David Nieves Jr. is buried in the Garden of Promise, under a gravestone emblazoned with a teddy bear, clad with a bow.
"He was the sweetest little boy. He couldn't defend himself," recalled Jocelyn Pridemore, a registered nurse who warned the Department of Children & Families that David, developmentally disabled, might be in danger. "I feared he would end up dead."
He died Feb. 21, 2000, at 22 months old.
David is one of at least 37 Florida children who died of abuse or neglect in the last five years after prior warnings to the DCF went unresolved - a fatal breakdown that has left thousands of other children at risk, according to a Herald investigation.
David's 13-pound, 4-ounce body, covered with bruises, revealed months-old fractures and at least 22 bite marks.
"This case still gives me nightmares," said John Terry, the Hillsborough County prosecutor who handled the case. "It was horrific how this little child suffered. It's amazing to me that DCF never caught on."
The toll of this bureaucratic failure, in David's case and others, is chilling:
* Natalie Gomez-Perez, 2, of Kissimmee was beaten by her mother's boyfriend, her spleen "hit so hard that blood was forced out."
* Glemus Guyton, an 8-year-old Miami boy being cared for by a 10-year-old sister, was hit by a car as they crossed a bustling street to get home. Reports say their father often left them alone, though the father denies it.
* Tony Bragg Jr., just 9 months old, died of a blow that tore his heart. His father threw him into a utility closet and left him to die.
In each case, the agency knew the child was in danger. Somebody - a teacher, a counselor, nurse, doctors - had phoned in a warning to the state's child abuse hot line.
Nobody helped the children in time.
DCF administrators acknowledged mistakes in some investigations.
"Yes there were problems with cases," said Jim Spencer, who oversees the DCF's death-review process, but he called the errors "isolated."
Spencer said investigators have heavy caseloads and new, urgent, reports are coming in all the time. But if a case remains unresolved, Spencer said, it's not because investigators ignore it.
All 37 children died while their cases, or one involving another at-risk child in the same family, lingered for more than 30 days. Some cases were open for a year or longer.
Despite attempted reforms by Gov. Jeb Bush and others, the problem remains as stubborn as ever. At last count, 43,000 DCF cases were unresolved for at least 30 days, and more than 33,000 were open for 60 days or longer - more than half of all active child-safety investigations.
Among 30,000 cases last September in this so-called "backlog" - meaning reports unresolved by the deadline mandated by state law - 9,279 were open for more than a year. More than 8,600 others were open between six months and a year, records show.
As the cases piled up, DCF caseworkers and supervisors made the same mistakes over and over, failing to provide basic safeguards for vulnerable children, the Herald review found.
Time and again, the record shows, investigators blindly accepted family members' explanations that their children were just clumsy, although they were seen with bite marks, severe burns, black eyes and bruised vaginas.
The Herald reviewed documents in child death cases from the last five years along with court cases, personnel files, medical examiner reports and other documents. The records show: