Review: Child's death exposes recurring, fatal flaws in system

SEATTLE (AP) — State social workers ignored evidence and failed to protect Rafael Gomez, an Ephrata 2-year-old who died last September, according to an outside review that delivers a scathing critique of the state's child welfare system.

Rafael, nicknamed Raffy, suffered two broken legs, concussions, burns and bruises while in his birth mother's care. He went into foster care four times, but state caseworkers kept pushing for reunification with his birth parents.

Six months after the state reunited him with his family, Raffy died of blunt force trauma to his head. His birth mother, Maribel Gomez, 29, has been charged with manslaughter in her son's death.

The state Department of Social and Health Services released the Child Fatality Review on Wednesday night. A team of 13 experts, including doctors, social workers and lawmakers, spent six months investigating the events that led to Raffy's death.

The conclusion: social workers were biased in favor of the birth parents, and ignored or dismissed glaring signs that Raffy was in danger in their care. Others who could have intervened — including a local judge and the Child Protection Team assigned to Raffy — either didn't get the necessary information or failed to ask critical questions.

”There was enough information known about Rafael to rule out accidental or self-inflicted injuries,” the report said. Raffy's injuries and the reports from doctors, other professionals and witnesses ”should have caused significant concern about Rafael's safety while in the care and supervision of his parents.”

DSHS Children's Administration director Uma Ahluwalia, who was hired a month after Raffy's death, called the report ”very fair.”

She said the social worker who handled Raffy's case is no longer working with child welfare cases, though he's still employed with the department. She said an internal investigation will determine whether anyone with the agency should be fired or reprimanded.

The review notes that while Raffy consistently got injured with his birth parents, his foster parents provided ”consistently safe and nurturing care” — only to see their concerns be unfairly dismissed by state workers who implied they were ”overly attached” to the baby or even prejudiced against Raffy's Hispanic parents.

Denise Griffith of Royal City, Raffy's foster mother, said reading the review made her feel excited for one of the first times since the child's death.

”I am so shocked to finally have this system be held accountable for their actions. I want to thank them for finally stepping up and doing the right thing,” Griffith wrote in an e-mail to The Associated Press. ”No more cover ups, no more social workers playing God and no more preventable deaths!”

The review blasted state officials and social workers for failing to reform their ways after previous deaths of children in the system. The report compared Raffy's death to those of Zy'Nyia Nobles and Lauria Grace, children who died of abuse after the state reunited them with their biological parents. In places, the review even quoted from Zy'Nyia and Lauria's fatality reports.

The department failed to follow its own policies on putting child safety first, the review said, including rules enacted after Zy'Nyia's death.

”There is frequent mention in case notes and in staffing information that there was no 'evidence' that the injuries were a result of child abuse,” the report said. ”It is not the role of social workers in Washington State public child welfare to prove, beyond a reasonable doubt, that abuse or neglect occurred. The Committee finds it difficult to understand the emphasis on proof when the risks to Rafael were so numerous.”

Ahluwalia said she believes previous reforms have improved the system, even if problems persist. Even good tools won't work properly if they're tinged with a bias toward reunification, she said. Many of the recommendations in the Gomez Fatality Review have already been incorporated into Ahluwalia's plan for reforming the child welfare system, launched last month.

She said she met Wednesday with the workers in Moses Lake who handled Raffy's case, and described them as ”devastated” by the child's death. Ahluwalia said she hoped people would not lose faith in the system and the planned reforms.

”If there is no hope it becomes very difficult to do this work,” she said.

On the Net:

DSHS: http://www.dshs.wa.gov

AP-DS-06-03-04 1148EDT