Diella Beth Ludwig and her twin sister were born while their mother lived at the state’s Lowell Correctional Institution. From there, state child welfare administrators sent them to live with their father, an unemployed, drug-abusing 24-year-old with a long criminal history and a prior report concluding he should never be left alone with children.
Bothered by the fussy, underweight baby’s crying, Thomas Ludwig crushed Diella’s skull. She wasn’t even 2 months old.
The state Department of Children & Families was so troubled by Diella’s death that administrators strengthened a policy requiring staff to look closely at infants born to parents already under an abuse or neglect investigation. They called it the Ludwig Protocol.
But when Emma Morrison was born late last year to parents with a long history of drug abuse and domestic violence, the Ludwig Protocol was ignored . Now she, too, is dead.
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Although there is no evidence Emma met such a violent fate, DCF, the Palm Beach County Sheriff’s Office and medical examiners are investigating the murky circumstances of her Jan. 17 death. No one has been charged, although police found a crack pipe in plain view when they entered the house, a source told the newspaper.
Emma was the same age as Diella.
Emma’s death raises troubling questions about lessons learned and not learned, even as DCF launches the most recent of many agency-wide reforms designed to better protect children.
Emma had lived 49 days. She spent 34 of them the subject of a DCF investigation into her welfare.
Though Emma’s parents had been the subject of more than 10 prior reports to the state’s abuse hotline — and four other children had been taken from the mother by the state — child welfare administrators did virtually nothing after receiving a report that Emma had found herself smack in the middle of a physical altercation between her parents.
Authorities refused to discuss Emma’s case. Chief Medical Examiner Michael Bell would not disclose her name.
Neither of Emma’s parents could be reached by The Miami Herald.
Emma’s death occurred less than a week after Hallandale Beach police found a tiny skeleton buried behind a house where, three months earlier, DCF had ignored a report that Dontrell Melvin had disappeared 19 months earlier. No one — not his parents, not police, and not DCF — went looking for the infant, who apparently vanished when he was about 5 months old. Authorities have yet to determine whether the bones belong to Dontrell, who would now be 2.
Though Emma’s mother, 33-year-old Lisa Lamoureaux, had a long history of drug abuse and arrests — and had permanently lost custody of all four of her children — the extent of DCF’s intervention after her latest birth was to refer her to parenting classes and other services that either were unavailable or that she rejected.
Reports show investigators failed to inquire whether Lamoureaux was still using drugs, failed to interview her neighbors or family members, and failed to seek the advice of their own lawyers regarding the best way to protect Emma.
Referring to DCF’s most recent reform effort, called the Child Protection Transformation, DCF’s top child welfare attorney, Mary Cagle, wrote in a Jan. 24 email: “With the transformation project I am hoping we can change this culture.”
Short of removing Emma from her parents’ custody, the department had a range of options, including filing a court petition to force the Palm Beach County couple to accept help from the state, such as drug treatment and better-parenting education — though records suggest such services had failed in the past.
DCF spokesman Joe Follick said “the threshold is very high for the state to remove a child from his or her mother — especially when there are no clear signs of imminent danger or abuse. It is very easy for others to indulge in hindsight second-guessing. The reality of making decisions on separating an infant from his or her mother is a much more complex process that every employee at the department takes very seriously.”
DCF refused to release any records pertaining to the investigation into both Emma’s death and the hotline call that preceded it by more than a month, saying the records are confidential unless it is determined that her death resulted from abuse or neglect.
“Every death affects us deeply,” Follick said. “We have reviewed the history of this family and the investigation of this case. It would be entirely premature and reckless to speculate on the cause of death while local authorities investigate.”
Still, a sketchy account of Emma’s short life emerges from the handful of documents The Herald did obtain under the state’s public records law: a review of the family’s DCF history in which nine of 13 pages were redacted and three others were partly redacted, a five-page review of the open investigation, a one-paragraph incident report and several agency emails.
There is no question that Lamoureaux had a long and bitter record with the state’s child welfare agency, though the details remain a mystery. A family history that is almost completely redacted shows that Emma’s parents had at least 11 prior contacts with DCF. She has been arrested nine times since 1999, on charges including larceny, exploitation of the elderly, cocaine possession, driving under the influence and prostitution.
Emma’s father, 48-year-old Dwayne Morrison, has a far more violent criminal résumé. He’s been arrested 35 times since 1992, including charges of carrying a concealed weapon, weapons possession by a convicted felon, kidnapping, robbery, battery, aggravated battery on a pregnant woman, larceny, shoplifting, burglary, fraud, contempt of court, escape, and several charges of either cocaine or meth trafficking.
Records show the Palm Beach County Sheriff’s Office had made “numerous” calls to the house Lamoureaux shared with Morrison, who was the subject of two domestic battery calls when Lamoureaux was pregnant with Emma. On two occasions, Morrison was arrested after domestic violence calls. Both times, Lamoureaux did not cooperate and charges were later dropped.
On Dec. 13, DCF’s abuse and neglect hotline received another report — that Morrison had slapped Lamoureaux in the face while she was holding newborn Emma. Morrison was charged with battery, but, as had happened in the past, the charges later were dropped and Morrison was released from jail.
“Missing” from an early assessment of risk to Emma, a short report said, was any “mention of the mother’s history of substance abuse.”
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.”
“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.