James "Jimmy" Alford was the kind of child whom the Department of Children & Families was supposed to protect. But he died, anyway - in a squalid shack on Hard Times Lane in Florida's Panhandle.
The home was rife with roaches, maggots and flies. And in the end, filth killed him.
Jimmy, 14, and his family had been the subject of 23 separate complaints to the state's child-abuse hot line. Over the years, he was beaten with a switch, smacked with a board. He suffered burned fingers, bloody welts.
Time and again, investigators from the Department of Children & Families visited his house, examined his injuries and made reports.
Still, he died last year, a casualty of questionable casework and poor care.
A Herald investigation of more than 2OO child deaths statewide has found that flawed probes on the part of the DCF may have contributed to the deaths of at least 100 Florida children over the past five years. That number could be even higher, The Herald found, because the DCF never thoroughly documented or investigated its own performance in some 80 child deaths.
Among the findings: Caseworkers and supervisors poorly evaluated the true danger to children, skipped safety checks on desperate children, blindly accepted caregivers' excuses when children turned up with suspicious injuries and failed to document family problems that DCF lawyers could have used to remove children from dangerous homes.
"This was a real red-light case, " said Dr. Michael Berkland, an Okaloosa medical examiner, of Jimmy Alford's death. "You had a mentally challenged child who needed assistance, he needed to be washed every time he went to school; his house was bug-riddled.
"How many more indicators did DCF need before yanking him?"
Despite Florida's emphasis on protecting children over the last decade, The Herald's analysis found that DCF caseworkers and supervisors made the same mistakes over and over again.
Last month, The Herald reported that at least 37 children died of abuse or neglect since 1998 while warnings to the DCF about the children's peril went unresolved in so-called "backlog, " despite state laws mandating prompt investigations within 30 to 60 days.
But those cases account for only a portion of the death toll.
The problems run much deeper: Even when the DCF does investigate, lapses in the handling of allegations often leave young children in danger.
DCF Secretary Jerry Regier, who took over the agency in August, said the loss of life is unacceptable.
"The protection of children, in terms of safety, is absolutely a priority, " Regier said.SHOCKING SITUATION
"I'm still reeling from these kind of numbers, " DCF spokesman Bob Brooks said. "The loss of one child is tragic enough. It really leaves me speechless. It points out the need for additional training."
Brooks said Regier has already taken steps to prevent future tragedies. For example, he has instituted procedures to better track abuse and neglect complaints and reduce the backlog of cases.
"This is the kind of thing that makes you redouble your commitment to make sure this does not happen again, " Brooks said. "This secretary is committed to Florida's children and improving the department."
Richard Gelles, interim dean of the University of Pennsylvania's School of Social Work, has studied hundreds of child-death cases.
"I'd say for a majority, a very large majority, the primary cause is an accumulation of bad casework, " he said.
* In Miami-Dade County, José Antonio Pérez bludgeoned his two children to death - after DCF investigators misunderstood a call to its child-abuse hot line and went searching for a mother they mistakenly believed imperiled her childrens' lives.
In fact, it was Pérez, the children's father, who wanted to kill the family. His threats had been documented a week before the murders in police reports and a restraining order that the caseworker failed to find.
* In Bay County, child-welfare workers had at least nine chances to intervene in the life of Melissa Matuzek and her son Chance, 3. The DCF received numerous reports claiming Matuzek was neglectful, sometimes drunk, and involved in an abusive relationship.
Another report claimed that her boyfriend was threatening and abusive toward Chance as well.
But DCF records suggest that the agency did little more than make suggestions for help that the young mother refused. The agency ordered her into addiction treatment but did not check to make sure she went.
The boyfriend, Brian Morrison, left alone one day to baby-sit Chance, killed him by throwing him to the floor. Matuzek told The Herald that Morrison was abusive to her but that she didn't think he would ever hurt her son. Morrison, convicted of murder, is now in prison.
* In Hillsborough County, a DCF caseworker failed to document in the agency's files that Laura Cruz had been ordered by the agency to stay away from her abusive boyfriend, who was the father of her infant daughter, Rosinda "Michelle" Fajardo. The DCF also failed to write that Cruz had not followed through on other requirements to keep her children safe.
The information in case files is critical for tracking a child's welfare. But not knowing all the facts in Cruz's case, a judge released the mother from DCF supervision. The father, Pablo Fajardo, was back in her life. He later beat the baby to death, was convicted and faces life imprisonment.
