Guerrero told police: "I accidentally tripped. I fell on him but it was my knee part that went, I guess, in his stomach. I didn't know he was like dying."

The medical examiner said David could have lived if he had received medical care sooner. She also found signs of previous abuse: a fresh ankle fracture, recent wrist fractures, two older rib fractures and 22 bite marks.

"Injuries consistent with a battered child," Suzanne Utley, the medical examiner, said in an interview.

Guerrero pleaded guilty to manslaughter and got 30 months in state prison.

The bite marks, prosecutors said, matched Molina's teeth. She pleaded guilty to aggravated child abuse but denies biting her son.

"I know deep down inside I didn't do that," Molina, now living at home on probation, told The Herald. "I was a safe and loving mother."

The DCF acknowledged that it failed to thoroughly interview Pridemore, talk with David's family, document injuries or verify whether Guerrero lived in the house or had a criminal background.

"A major flaw in this investigation was the delay in making initial contact with the victim," the death review said, adding that investigators downplayed Pridemore's warnings. The agency fired one investigator in the case after David died.

Some of the same failures found in David's case contributed to the death of other Florida children under DCF supervision, the review shows.

Among them:

* Alexis Nicole Griffis, born a month early to two teen parents in the small North Florida town of Williston, was shaken to death just four months later. When she died, the DCF had an open report of medical neglect - mother Danielle, not yet 16, left the hospital a day early. "Rather immature," the report said.

FATAL LOSS OF TIME

The DCF investigator, brand new on the job, never found the young couple's trailer. She never learned about Brian Griffis' juvenile record, or about the restraining order that Danielle Griffis got two months later. The court record contained an important detail: the family's correct address.

"He also smacks our two-month-old baby quite often," Danielle wrote in the court file, though she later asked that the case be dismissed.

A DCF doctor called the shaking "violent and ferocious." The baby's retinas were shaken loose. Tests showed the baby had two brain injuries, one inflicted "at least several days," maybe weeks, before the other.

Brian Griffis, home alone before the baby died, was charged with murder but was acquitted after his lawyer suggested Danielle might have done it. They're now divorced. Brian, who denied shaking Alexis, is serving five years on a child-abuse charge. Danielle also said she never shook the baby.

Brian Griffis' lawyer, Thomas Edwards, said the DCF had failed the young couple by not offering services.

"Perhaps that child would be alive today, but that is pure speculation," Edwards said.

The death review faults investigators for failing to find the family, complete criminal checks and obtain medical records. After Alexis died, three DCF workers resigned after they admitted back-dating case records to make it seem that they'd completed their report sooner.

A spokesman said the agency, though it bungled the case, probably could not have predicted the violence.

"Leaving the hospital without getting blood work done, and murder - they don't connect," said Tom Barnes, a spokesman for the DCF.

* Glemus Guyton Jr., known as "Lil' Pee Wee," and his sister were raising themselves in a Northwest Miami-Dade apartment. Their father left for work before dawn and returned after dark. The children groomed, fed and dressed themselves. One cold morning Glemus arrived at school wearing pajamas.

On Jan. 5, 1999, the childrens' therapist called the DCF and reported that Glemus and his sister were neglected and "placed in a situation that requires judgment greater than the highest level of maturity that they have demonstrated."

The agency ordered a "24 hour" response, but it took the DCF a month to meet with the father. The investigator told Glemus Guyton Sr. that he needed "to make better arrangements for the care of his children." There is no record that the DCF interviewed the children's therapist or Glemus, who suffered from hyperactivity and got suspended from school for attacking the principal.

The DCF referred the father to a social service program and let the children stay.

On March 6, Glemus and his sister tried to cross busy Northwest 103rd Street at 10th Avenue on a bicycle. A car hit them. Glemus, sitting on the bike's center bar, died. His sister survived.

Edith Hall, principal of Van E. Blanton Elementary, where Glemus was in the third grade, said school officials feared the children were not safe.

"A tragedy waiting to happen," Hall said. "These children were raising themselves."

Glemus Guyton Sr. said he did not leave his children unattended. "Absolutely not true," he said. He said he was trying to find help for his son but kept getting sent from agency to agency. "I feel responsible a little bit," he said of his son's death. "I should have followed up with HRS more."

