New York's child services agency reportedly failed to prevent the deaths of 2 abused kids

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Associated Press/John Minchillo

New York City Department of Investigation Commissioner Mark Peters listens during a round table conference with reporters at the Manhattan District Attorney's offices, Wednesday, July 2, 2014, in New York.

Two New York children died of neglect and abuse because the city's Administration for Child Services (ACS) demonstrated "systemic" failures in protecting their well-being, a Department of Investigation report has determined.

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The report, released Tuesday, outlined allegations of missteps and systemic deficiencies in the child-welfare agency's operations.

Some of those include failing to follow basic protocol, conducting inconsistent investigations, and failing to identify signs of neglect, repeated abuse, and food deprivation.

"On several occasions ACS and its provider agencies failed to take necessary steps to protect children and at times may actually have put them in harm's way," the department's commissioner Mark Peters said in a release.

"Equally troubling, data obtained by the DOI suggests that these are not isolated instances and that ACS may have repeatedly failed to meet legal and procedural requirements," he said.

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The 18-month investigation concentrated on three children, who were identified only by the pseudonyms "Chris," "Morgan," and "Alex" to protect their identities.

The report concludes that in each of the three children's cases, the child-welfare agency had "multiple opportunities" to intervene in the situations, but didn't do so.

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Severely malnourished, life-threatening injuries

"Chris" nearly died from an injury inflicted by one of his parents, despite four previous ACS investigations into his living situation that were performed over the course of two years. Those investigations revealed increasingly severe physical injuries. The report found that ACS failed to follow its investigative procedures during that period, and didn't interview his friends, who knew he was being abused and starved at home.

The report says caseworkers assigned to Chris also grossly overestimated his weight, and didn't verify with a doctor whether his injuries were caused by accident, as his parents had claimed. The report found that the caseworkers didn't take proper investigative steps until Chris suffered a life-threatening injury - after which he was placed in foster care and his parents arrested.

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Chris is now living with a relative, and his siblings are in foster care while their parents' criminal cases are pending.

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Cocaine and death under "suspicious circumstances"

"Morgan" died "under suspicious circumstances" related to neglect, the report found. Morgan's cause-of-death could not be determined, but the report found that ACS had documented 11 instances of neglect on the part of Morgan's mother to her other children - including exposing them to cocaine - over the course of 12 years.

The report charged ACS with failing to identify the chronic neglect that persisted under the care of Morgan's mother, and the "uninhabitable" condition of her home. Morgan's siblings were placed in foster care after the child's death, but one child has since been returned to the mother and a court-ordered plan indicates that the remaining three siblings will be returned to her as well.

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"Excessive corporal punishment"

"Alex", a preschool-aged child, died after a severe beating from her mother.

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Similar to Morgan's case, ACS had been investigating Alex's mother for 12 years and had documented instances Alex was hit in the face to the point that it caused disfigurement.

The report also alleges inadequate guardianship and lack of medical care.

Alex and her siblings had been living in foster care for a time, but were ultimately returned to the mother, despite a pending investigation into instances of neglect.

ACS continued to receive reports that Alex's mother was mistreating her children, but determined that the allegations were "unfounded." After Alex's death, her mother was arrested and given a lengthy prison sentence.

No ACS workers have been arrested in connection with the DOI's May report. The department recommended that seven staff members be disciplined, but ACS is only pursuing a discipline process for one of them.

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Gabriel Fernandez

Multiple sources

Gabriel Fernandez

A nationwide problem

New York isn't the only city to document critical failures at child-welfare agencies that resulted in death.

Last month, two Los Angeles social workers and their two supervisors were arrested for falsifying reports that were supposed to document signs of the escalating physical abuse suffered by an eight-year-old boy, the Antelope Valley Times reported.

The child, Gabriel Fernandez, was allegedly beaten and tortured to death by his mother and her boyfriend.

The Los Angeles county district attorney alleged that the social workers in that case were "criminally negligent" and willfully disregarded Gabriel's well-being. The defendants could each receive up to 10 years in prison.

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