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On state's watch, 10 young lives lost
By CURTIS KRUEGER, Times Staff Writer PALATKA -- By the time Versena Phillips could say "Mama, Da-da," the signs that she lived in a troubled home were well known to the state's child abuse agency. Her mother lived through two house fires. There were three child abuse investigations. Allegations of drug use by her mother. A suspicious cut on the back of the child's tongue. And beneath her baby-soft skin, broken ribs -- no bigger than twigs -- lay waiting to be discovered. But doctors didn't find them. They might have, if the Department of Children and Families had scheduled a medical exam state law required. On Feb. 12, 2000, Versena ran out of chances. An ambulance was called to the Budget Inn in Palatka, where Versena was staying with her mother, her mother's boyfriend and four brothers and sisters. Versena was not breathing. "I just kept saying, "What's wrong with my baby?' I kept calling her name," her mother, 29-year-old Troilanda Phillips, recalled tearfully. The girl was dead. Authorities said she suffered "blunt trauma to the head." Police consider the death a homicide. Two years later, no one has been arrested. The state has taken away Phillips' other six children. An outside review team has found that the state bungled its oversight of Versena's case. And state officials say they have developed new procedures and technology designed to prevent catastrophes like Versena's. But that's what they've said before: Versena died after a 1999 state law enacted to make sure caseworkers don't miss signs of abuse. And she's not the only one. * * * When Gov. Jeb Bush and Secretary Kathleen Kearney took over the Department of Children and Families in early 1999, they vowed to improve the training, management and efficiency of the long-maligned agency. They say they have worked hard at these improvements, by increasing funding and bringing sophisticated computers on line to help track problem cases. But kids are still dying. The statewide Florida Child Abuse Death Review Committee found 60 children died from abuse or neglect in 1999 and 2000 even though DCF had previously taken a call about each child. Of those, the review identified 10 particularly troubling deaths. In each of them, DCF had provided "inadequate" response to the allegations. The implication: a better investigation or stronger response from DCF might have saved children's lives, at least in some cases. At the request of the St. Petersburg Times, the department for the first time released records about all 10 children who died after these "inadequate" investigations. The records show missed medical exams and sloppy procedures. They also show that some of the questionable DCF actions occurred before Kearney took over the agency in January 1999. In Versena's case, the agency later found its workers had: failed to notice prior abuse and neglect investigations; failed to get proper medical documentation; and overlooked possible cocaine use by a family member. Versena lived 11 months. But the state's missed opportunities stretch back years. * * * Before Versena was born in 1999, Troilanda Phillips lived with her other children in Ragsdale, a public housing complex that lies beneath towering pines in Palatka, about 40 miles east of Gainesville. DCF caseworkers first paid Troilanda Phillips a visit in 1996. Someone claimed that she had left her children unsupervised and that her boyfriend had tugged the ears of her oldest kids, who were 3 and 1. But "the investigation was superficial," the DCF's staff later concluded. Investigators spoke to family members just once. They never talked to the person who initiated the complaint. They failed to complete a basic document called a "risk assessment," which measures the threat to a child. Caseworkers learned that police had gone to Ms. Phillips' home twice for domestic violence complaints involving her boyfriend. And that wasn't the only hint of trouble. One day in September 1996, while Ms. Phillips was out, her apartment on Pineneedle Circle caught fire. Only a few days before, her boyfriend at the time -- the man who would later become Versena's father -- had been served with a domestic violence injunction. The fire marshal wrote: "Fire is possibly an arson, caused by girlfriend/boyfriend feud. Arguments and threats had been a daylong problem." The fire, with its overtones of domestic abuse, took place while DCF was in the middle of its child abuse investigation. But DCF closed the case "without resolution of issues that caused the report," the agency said later. * * * Early the next year, DCF visited again. Ms. Phillips had recently brought one of her children to the Health Department for a checkup. He was "dirty, inappropriately dressed and underweight" and getting behind in his shots. Health Department workers also speculated "that the mother could be using crack cocaine as she was observed to have a large blister on her lip that could have been from smoking crack, and that numerous people were observed to be in and out of the home." When DCF workers arrived at Ms. Phillips' mother's house, where the family was staying, "two of the children were observed outside with only tee shirts and diapers and no shoes," a DCF report says. It was January in North Florida. As DCF investigators arrived, Ms. Phillips and her mother were "picking up beer cans in the yard," records state. Ms. Phillips had never been charged with a drug offense, but DCF reviewers later criticized case workers for making "no documented attempts to resolve the issues of drug use" that some had claimed. The family history of domestic violence and several other safety-related issues were "not given proper consideration," DCF later concluded. Just as in the previous investigation, this one was closed in 1997 "without resolution of issues that caused the report." * * * Versena Phillips was born March 23, 1999. On Jan. 16, 2000, 10 months later, Ms. Phillips took her baby to Putnam Medical Center. She said she had noticed Versena had a cut on her tongue. The injury was considered suspicious in a baby with only two teeth. It led to the family's third abuse investigation. As DCF began again, workers didn't notice their past investigations. They said Ms. Phillips had "no priors." This led the workers to look at Versena's case differently. Children in homes with previous abuse investigations often are considered at greater risk. In riskier cases, DCF asks a judge to remove the child from the home. That didn't happen with Versena. Instead, workers referred Ms. Phillips to a parenting program called Family Builders. Versena's case was exactly what the Florida Legislature had in mind when it passed a 1999 law designed to remove the guesswork from abuse investigations. Alarmed that a 