"Indications of the possibility for a tragedy such as this to occur did exist, and in a sense might be considered predictable, " a DCF death review later concluded.
* In Duval County, Justice R. Hires, 21 months old, was allegedly strangled and thrown to the floor by his mother's boyfriend because the baby picked something up off the floor and put it in his mouth. There was a report to the DCF five months before his death that Justice had been in the emergency room with a suspiciously injured leg.
But the agency never completed its investigation of that first report. Key witnesses had not been contacted. The hospital doctors weren't interviewed. No one at his day-care center was called. Justice's is among more than 30 death cases in which caseworkers were remiss in contacting medical professionals, schoolteachers, neighbors or relatives who could have provided evidence that children were in danger.
The boyfriend, Charles Arline, has been charged in Justice's death.
* In Broward County, the abuse hot line received a report on March 4, 2000, that Nicholas Bahamundi and his six siblings were unsupervised and living in filthy conditions. By law, workers must see at-risk children within 24 hours of receiving a maltreatment report.
The caseworker said she could not find the home. The visit finally occurred two months later, on May 3, 2000. Nicholas had drowned in the family's pool, which was green with slime. The house was a disaster, full of feces, rotting meat on the kitchen counter.
Nicholas' six siblings were removed and now live with their maternal grandmother in Hollywood. Lori Bahamundi, the children's mother, said she and her husband are good parents and are doing everything they can to regain custody of their children.
* Then there is the story of Jimmy Alford, whose case, which spanned more than a decade, was mired in problems from the beginning.
Jimmy was physically disabled and mentally impaired. He could barely speak. He had a genetic disorder that made it hard for him to fight illnesses or infection. Calls to the abuse hot line started when he was just a toddler.
"Paramour beats, hits and kicks Jimmy, " a Nov. 2, 1990, report to the hot line said. "Michelle [Wesson, the mother] fails to protect the child. Child has a mass of bruises."
The DCF closed the case two months later without taking action, noting: "no indicators of bruises, failure to protect."
But things became worse as the years passed, records show.
"Jimmy wandered away from his house; he was observed a mile away wearing only a diaper, " a June 29, 1992, report said. "There were bruises on his back and arms."
Again, the DCF closed the case, saying, "no indicators of bruises, inadequate supervision."
But just a year later, Jimmy arrived at school with facial injuries and a bruised buttock. He had "switch marks" and bruises under his eyes.
"Jimmy was prone to falling, " his mother told investigators. The DCF suspected abuse.A SILENT VICTIM
But Jimmy, then 6, could not tell caseworkers what had happened. The department repeatedly referred his mother to counseling and parenting classes. Sometimes Wesson resisted, arguing that the DCF was picking on her.
Wesson, a former housekeeper arrested on charges of criminal child neglect after Jimmy died, said the DCF's complaints were blown out of proportion.
"I love my children with all my heart, " Wesson told The Herald. "DCF overstated every report, especially Jimmy's. I would never put my children in harm's way."
Investigators, however, were worried about her living conditions, records show. The shack was hard to find, tucked off a dirt road, and coming apart.
Spiders abounded. Cockroaches lived inside the refrigerator. Maggots wiggled about the kitchen.
On July 7, 1995, caseworkers tried to inspect the house.
"Mother refuses access to the home and children, " the report noted. "No further attempts to enter the home." Wesson said she had cooperated.
Once again the DCF closed the case, suspecting hazardous conditions but taking no action. The agency, in its death review, called that a mistake: "The Child Protective Investigator should have attempted to complete a home visit the following day with law enforcement" or gone to court.
In 1996, a relative warned the DCF that Jimmy and his siblings needed to be removed, saying they "should be placed in an environment [where] they can grow up and learn and be provided for emotionally, physically and mentally so they don't end up in prison or dead."MULTIPLE WELTS
On Sept. 19, 1996, the DCF got a call that Jimmy had arrived at school with welts - 32 of them - on his buttocks and thighs.
Caseworkers were told to see him within 24 hours. It took them four days.
"Mother admitted she hit James with a switch, " reports show.
Social service workers involved with the family concluded that Wesson's children were in danger. The Health Department said her house "was not in livable condition."
"The mother was unable to adequately supervise the children, " the report says.
This time, the DCF placed Jimmy in a group home. Wesson and her other children went to her father's under court supervision.
"The goal is to reunify James with his family once it is felt that he nor [sic] his siblings are at significant risk, " the DCF said, adding that Wesson needed to fix the house.
By April 1997, Wesson had cleaned up the house and regained custody of her children. Calls to the hot line soon resumed.
