Between 2008 and 2011, more than seventy children who passed through the Los Angeles County Department of Children and Family Services have died due to child abuse or neglect. Many of the lives and deaths of these children have been rigorously documented by Los Angeles Times reporter Garrett Therolf and by the paper’s invaluable Homicide Report blog.

Spurred at last into action by the death in 2013 of a third-grade boy, Gabriel Fernandez, who was tortured to death by his mother and her boyfriend in Palmdale despite at least six child abuse claims logged against the boy’s mother with DCFS, the Los Angeles County Board of Supervisors assembled a Blue Ribbon Commission to come up with a series of sweeping reforms for the child welfare agency. Preliminary recommendationscoming out of the Commission at the end of December included hiring hundreds more social workers, yanking up the standards of training, and constructing a cross-agency database so social workers could more adequately check medical and criminal files of foster parents. There was even mention of a child welfare czar, a single public administrator anointed with the power to impose reforms across agencies. County Supervisors assured the media and public that they were prepared to implement wide scale changes.

And then at a meeting of the Board of Supervisors, it seems as if the urgency—and money—to take on the Commission’s “life-saving” reforms has dried up. The Commission’s calls for immediate action on their preliminary recommendations were met with phrases like “cost neutrality” and “economic feasibility” and “doing what is being recommended with existing resources.” Ultimately, the board only approved one of the Commission’s initial recommendations: to install a member of law enforcement at local DCFS offices to expedite background searches for emergency placement foster parents. They said they’d wait for a final report in April to consider the rest. The Commission, in turn, explained that the recommendations would not be changing for the final report.

Supervisor Mark Ridley-Thomas endorsed the Commission’s recommendation to have a nurse attend DCFS house visits that involve infants. And then the board voted against the motion, until further fiscal analysis could be made.

When paramedics arrived, eight-year old Gabriel Fernandez was not conscious. His skull was cracked. Three ribs were broken. Bruises and burns covered his body. Two teeth were knocked out of his mouth. X-rays would later show that the third-grader had BB pellets embedded in his lung and groin. Gabriel’s mother, Pearl Fernandez, 29, and her boyfriend Isauro Aguirre, 32, told the paramedics that Gabriel’s injuries were self-induced. Later Aguirre said that he delivered ten or so blows to Gabriel’s stomach for lying and “being dirty.”

Before Gabriel’s death, his mother was the target of six investigations of child abuse. One of Gabriel’s teachers reported the boy coming to school battered. One of Gabriel’s therapists reported that Gabriel said that he was forced to perform oral sex on a family member. Gabriel told a teacher he’d been beat with a belt buckle until he bled and his mother shot him with a BB gun. Gabriel wrote a suicide note, found by his teacher.

According to documents obtained by the LA Times and a recent wrongful death lawsuit filed by Gabriel’s grandparents, Gabriel was never interviewed privately by a social worker about his abuse. Fernandez and Aguirre have been charged with first degree murder of a child. The two have yet to enter their pleas. Two months after Gabriel’s death, four DCFS employees related to his case were fired.

The Department of Child and Family Services refuses to release the case details of child fatalities. But a confidential audit on child fatalities from 2010 to 2011, conducted by the Los Angeles County Board of Supervisors’ Children’s Special Investigation Unit, isolated at least thirteen children’s deaths that resulted from systemic “weaknesses” inside DCFS. Here is what happened to those children.

Vyctorya Sandoval

Four days after Vyctorya was born she and her eight siblings were removed from their parents, Jennifer Dalhover and Joseph Sandoval, because of domestic violence and charges of sexual abuse between the couple.

Dalhover and Sandoval also had 11 child abuse complaints filed against them with DCFS. Vyctorya was placed in three different foster homes before reaching a couple in Placentia who were willing to foster and then adopt her in April, 2010. After Dalhover and Sandoval vanished for several months—falling out of contact with social workers and parenting counselors—they resurfaced at a Pasadena homeless shelter with another newborn baby in September, 2010. Less than three months after the couple left the homeless shelter, DCFS decided to reunite Vyctorya, then 25 months old, with her biological parents. At the reunification hearing, Vyctorya’s social worker, foster care supervisor (you can read her letter here), and siblings attended to make statements against putting Vyctorya back with her parents.