* Tony Bragg Jr. was born Sept. 29, 1999, in the Tampa suburbs to a family with a long history of neglect and abuse. Mom Brandy Rozier grew up herself in an abuse-scarred household and was well known to the DCF.

The boy's father, Tony Sr., had a criminal record, but Rozier would drop the child off with him for a week or more.

In October 1999, when Tony was just two weeks old, a report was made to the hot line about his 2-year-old sister, who had a red and swollen ear. "Jasmine said that her mother slapped her in the face so hard," the report says.

But the safety of Tony or the other siblings in the family was never mentioned. Supervisors caught the error later, but records show the agency dawdled for months - giving Rozier time to flee.

By luck, they later found her in a relative's home, while investigating an unrelated abuse report. Referring to Rozier, that report said: "There is another girl in the home . . . who is 'hiding out' because of child abuse charges."

But Rozier was not identified by name and the DCF did not follow up. Nobody got to Tony Jr. before his death.

A neighbor said she heard a "small scream" from a child around midnight on July 14. At 7 p.m., Tony Bragg Sr. called 911 and said his son wasn't breathing.

The autopsy said he died from a torn heart caused by blunt impact. Tony Sr. said he accidentally banged his son on a door frame, then put his son in the closet, shut the door and failed to check on him for 24 or 36 hours. He pleaded guilty to manslaughter and was sentenced to 15 years. After the death, the DCF moved Rozier's other children to other homes.

* In January 1999, Natalie Gomez-Perez's grandfather bluntly told a DCF investigator that his granddaughter was being beaten.

"If the Department of Children & Families did not do something, Natalie would not live to be 6 years old."

Four months later, 2-year-old Natalie was dead. Her mother's boyfriend, Juan DeSantiago, a convicted rapist and batterer, had ferociously pummeled the toddler. The motive: DeSantiago became enraged when Natalie's mother, Raquel Gomez, failed to paint her fingernails the same color as her toenails: fluorescent orange.

DeSantiago attacked "Natalie because he did not like the way she was looking at him." In January, it took DCF investigators eight days to see Natalie after her family alleged she had been beaten by DeSantiago. The cause of the delay: The DCF could not find the apartment. Investigators documented bruises to her face, stomach, upper left thigh, lower back and in the web between her fingers. Gomez said some of the bruises happened when her daughter fell on a toy.

But the DCF left the child in the home, with orders that DeSantiago stay away. Even after Gomez moved back in with DeSantiago, DCF investigators judged the risk "low."

"Another critical error that could have changed the outcome of this case," the agency's death review later concluded.

'EXTREMELY VIOLENT'

One month after the risk was judged low, the DCF received two more abuse reports concerning DeSantiago. "Extremely violent," the report said, alleging that he had punched another woman.

The other report charged that he beat Natalie again. The child was seen with "blood marks" behind her ear and black eyes.

This time, it took investigators 10 days to find the mother, because DeSantiago told them she and Natalie were out of town.

Meanwhile, Natalie turned up at a hospital with bruises on her right leg and a broken blood vessel in her groin. Her mother's story: Natalie fell off a swing.

The investigator accepted the explanation, never notifying law enforcement or the DCF's Child Protection Team.

Two days before Natalie died, the investigator quit. She placed the file on a supervisor's desk with a note: "The case needed to be staffed. Juan DeSantiago was dangerous."

Supervisors never reviewed the file.

* In the month before 4-year-old Stanley Moore died, investigators had three opportunities to save the St. Cloud youngster - but missed all three.

On Aug. 12, 1998, a friend or neighbor of Stanley's family called the department to report concerns that the boy's father was "having difficulties raising" his six children after his wife died. The children smelled badly, were caked in mud, and complained they had no food.

"Dad gives them crackers for dinner," the caller said.

Within two weeks, two additional calls were placed to the child-abuse hot line. The children appeared malnourished, and one was seen eating food from a neighbor's garbage.

The reports were unresolved Sept. 12, 1998, when Stanley, left without adult supervision, drowned in a fetid swimming pool. When told by his other, hysterical children that their brother had died at the bottom of the pool, the father reportedly said: "Get me a beer."

Herald computer assisted reporting editor Jason Grotto contributed to this report.