* May 27, 1997: "James has bruises on the back of his legs. He has a burn on his hand." But the case was closed three months later with no evidence of bruises or hazardous conditions noted.
* Feb. 25, 1998: "James is mentally retarded and non-verbal . . . he got a whipping."
The DCF's Child Protection Team and caseworkers examined Jimmy's injuries - linear marks stretching 1.5 to nearly four inches in length. Jimmy's step-uncle admitted whacking him three times with a rubber hose. Again, no action was taken.
* July 12, 2000: "The family has two goats, two pigs, six dogs, two cats and also some kittens and puppies. The animals are exposing the children to possible infections. James has had on the same clothes for eight days. The clothes have not been washed, and James has not had a bath."
This time, caseworkers arrived at the house and so did health inspectors. They took water samples and demanded that a 50-foot perimeter around the house be cleaned. The children were riddled with bug bites and were hungry.
"They get food from neighborhood children, " a caseworker wrote. "They eat pears off the trees in the backyard."
Two months later - yet again - the DCF closed its case because Wesson had cleaned the house.
The agency later faulted the case supervisor for poorly monitoring a hazardous situation involving a child who couldn't speak.
* Summer 2001: Police arrested Wesson for welfare fraud, and investigators, again, found the house in tatters. Dogs and cats defecated inside and the children "sleep anywhere they can."
Once again, relatives cleaned the house, replaced a rotting door, purchased a new refrigerator, installed two sets of bunks beds and placed a trash can in every room. Wesson came home from jail.
"The home had changed 101 %, " a caseworker wrote. "Amazing that such a change could be made."
Still, caseworkers recommended that Jimmy be put in a group home, and they wanted Wesson's voluntary consent to do it.
At first, Wesson agreed. Later, she changed her mind. The reason she gave: Her doctor gave her new medication that seemed to control Jimmy.
"I was his mother and I could care better for him than anyone, " Wesson said.
The DCF considered going to court to remove Jimmy, but the lawyers would need a letter from his doctor.
"There is nothing we could do legally to force mom to place Jimmy into a group home unless a [doctor] would swear in court that it is detrimental to Jimmy not to be in one, " a caseworker wrote. "Then we could remove Jimmy based on medical neglect."
Weeks passed. No doctor's letter or agreement went into Jimmy's file.
The DCF closed the case Oct. 15, 2001, saying there was evidence of maltreatment.
But Jimmy was not removed.
A report says Wesson was making significant improvement in cleaning the home.DEATH CLAIMS JIMMY
One month later Jimmy went to sleep at 979 Hard Times Lane and never woke up.
Paramedics found him on the wood floor, atop a queen-sized mattress, next to a broken toilet bowl filled with excrement, and a stack of soiled toilet paper nearly three feet high.
The house had no sheets, no blankets, no pillows. The family had been collecting its water from a disconnected sink pipe that leaked into pans.
Jimmy, five feet five inches tall, 217 pounds, died Nov. 11, 2001, from an apparent infection.
All his internal organs - from his brain to his bone marrow - showed "marked overgrowth" of bacteria, the coroner said.
Wesson said Jimmy died from side effects of an antipsychotic drug.
"In my heart I know that killed him, " she said.
Not so, the coroner said.OWN WORST ENEMY
"Mom was her own worst enemy, " Berkland said. "She told everyone that Jimmy catches whatever goes around, and he's laying next to piles of feces. His body was overrun by bacteria."
Even then, DCF administrators closed the death investigation with no "verified" finding that neglect had killed Jimmy.
"They were in a fire-suppression mode, " Berkland said. "Everyone tries to make these cases look pretty afterward, but this one was a real problem."
On July 30, 2002, Okaloosa County sheriff investigator Laurie Keller arrested Wesson, 34, on charges of criminal child neglect. The officer used the DCF's own reports and the autopsy to build a criminal case.
"In almost each of the [DCF] reports, there are concerns about the hygiene of James and his siblings, " the warrant said.
Wesson pleaded not guilty and is scheduled for trial in February.
"When we look back on situations like this, there are always things we can improve on, " said Betty Hooper, a DCF spokeswoman in the Panhandle.
"This is a case that we looked at very, very closely. And we have made some adjustments so that we can do better in situations that might be similar."
Weeks after Wesson's arrest, the DCF decided to reopen the case and conduct a death review. Only then did administrators fault caseworkers for letting Jimmy return to Hard Times Lane. The DCF changed its finding to "verified."
Neglect had killed Jimmy.