The failings of Florida's chronically troubled child welfare system were first laid bare more than a decade ago, in the summer of 1989, when Bradley McGee's stepfather killed the toddler by using his head as a toilet plunger.
Bradley, 2, who had been returned to his mother by the state despite a history of abuse, had soiled his pants.
Others followed: Lucas Ciambrone, Kayla McKean, Alfredo Montes.
Their names have become synonymous with a broken child protection system. Fact-finding commissions were appointed. Fixes were proposed and abandoned.
Sign Up and Save
Get six months of free digital access to the Miami Herald
Through it all, the state has struggled to find a strategy - indeed, even a philosophy - to guide child welfare efforts.
When then-Health and Rehabilitative Services Secretary Ed Feaver took over the department in 1995, he appointed a Family Safety and Preservation chief who believed children were best protected by keeping troubled families together with meaningful services and intervention.
Four years later, Secretary Kathleen Kearney, a former Broward County juvenile judge, told caseworkers to err on the side of child safety by removing children from troubled families.
She removed the word "preservation" from her mission statement.
Charles Mahan, professor and former dean of the College of Public Health at the University of South Florida, says the state is doomed to repeated failures until lawmakers have the will to dramatically increase funding, and make a commitment to efforts to prevent child abuse.
"Year after year, time after time, this is absolutely not a safe place for at-risk children, " said Mahan, who has served on two child-welfare task forces.
"This is a recurring nightmare that has left Democrats and Republicans equally at fault, " said Jack Levine, president of Voices for Florida's Children. "I lay it on the doorstep of every political leader who uses children as a campaign pitch but does not believe that their protection is a high political priority."
"This is a problem of money, morale and management - and none of those are outside the reach of a state with the wealth of Florida, " Levine said. "There are no more excuses."
In his first few months, new DCF Secretary Jerry Regier has made clear he believes the pendulum must shift back again; his office will bolster programs designed to make families better able to care for their own children.
"The ability to retain children in existing families is also a high priority, because once a family comes into our system it is very difficult to reunify that family, " Regier has said. "So, both protection and prevention are high priorities."
Regier already has begun an effort to dramatically improve the state's child-welfare program, he said. In coming months, administrators will strengthen the training of caseworkers and investigators, design a better tool for determining the safety of reported abuse victims, and beef up the services the department can offer to at-risk families.
To pay for such upgrades, Regier has asked Gov. Jeb Bush and the Legislature for an additional $22 million for services designed to prevent abuse and neglect, such as in-home nursing care and Healthy Families Florida, a well-regarded program that provides hands-on advice and training for struggling parents.
"When we can leave a child [with biological parents], and the child is safe, that should be the course taken, " Regier said. "But it should be taken with appropriate and proper services."