Also missing, the report said, was any indication that a caseworker assigned the investigation, Ramon Dunn, had ever considered the family’s history with DCF.

DCF referred Lamoureaux to three service providers — and then stopped monitoring.

If the referrals were supposed to provide safety to Emma, they didn’t. A hands-on parenting program called Family Preservation Services never had a chance to work with Lamoureaux before Emma died; though the agency recommended weekly treatment for the mom, they were never able to reach her again. Another program, Boys’ Town, had a wait list.

A third agency, Triple P Parenting, was given a referral for “the highest level of services that the agency can provide,” but Lamoureaux wasn’t interested. “The mother told them that she didn’t know why she would need the services,” a report said, adding: “The mother declined.”

After that?

“There is nothing in the notes,” a review said, “indicating any active ongoing case management” or attempts to interview family members, friends, neighbors or doctors occurred after the referrals were made. “Also, there is not an assessment of the [agency’s prior history with the family] or criminal history” in any records before the newborn died.

Also absent was any attempt to schedule a meeting of investigators, caseworkers and agency lawyers to discuss whether Lamoureaux’s unfavorable history with DCF, and the pending investigation, suggested Emma was in real danger.

The investigators “never set a Ludwig staffing with [Children’s Legal Services] before the baby was born,” Cagle wrote, “as is required.”

Agency records do not shed light on why the procedures were ignored.One review of the case said a case worker briefly discussed Lamoureaux with a DCF lawyer who concluded that no “legal sufficiency” existed to do anything other than hand out brochures. On Jan. 17, Lamoureaux put Emma to bed at about 12:30 a.m. A DCF incident report says the mom woke up at 7, “did not check on child,” and went back to sleep. Nine hours after Emma was placed in her crib, Lamoureaux woke up and found the newborn “deceased.” An hour later, Lamoureaux called 911, the report said.

Paramedics who arrived at the house set the girl’s time of death as 10:32 a.m.