.
Miriam Gallegos defended her boyfriend, Angel Ray Montoya, after he was accused of sexually assaulting Neveah. The Denver County Department of Human Services asked Gallegos to take parenting classes. She did, and then promised Neveah wouldn't go near him.
So child protection workers closed the case.
But Janet Gallegos had a feeling her 3-year-old granddaughter was in danger.
"We asked and asked and asked them, 'Please protect Neveah. Do a follow-up,'" she said of her pleas to caseworkers. "They didn't do anything to help."
Nine months after caseworkers closed their case on Neveah, Montoya killed her. Neveah's mother helped him stuff her body into a plastic trash bag.
"She didn't protect Neveah," Gallegos sobbed into a tissue as she sat in the garden she and Neveah planted. "I would have protected her."
Denver County officials would not discuss their decision not to intervene before Neveah was murdered, but a state report showed caseworkers were swayed by her mother's lies.
Angel Ray Montoya and Miriam Gallegos. Montoya was sentenced to life in prison without parole for murdering Neveah Gallegos. Miriam Gallegos pleaded guilty to child abuse resulting in death and was sentenced to 12 years in prison.
When Colorado officials have uncovered deficiencies in the system, change has come slowly.
The state human services department, after reviewing child deaths for five years, found in 2002 that child protective workers were doing a poor job assessing the safety risks of children living in allegedly abusive homes.
Eight years after the release of that report - in 2010 - the state department checked whether those charged with protecting children were doing a better job.
In 2010 and 2011, reviews in 33 counties found that casework was still inadequate. Just 41 percent of the time, caseworkers accurately conducted a safety assessment.
And when caseworkers decided a safety plan was needed, the plans were sufficient only 24 percent of the time.
Over-the-shoulder training was ordered after the 2010 study, and state officials are working on a new standardized form for caseworkers to follow. Inexperienced caseworkers shadow staffers with more experience in counties that still aren't meeting standards, said Marc Mackert, the director of the state Department of Human Services' administrative review division.
The additional training is making a difference, but not enough follow-up reviews have been done to determine whether significant improvements are taking place, he said.
Colorado has made improvements to caseworker training in recent years, opening an academy in January 2010.
New caseworkers - who are required to have a bachelor's degree in sociology, psychology or another behavioral science - now must attend 210 hours of training at the academy in Douglas County.
In class, they learn how to fill out forms used to determine whether a child's safety is in jeopardy, how to tell what qualifies as imminent danger and even how to ask parents open-ended questions. For example, instead of asking, "Do you hit your kids?", try "Tell me about the hardest part of your day," the teacher recommends.
"The people in there - they don't realize what they are getting into," said Art Atwell, who was a caseworker for 20 years and now is the state's director of children and family training. "Until you get out there and it's pulling at your heartstrings, you don't know."
A grimmer story surfaces
Colorado does not know how many children its caseworkers are tasked with protecting at a time; it is one of 11 states that does not report this to the federal government. The state has no requirements about how much caseworkers are paid; that's up to each county. And Colorado does not track how long caseworkers stay in their careers, although typical burnout is about four years, according to interviews.
After numerous requests under the Colorado Open Records Act, the state released data it had never previously gathered showing the average workload for caseworkers in the 10 largest counties. Child welfare worker caseloads vary from 8.4 cases per worker at a time in Pueblo County to 13.6 in El Paso County, according to the data.
Smaller, rural counties told The Post that their caseworkers probably manage 12 to 15 families at once, and starting salaries range from $30,000 to about $40,000 per year.
But interviews with caseworkers revealed a grimmer story.
Amy Hinkle, an ambitious new college graduate, lasted one year. She earned $28,000, worked 60-hour weeks and once returned from four days off to find her voicemail jammed with 99 messages.
But that wasn't what made her quit.
"Every single day, I wanted to give those kids the time and attention they deserved," said the 23-year-old, who now works for an adoption agency. "It would become hard to turn the focus back to the children."
Hinkle said she had 25 foster kids to keep track of at once, but many days, before she could check on them, she had to deal with biological parents who showed up intoxicated for supervised visits or missed their court-ordered therapy, and she had to deal with the paperwork that resulted from those problems.