During the seven months Vyctorya was back at home she lost almost half her bodyweight and her hair was falling out in clumps. DCFS closed her case. Two months later Vyctorya died of severe malnutrition and physical abuse. Medical reports showed she died hungry and thirsty. 1

Viola Vanclief

Viola Vanclief was born to a schizophrenic mother who refused to take her medication. Viola was put into foster care for a short period of time before being reunified with her mother—but was removed again when investigators found that Viola’s mother was still not taking her medication, was abusing cocaine, and had violently attacked another person. Viola, still an infant, was placed with Kiana Barker, who hadseven child abuse and neglect complaints filed with DCFS regarding her own two biological children. Barker obtained a waiver through a private foster care agency to allow her to foster and adopt children; according to state code, Barker should not have been allowed to do so.2 Barker was also living with her boyfriend, James Julian, a convicted felon, while Viola was in her care. Barker was approved to adopt then two-year-old Viola by DCFS in March, 2010. Barker called 9-1-1, saying that she accidently struck Viola with a hammer while trying to free the toddler from being stuck inside a bed frame. Viola died from her injuries, which medical examiners say were likely inflicted by a belt and were sustained a full day before Barker called 9-1-1.3

Cynthia F.

Cynthia’s mother also had a documented history with DCFS. She had lost custody of her four other children due to drug abuse. A child abuse/neglect call was made to the DCFS hotline the day Cynthia was born, because her mother gave birth to her while on methadone. But whoever answered the DCFS hotline that day left Cynthia’s risk assessment completely blank, so any investigation into Cynthia’s well-being was “evaluated out” and no investigation took place. Cynthia died at two months, when her parents, who were drunk at the time, left her face-down in her crib.

Christian and Michael Dixon

Christian, 5, and Michael, 1, were shot to death by their mother, LaTonya Dixon, in a failed murder-suicide attempt. While pregnant with Christian, Dixon aged out of child services and transitioned into an adult services program, although she was not compliant with her treatment plan. Dixon had a documented history of mental illness as well as mild to moderate developmental disabilities. After Dixon gave birth to Christian, two abuse claims were referred to the DCFS, alleging neglect of the infant. The referrals were deemed “unfounded” and no services through DCFS were offered.

Jorge Tarin

Eleven-year-old Jorge Tarin told a school counselor that he wanted to kill himself “because I’m tired of people hitting me all the time.” Jorge told the counselor that he was beaten by his mother and stepfather and described the abuse as “unbearable.” Jorge said he would kill himself either with a gun or with a rope. The counselor called DCFS. The school decided Jorge was well enough to go home at the end of the school day. He was put on the school bus with a note asking for Jorge’s mother to call the counselor.

Two emergency service workers and police officers came to Jorge’s family apartment. They interviewed Jorge privately; he said he no longer planned to kill himself. The boy shrugged when asked if he was afraid of his mother or stepfather. The officer searched the home for a weapon and found none. The emergency workers interviewed Jorge’s mother, who denied hitting him. The DCFS workers and the police officer left Jorge.

DCFS had visited Jorge before. His file noted violence, drug abuse and neglect at the hands of his parents, starting from his infancy. Jorge spent over a year in foster care homes before being reunified with his mother the year before his suicide. According to the Los Angeles Times, in 2007 DCFS paid $5.9 million for about 2,400 wireless tablets so employees could access case files remotely—but the department only bought 400 wireless cards. “The overwhelming majority of the tablets gather dust on social workers’ desks,” Garrett Therolf wrote. Shortly after DCFS workers left, Jorge went to his mother’s bedroom and hanged himself using a jump rope. Eighteen days after his death, Jorge was entered again into the DCFS database as “high risk.”

Erica Johnson

Erica, 2, was beaten to death by her mother’s 21 year-old boyfriend, Davon Smith, on October 7, 2010, at her grandmother’s house. A DCFS complaint was made to the hotline because both her parents, Taelor Moore, 16, and Eric Johnson, 17, were on probation, and both were former DCFS dependents. Before Erica was born, Moore’s mother, father and grandparents alerted DCFS about Moore’s propensity for being violent with her relatives. The DCFS worker who took the hotline call filled out a risk-assessment worksheet for Erica (she was deemed at “high risk” for abuse) and recommended the case be promoted. The case was closed because the allegations in the risk assessment were deemed “unfounded.” According to DCFS, the criteria for an allegation to be “unfounded” is that an investigator find the accusation to be 1) false 2) inherently probable to involve an accidental injury or 3) did not constitute child abuse or neglect. Moore was incarcerated at the time of her daughter’s death.

Adrian R.

Adrian, who was likely over 13, as he was on probation, died after taking 300 pills prescribed to his grandmother for her gout. Adrian’s father had three separate allegations of physical abuse and was also enrolled in Voluntary Family Maintenance classes.4 After Adrian’s father completed the VMF classes, a call came into DCFS saying that Adrian’s father continued to beat Adrian. Though Adrian showed physical marks of abuse, all three allegations against his father were listed as “unfounded” based on Adrian’s father’s denials.

