Eleven-month-old Olivia Forrest died in 1998. Her autopsy showed that her brain had been subjected to gravitational forces more intense than those experienced by fighter pilots.
Aubrey Hannsz was 4 months old when she was rushed to a hospital in 2012 with a bleeding brain and eight broken ribs.
Both infants’ deaths were studied by the Hampton Roads Child Fatality Review Team, a panel formed in 1996 that was held up as a model for Virginia. Its mission: use the lessons learned from such cases to save other children.
In the team’s first years, Hampton Roads led the state in the number of child abuse deaths. Nearly 20 years later, it still does.
Through 2012, the team had counted 223 deaths from child abuse, a total that’s about to get higher.
Database | Child abuse deaths in Hampton Roads
The exact figures have not been released, but the team announced Friday that 36 percent of the child abuse deaths in Virginia last year occurred in the district. That could rise to 47 percent, but four cases have not been counted yet because they are being appealed. The team will discuss the deaths further at a news conference Wednesday.
State law has always limited the way the Hampton Roads Child Fatality Review Team operates. It cannot subpoena people involved in cases, nor hand down directives based on its findings.
Its funding is meager, its recommendations go unnoticed by lawmakers, and its control over social services departments is negligible. Members measure successes in small victories – a public awareness video produced by volunteers, training sessions with social workers.
Ultimately, the lack of attention to the alarm the team sounds is the fault of no single individual or organization. It is an entire system that has accepted the death by abuse of an average of 13 children each year in the region.
Communities, and the nation as a whole, do not have to accept that a certain number of child abuse deaths simply will happen, said Dr. David Sanders, chairman of the new national Commission to Eliminate Child Abuse and Neglect Fatalities.
“You can set the tolerance level at zero and really, can any community set the bar higher than zero?” he said. “There is research that says who is at risk, and there are things that can be done to mitigate that risk.”
Betty Wade Coyle, the team’s vice chairwoman, said her group of volunteers lacks the authority to make the changes needed to protect children. That responsibility, she said, must fall to state legislators, municipalities, law enforcement and the community overall.
“We have no power,” Coyle said. “None.”
Each month, the review team – made up of representatives from child welfare organizations, law enforcement, hospitals and the medical examiner’s office – analyzes child deaths that were investigated by social services departments. Then it issues an annual report that compiles statistics about the cases and offers recommendations.
One concern noted repeatedly by the team is the consistently high number of children who die in the district that includes Hampton Roads. Various groups have hypothesized why that is – the military presence and the area’s transient nature are theories – but no research has pinpointed the reason.
Coyle says it’s partly because her district is more vigilant about reporting child deaths. Each regional fatality review team has its own bylaws, and they may have different practices for what social services investigates, she said.
Year after year, the team’s reports cite many of the sameproblems. The need to give higher priority to repeated reports of abuse of the same child, or reports from professionals. Poor communication between the various agencies that help troubled families. Police and social services failing to conduct joint investigations of child deaths, as the law requires.
The team is not allowed to disclose specific information about the children’s deaths – state law requires it to be kept secret to protect the privacy of children and families involved in the child welfare system.
Virginia officials cannot enforce the review team’s recommendations at local social services departments.
Unlike in most states, the Virginia Department of Social Services does not oversee local departments, serving only in a supervisory, not administrative, role.
When the state reviewed the Virginia Beach Department of Human Services in 2012 after the death of 10-month-old Braxton Taylor at the hands of his foster mother, it did so at the city’s request.
In a review prompted by Braxton’s death, the Child Welfare League criticized Virginia’s system and called for a “more comprehensive interdisciplinary review” of child fatalities. The league recommended that the state talk to national child fatality organizations to collaborate and get ideas.
The system hasn’t changed.
Each spring, the Hampton Roads team releases its findings for the Eastern District – which includes South Hampton Roads, Newport News and Hampton as well as the Eastern Shore – at a news conference, then sends a report to the state child fatality team. The team will release its most recent findings Wednesday.
One key group that hasn’t seen the reports: state legislators.
Del. Glenn Davis, whose district includes areas of Virginia Beach, got a copy of last year’s report from a Pilot reporter. He called it “eye-opening.”
The state should look at collecting more data on child deaths because if anything, the report doesn’t give enough details of how to prevent them, he said. Davis was a Virginia Beach City Council member when the deaths of Braxton and another infant forced the city’s human services department to change its practices.
“Collecting more data would help us better understand the situations that lead to these tragedies,” he said.
Del. Ron Villanueva, whose district includes parts of Chesapeake and Virginia Beach, also received the regional team’s 2013 report from a Pilot reporter.
“Obviously, this is evidence of holes in the system,” he said.
Like Davis, Villanueva says legislators should take a closer look. “It’s our job to help fix it,” he said.
Preventing child abuse deaths takes a broad, systemwide approach involving city and state officials, said Sanders, the chairman of the national commission.
He pointed at Tampa, Fla., a city that went from more than 10 child abuse deaths a year to zero last year.
“They reviewed all of the cases… and tried to identify the key components, the characteristics that seemed to predict areas where children would be harmed,” he said. “It was a pretty systematic way of making improvements.”
Sanders said Philadelphia and the state of Michigan also have driven down their numbers of child abuse deaths.
“In both cases, it’s clear that it’s either the governor or the mayor that sees themselves accountable for the changes and that there’s a clear structure to implement the changes,” Sanders said. “They are not just making recommendations to do things.”
Some argue that keeping information about cases private allows police and social workers to better do their jobs.
But Sanders said his experience has convinced him that the more the public knows, the more likely children are to be safe.
In 2001, officials almost did something.
That spring, the Rev. Rufus Adkins, who was a state Department of Social Services board member from Richmond, called for an inquiry after seeing that 17 of the 32 child abuse deaths in Virginia were from Hampton Roads.
“What’s going on in the Tidewater area?” Adkins asked.
Attorney General Mark Earley began an investigation involving his office and researchers from Virginia Commonwealth University, Norfolk State University and Radford University.
In September 2002, the researchers released their findings, which offered state-level recommendations and analysis.
By that time, there was a new governor, and any momentum for change was lost, Adkins said in a recent interview.
“No one did anything,” he said. “It seems like attention shifts whenever the board changes.”
He never got his answer.