6-year-old Lake County girl, Kayla McKean, had been killed by her father despite previous signs of abuse, the Legislature passed a law that set up strict procedures. One of them was that state-funded Child Protection Teams should review all complaints phoned into the Florida Abuse Hotline, and decide which kids need medical exams. With Versena, the system worked, but only so far. When a call about Versena came into the hotline, the team saw Versena's name. They told DCF to set up an appointment. A DCF supervisor got that note, and transferred it to an investigator. But then DCF dropped the ball. For reasons never fully explained, the investigator never made the appointment. In medical exams like this one, doctors often do an X-ray and look over a "skeletal survey" of the child, said DCF spokesman Tom Barnes. If this had been conducted on Versena, he said, "It's reasonable to assume that those rib fractures would have been found and it's reasonable to assume that there would have been some sort of protective intervention that might very well have saved this child's life." Ester Tibbs, the department's district administrator for the North Florida region that includes Palatka, says "the most concerning thing that I remember about the case was if that case had been referred to the Child Protection Team as the supervisor directed that it be, then maybe this death could have been prevented." * * * The medical exam wasn't the only missed opportunity for Versena. Asked about prior drug use, the workers said "none," even though health workers had previously suspected the mother was using cocaine. And on Feb. 1, two weeks after the child abuse investigation case began, Ms. Phillips and Versena appeared on the front page of the Palatka Daily News. The article told how a fire had driven the family from its home. It was the second apartment fire for Ms. Phillips in Ragsdale. Palatka Fire Marshal John Holley recalls that local kids claimed one of Ms. Phillips' children had started the blaze. Holley gave the boy a lighter and asked if he knew how to use it. "He knew just exactly how to do it," Holley said. "The kid was 4 or 5 at the time." That wasn't enough for a firm conclusion. His report lists the fire's cause as unknown, but notes that it "could have been started by a child playing with a lighter or matches." But the front-page news did not seem to make a difference in DCF's investigation of Versena. All of the children stayed with their mother as she and her boyfriend found a room at a Budget Inn, with help from the Red Cross. * * * Victor R. Hill, 29, is a friendly masonry worker and sports lover who had never been a father figure. Until he began dating Ms. Phillips. Her other boyfriend -- the father of Versena -- was out of the picture, serving a 15-year prison sentence for burglary to an occupied dwelling. By the fall of 1999, Hill was part of the family that included Versena and five children. Versena was not his daughter, but he loved to care for her, Hill says. "She had just started calling me Da-da, for real. Four times." On Feb. 12, 2000, the family went to Hill's mother's house so Ms. Phillips could braid her mother's hair. Hill was holding Versena while Ms. Phillips braided, she said. Later, back at the Budget Inn, she took her baby and noticed she wasn't moving. "It's like I was in a whirlwind," Ms. Phillips recalled somberly. "I just couldn't believe that, you know, my baby wouldn't respond to me." "Losing a child is like losing your heart," she added. "And my life has been -- sometimes I just have to pray to God, help me." The medical examiner made a firm conclusion about how to classify this death: homicide. Palatka police began investigating, and their main suspects -- Hill and Ms. Phillips -- agreed to talk. "We're talking about hours and hours and hours of interviews," Lt. James Griffith said. But neither one admitted hurting Versena. And neither one accused the other. "There's nothing to indicate how this happened. It's very frustrating," Griffith said. " ... the only thing you've got to go on at this point is what the people tell you. And unfortunately we're not getting enough information there to paint the picture." Hill said it was disturbing to be interrogated by police, especially when it was "almost like they (were) pointing the finger at me." "I'm a lot of things, man, but I'm not like that." * * * DCF administrators say they are constantly trying to improve their training, staffing and technology to prevent flawed investigations like the ones involving Versena. They are excited about a new computer system they say will allow them to spot problems, such as a medical exam that never gets scheduled, while the case is being investigated. In Versena's case, the investigator who failed to set the medical exam has been demoted and works in an office that determines whether people are eligible for welfare. The supervisor quit. The Palatka Police Department's homicide case remains open. In the intervening two years, Hill and Ms. Phillips have split up and have lost some of their reluctance to talk about each other. When a reporter asked Hill how Versena died, he didn't answer directly. He hinted. "You can live with somebody for a long time, but that doesn't mean you know them," he said. Ms. Phillips was more direct. She said she has concluded Hill, her former boyfriend, was responsible. She would like to ask the police chief: "What is they going to do? Why haven't they did something with this person for what he did?" She said she wonders "how a person could actually do anything like that to a child ... he knows how crazy I was about my kids. He knows my kids loved me. But I have learned you cannot trust everyone around your children." In the meantime, she said, she is trying to cope. Ms. Phillips, who is 29, has given birth to seven children. Four were born before Versena, two after. She is not allowed to see them. The state has terminated her parental rights for five of the surviving children, and it is trying to do the same with the sixth, she said. She divides her time between her mother's house in Palatka and a beige-colored shack made of crumbling wood and surrounded by weeds. "I pray every day," she says. "I have the preacher to pray for me. I write this Christian place and I ask them to pray for me and my kids. And I ask the pastor to pray for me and my kids to be together, and make sure that they're all right." And Versena. She still thinks of Versena. "She was so sweet. She was just a little baby." -- Times researchers Caryn Baird and Kitty Bennett contributed to this story. Staff writer Curtis Krueger can be reached at krueger@sptimes.com or by calling (727) 893-8232.
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From the Times state desk
From the state wire
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