The infant, Chad Munoz, was under some level of DHS supervision when he died in January 2008 of head injuries. His father, Juan Munoz, was convicted last year of reckless manslaughter and is serving a nine-year-prison sentence.
State law requires that county and state officials conduct a "child fatality review" whenever a child under state supervision dies. The purpose is to promptly identify and correct any mistakes so they are not repeated.
DHS started but never completed the review of Chad Munoz's death, Liz McDonough acknowledged Tuesday. McDonough gave differing explanations throughout the day Tuesday of the status of the review, but late in the day said the agency had completed an investigation and implemented changes, but never finished the required report.
"This is truly embarrassing," she said. "These are generally completed within about six to eight months. For whatever reason, this one got dropped along the line somewhere."
"The report was written and actions were taken in terms of meetings with Larimer [County officials], in terms of findings, but the formal report was never transmitted to them for formal feedback," McDonough said Tuesday night.
The DHS fatality review is a multi-step process. When a child dies while under any level of DHS supervision, the local county department has 60 days to complete an internal review. State DHS staff then conducts its own review, culminating in a draft report process that gives the county a chance for input on any findings of policy violations or recommendations for corrective action.
After the county has provided its input, the report is finalized and made public. McDonough said the last step never happened with the Munoz review.
"It is in violation of our own procedures, yes. We didn't follow our own procedures, yes," she said.
The final report is the only document ever made public in a child fatality review. Because the document was never completed, DHS cannot comment on its findings or recommendations.
McDonough said DHS is working on finalizing the report.
The Munoz fatality review came to light after the January death of Summer Moon Hawk, a Loveland newborn who died while under DHS supervision. The Coloradoan inquired about other recent child fatality reviews in Larimer County, and McDonough identified the Munoz case as the only other pending review.
She said the agency learned shortly before the Coloradoan inquiry that the Munoz review had never been completed. However, she said she didn't know how or when the agency became aware of that.
The Coloradoan made at least six separate inquiries to DHS since Feb. 9 about the Munoz review, with the agency either saying that the review was near completion or ignoring the question. Tuesday was the first time the agency revealed that it knew that the review had never been properly completed.
McDonough said key vacancies in 2008 contributed to the error.
"At the time we did have a significant staff shortage and we had two critical positions become vacant," McDonough said, adding that the positions were the child protection manager and division director of child welfare services.
"I am not excusing it because there is no excuse for it, but that does offer something for an explanation."
When asked whether any other child fatality reviews in Colorado were left incomplete, McDonough said: "We are making sure right now that everything that's supposed to be on track is on track."
State Rep. John Kefalas (D-Fort Collins) said the failure by DHS to finish the Munoz review is inexcusable.
"Completing a child fatality review in a timely manner should be the Department of Human Services' highest priority," Kefalas said. "Regarding the 2008 death of Chad Munoz, there is no excuse for the delay in completing this review, and the department must get this done so we can better understand the flaws in our child welfare system and prevent such tragedies from occurring.
"Keeping our children safe is one important reason why I am cosponsoring SB10-171 that creates the Child Protection Ombudsman Program."
The ombudsman legislation was introduced last month by Sen. Linda Newell (D-Littleton) in response to the deaths of more than 30 children under state supervision over the past three years. It would create an independent overseer of child protective services that would help find solutions to valid complaints.
Sen. Josh Penry (R-Grand Junction) has proposed adding another layer between the ombudsman and DHS leadership to assure independence.
McDonough said DHS has made adjustments to ensure a similar slip up does not happen again.
"We have now put a system in place where we are tracking each of the cases much more closely so we get a status on the cases frequently," she said.
Because of confidentiality laws, little information is ever made public about DHS's involvement with individual children. By law, the agency can't say how or why it was involved with Chad Munoz in his short life.
Chad's mother, Anna Mercado, told the Coloradoan last month that DHS became involved because a doctor alerted officials of a domestic violence incident after finding a bruise on Mercado during a routine pregnancy checkup. Chad also had alcohol in his system at birth, which Mercado attributed to a glass of wine she drank to induce labor.
She said a DHS caseworker made one visit after Chad came home from the hospital, where he had spent a week in the neonatal intensive care unit. He was dead two weeks after coming home.
Mercado said on Tuesday she wasn't aware of the state's review of Chad's case prior to the Coloradoan's inquiry, but said she's left "speechless" that the review has taken so long.
"It leaves me interested to know what their findings are," Mercado said.
She also said her son's death was the result of poor parenting and she does not blame DHS.
This story written by Nate Taylor, Fort Collins Coloradoan.
(Copyright © 2010 Fort Collins Coloradoan, All Rights Reserved)