"I just wanted to just crawl in a hole and die after a year," said Hinkle, who worked for an El Paso County caseworker agency that contracts with the county. "It's a very emotional and tiring job."
The average caseload tallied by the state does not include rural or medium-sized counties, but does include contract workers, including Hinkle.
Nationwide, the average tenure for child welfare workers is about two years, according to a 2003 report from the U.S. Government Accountability Office. Caseworkers interviewed for that study said they spent 50 to 80 percent of their time doing paperwork.
"Is the work doable?" said Renee Rivera, executive director of the Colorado chapter of the National Association of Social Workers. "They go in because they care about kids, they want to help kids and help families and help society fix this problem, and they get just overloaded."
The Child Welfare League of America recommends caseloads never climb higher than 12 to 17 children per worker.
State officials told The Post that workloads aren't a problem.
"There is no clear number or science that you can get to that says, 'Here is the magic number that the caseload ratio should be: 10 families to one worker or five families to one worker or 50 families to one worker," said Reggie Bicha, director of the Colorado Department of Human Services.
"We can get that information and analyze it, but then compare it to what?"
A 2007 report from the administrative review division of the Colorado Department of Human Services on child abuse fatalities called for "a rigorous, sound analysis of the workload required" so state officials could create "realistic caseload standards." That recommendation was not followed.
Caseworkers' decisions are the subject of major scrutiny, especially when a child dies.
Child fatalities are reviewed by a state panel, and caseworker errors are noted. The consequences for violating state policy most often are extra supervision and a review of regulations.
But it's becoming more common across the country that relatives of dead or injured children take caseworkers to court.
In one Colorado case, watched across the country, two Denver County caseworkers were sued by the relatives of a boy who was purposefully starved to death by his mother's ex-boyfriend and his new girlfriend. The civil case is ongoing.
"SUNSHINE" AND DARKNESS.
Chandler Grafner, born Chandler Ashton Norris, is buried in the Guardian Angel section at Mount Olivet Cemetery in Wheat Ridge. The 7-year-old boy starved to death trapped in a linen closet while in the care of Jon Phillips and Sarah Berry, who are in prison for murder and child abuse. Chandler's story has been pointed to numerous times as an example of bungled casework.
Chandler Grafner died in 2007, after spending much of the last year of his life in the bottom of a linen closet, 35 inches wide and less than 18 inches high.
The 7-year-old weighed 34 pounds when he died from starvation and dehydration.
Chandler's story has been pointed to numerous times as an example of bungled casework. In all, there were eight referrals to child protection workers that alleged abuse and neglect.
One month before he died, Chandler's elementary school reported to Denver County Human Services that the little boy had not been at school for a month. Supervisors at the child-abuse division did not assign any investigation, saying there were no allegations of abuse or neglect.
The next time they heard about Chandler, he was dead.
Caseworkers assigned to look after Chandler violated six state regulations, including failing to make "timely contact" with the boy after his school reported suspected abuse. Jefferson County and Denver County child welfare agencies failed to communicate with each other, and so while it appeared in a state computer system that one county was looking out for the boy, neither county was.
The supervisors who handled the case - and were sued by Chandler's mother - are still working at Denver Human Services.
Jon Phillips and Sarah Berry are in prison for the murder and child abuse of Chandler Grafner.
Whether caseworkers are disciplined or fired for mishandling a case is a personnel matter and not usually public information. Denver County has fired caseworkers or given them "progressive discipline" plans over the years for violating state rules or county policy, said communications director Revekka Balancier.
Part of a supervisor's job, she said, is to provide "support for dealing with something as disturbing and tragic as a fatality."
"Having a fatality on a worker's caseload is an extremely traumatic experience," she said.
With the safety of dozens of kids on their conscience, caseworkers go alone to knock on the doors of hostile parents - to ask them what they feed their children and whether they hit them. They follow a checklist, ticking off questions and taking down answers on a state-standardized form. And they worry a kid in their care might die, a fear that keeps them up at night.
"It's an incredibly tough job. You can look back and say caseworkers should have done this or that, but the reality is you are making decisions best you can in the moment," said Julie Krow, a former Denver County caseworker who is now director of children, youth and families at the state Department of Human Services. "You have to walk away and hope that you made the very best decision."