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:
* In many of the abuse or neglect investigations, caseworkers had done very little - sometimes virtually nothing - in the weeks before a child died. In some cases, the caseworker never found the family.
The agency itself faulted workers for not thoroughly investigating prior complaints in 18 of the 29 cases where death reviews were available.
* In at least nine deaths, the agency failed to thoroughly investigate the family's history - basic casework that might have raised alarms. In 12 cases, the DCF failed to track down relatives, neighbors, school teachers, day-care workers and others who could help determine how much danger children faced.
In one Palm Beach County case, investigators learned only after the death of Michael J. Bernard, a disabled 9-year-old, that his father had been arrested 37 times in 14 years on charges including battery, drug possession, domestic violence and child abuse.
* In only five of the death cases were DCF workers disciplined or fired. In others, DCF case reviews excused or glossed over agency errors that helped leave children at risk.
A DCF "Rapid Deployment Team" that was supposed to target errors in death cases was ordered not to put any findings in writing - meaning its findings, which might prove embarrassing, never got public scrutiny.
"That was a personal decision made by [former DCF Secretary Kathleen Kearney]," said agency spokesman Owen Roach, who worked for Kearney. "It may be one of those things that needs to be fixed."
Florida child welfare administrators had not experienced a significant backlog in investigations until 1999, the year Bush signed legislation intended to close the gaps in Florida's child-protection network.
Named after a 6-year-old Lake County girl who was beaten to death by her father just before Thanksgiving 1998, the Kayla McKean Act required people who had regular contact with children to immediately report suspicions of abuse.
"This law makes us more vigilant on the issue of protecting children," Bush said.
But the act had dramatic, unforeseen consequences. The new reporting rules flooded the state's child welfare program with new cases; abuse calls nearly doubled. Though Bush nearly doubled spending, the new money barely kept pace with demand.
As caseloads grew, so did the backlog. Within two years of the law's passage, the official backlog soared from 4,000 cases statewide to a high of 51,310, records show.
The agency's response: change the deadline for closing cases from 30 to 60 days. It happened after then-DCF Secretary Kearney convinced legislators that, with high caseloads and limited resources, child protective investigators could do their work quickly or thoroughly - but not both.
The Herald's review shows that, in many cases, they accomplish neither.
"This is a terribly broken system, and no action is being taken," said Charles Mahan, a University of South Florida child-policy professor. "If nobody intervenes within 30 days, the problem will get worse and worse. One intervention, even a phone call, could probably let some of these kids live."
Some child welfare experts - including Kearney's immediate predecessor - called the change in policy a mistake, meant more to improve the department's statistical image than to protect children's lives.
"When a child is in danger - knowing full well we have failed from time to time - there is no excuse for failing to respond immediately," said Edward Feaver, a former DCF secretary who now teaches at the University of South Florida. "One day is too long when a child is in danger."
That's the point Jocelyn Pridemore, the nurse, tried to make when she called the DCF to report that David Nieves Jr. was in peril.
But she could not get the DCF to act. The agency, records show, bungled basic casework and supervisors never held caseworkers accountable.
DEATH IS REVIEWED
"It is clear there was a pattern of escalating domestic violence in the home putting David and his siblings at risk," the agency wrote in a review of David's death.
David was not an easy child. He suffered from Cri-du-chat (cry of the cat) syndrome - a genetic disorder causing mental retardation, stunted growth and facial deformities. Babies with the condition make cat-like cries.
Pridemore, a social service worker for Easter Seals, visited the family twice a week, checking on David.
Pridemore said David's mother, Lydia Molina, tried to take good care of him - at least until she hooked up with Alfredo "Freddie" Guerrero, described by friends as charismatic, handsome and flirtatious. The state of Florida calls him a burglar, armed robber and now a child killer.
He left prison in February 1999 and soon moved in with Molina in unit 138 in the Little Tadpole Mobile Home Park.
On Aug. 5, 1999, Pridemore said she drove to the trailer park and Guerrero greeted her carrying David. The boy had a large bruise on the side of his neck and face.
Guerrero hollered to the other children: "Tell her what happened!"
"The children looked terrified," Pridemore recalled.
Pridemore spotted the mother standing silently behind Guerrero.
Guerrero told her that David had slipped from his grasp, and he caught him by the head and neck before he hit the ground.
"'I have to report this,' " Pridemore told Guerrero and Molina, citing the Kayla McKean Act. "Freddie was pacing. . . . He was agitated."
"Child was seen with a bruise on face and cheek," the report said, mentioning his genetic disorder. Response: "immediate."
But investigators said they couldn't find the trailer and downgraded the case in priority. By the time they found David, five days later, the bruises were gone.
"I told them exactly how to get to the house," Pridemore told The Herald. "I even offered to drive them there myself."
Pridemore immediately quit after calling the DCF, saying her job was stressful and that David's injuries were "the final straw."
The agency's initial finding: no immediate threat to David and two siblings. "Both she and paramour are committed to caring for the children."
As in all cases of suspected abuse, a Child Protection Team was supposed to staff the case, but that didn't happen.
DAVID'S PERIL GROWS
Two months later, a DCF supervisor heard about David's case from other Easter Seals workers and sent an e-mail to colleagues saying the boy was at "high risk" for harm. The family was isolated, Guerrero was a felon and "child has a high-pitched cry, likely to frustrate a caretaker," she wrote. She, too, called for the Child Protection Team.
On Feb. 21, 2000, Pridemore watched an evening news report: Guerrero had been charged with killing David.
"I just broke down and cried," she said.
According to police, Molina came home that night after winning $40 playing bingo and found David with some yellow goo dripping from his nose. Guerrero called it the flu.
Later that night, David stopped breathing.
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.
* 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.
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.