Abigail Morales

Abigail was removed from her parents’ care shortly after she was born, due to malnutrition and inadequate weight and height caused by parental neglect. Abigail lived with a relative for two years before DCFS returned her—along with two siblings, both under 5—to her parents.

Abigail’s father, Michael Lara-Morales had an active arrest warrant for failing to enroll in a 52-week violence prevention program—one of the terms of his probation. The couple had ongoing criminal proceedings that required them to be in jail on weekends for the next 11 months.

These crucial details only came to light after an investigationinto Abigail’s death. The DCFS employee in charge of her case left narrative sections blank and only checked required boxes. In the months following Abigail’s return, her mother, Miriam Abrego told a Family Maintenance program worker that she had an “intense dislike” for Abigail, who was thirty months old at the time. The program worker reported this to DCFS but no action was taken. Later, the worker called the DCFS child abuse hotline directly when he discovered bruises on Abigail. The DCFS emergency responder did not interview Abigail’s grandparents, siblings, or daycare provider, all of whom could have provided details about Abigail’s parents. The case was closed. A month after the emergency worker’s visit, Abigail was in full cardiac arrest when her parents finally called 9-1-1, a full day after they had severely beaten her. When paramedics arrived at the couple’s home, they claimed Abigail fell. They had tried cover her bruises with blue paint. A few days later she was taken off life support and died at age 2. 5

Deandre Green

Deandre, age 2, was beaten to death by his mother’s 26-year-old boyfriend, Hector Ernest Jr. There were two open reports with DCFS on child abuse claims, filed just four weeks before the toddler’s death. One report came from Deandre’s biological father, who suspected Deandre’s mother and boyfriend were abusing the boy. Deandre’s father took him to a Hawthorne police station to show officers the bruises on his son’s body. Another hotline abuse complaint came from Deandre’s cousin. To determine if complaints that come in through the hotline have enough merit to them to launch a formal investigation into child abuse or neglect, the Emergency Service Worker must answer the following questions through interviews with family and others who have contact with the child: Did the alleged abuse/neglect occur? If so, what is the level of risk for the abuse/neglect to happen again? Is the child safe? If not, what needs to be done to ensure the child’s safety?

The Emergency Service Worker assigned to Deandre spent one month returning to the wrong address (eight attempts in 22 days), despite the department having the correct address on file. At the time of Deandre’s death no one from DCFS had made contact with him.

Amanda C.

Amanda was severely disabled. She suffered from a degenerative disease that depleted the white matter of her brain and a condition that enlarged her heart and liver. She was not receiving medical treatment for the latter condition. There were ten separate calls to the DCFS hotline about Amanda’s family—several regarding possible sexual abuse. Some of the allegations had to do with Amanda’s father: masturbating while watching Amanda’s sisters shower, as well as entering and leaving the girls’ bedroom at strange hours.The family was enrolled in a Voluntary Family Maintenance classes.

DCFS referred Amanda to a medical hub to be examined for sexual abuse. Medical hubs are healthcare programs co-administered by the Department of Health Services and DCFS. The hubs provide both routine examination of children in DCFS’s care and also conduct forensic interviews and examinations for open DCFS abuse cases. Social workers rely heavily on the reports of hub medical professionals—at times to detriment, according to the confidential report.6 The hub that Amanda was referred to refused to examine her for signs of sexual abuse unless or until she mentioned the abuse to a counselor. DCFS then closed Amanda’s case as “inconclusive.” Two years later, Amanda died. An examination of her body found that she suffered sexual trauma within 48 hours of her death.7 The coroner who examined Amanda’s body said she could have died from three things: cardiac arrest from her heart condition, the physiological stress and pain from blunt force sexual trauma, triggering an arrhythmia or a heart attack, or from being suffocated with a pillow.

Valerie Deras

Valerie, nine months old, was beaten to death by her father, twenty-year-old Jose Deras, during a fight with Valerie’s mother. At the time of her death there was an open DCFS investigation regarding injuries sustained by her two-year-old brother, Orlyn, who had a spinal fracture and a broken femur. His father claimed that Orlyn had slipped out of his arms while they were walking on a sidewalk. The medical staff believed Orlyn’s injuries were consistent with his father’s explanation. It took seven weeks for an emergency worker to initiate the request for a second opinion from the medical hub, and so the examination of Orlyn took place three months after his injury. Within three weeks of Orlyn’s examination at the hub, Valerie was murdered.8

The Blue Ribbon Commission is set to release their final recommendations in April.

Natasha Vargas-Cooper is a reporter in Los Angeles.