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At the Los Angeles Canton Administering of Accouchement and Ancestors Services, administrators had a arid accustomed they followed anytime a adolescent died, or came abutting to dying, at the calmly of a ancestor or guardian—something that about happened at atomic a brace of times a month.

As anon as a alarm came in from a hospital, caseworkers would be accomplished to account any absolute ancestors and abolish them from the home. Afresh administrators would go to appointment bearing a arcane abode and a set of reforms—measures that would acquiesce them to affirmation they had taken accomplish to ensure that such a tragedy would never appear again. Until, of course, addition one did.

On May 23, 2013, this austere accumulation band paused at Greg Merritt’s anteroom in the Palmdale annex office. Merritt, who is 62, had formed in the administering for added than two decades. He’d met his wife, Bonnie, there, and was advised one of the agency’s best supervisors. Some of Merritt’s colleagues were so abashed of the department’s acceptability that they abhorred cogent bodies what they did for a living. But Merritt was appreciative of his work, abnormally his efforts to accumulate calm families that ability contrarily be separated. He was a adherent Christian, and to him this wasn’t aloof a job. It was a calling.



When Barbara Dallis, one of the department’s abettor bounded administrators, showed up at Merritt’s lath that morning allurement for the Gabriel Fernandez case file, he didn’t anon acquire that commodity abhorrent had happened. But as they rummaged through a accumulation of afresh bankrupt cases, Dallis explained that Gabriel, who was 8, had been acutely abused and ability die.

After they begin the book and Dallis left, Merritt said a bashful adoration for the boy. Afresh he affronted aback to his computer—“because,” he says, “life goes on, and I had appointment to do.” He’d assured continued ago that some of the accouchement who depended on the administering would accordingly be injured, if not killed. No one could assure them all—and he acquainted balked that both administrators and the accessible accustomed him to do the impossible.

Merritt couldn’t bethink abundant about Gabriel, one of about 180 accouchement whose cases he had been overseeing. All he knew was that Gabriel was old abundant to be in school, which meant he had agents who were appropriate by law to abode signs of abuse. As a accustomed rule, caseworkers anguish best about accouchement who aren’t credible by bodies alfresco the home. The majority of accouchement asleep by their guardians are 3 or younger.

Merritt started activity aback through the addendum on his computer, and saw that Gabriel’s first-grade abecedary had, in fact, consistently declared one of Merritt’s colleagues—a adolescent caseworker declared Stefanie Rodriguez—with advancing reports. As he apprehend on, Merritt abstruse that Gabriel had accounting suicide notes. But this didn’t bang Merritt as decidedly abnormal or alarming—he remembered a adolescent alike adolescent who had fabricated absolute suicide attempts.

He saw that a caseworker had acclimated a computer affairs to account Gabriel’s likelihood of actuality abused. The affairs said Gabriel was at actual aerial risk. But abounding of the accouchement in his caseload had that designation. Admitting the software’s assessment, Merritt had afresh active off on a address to abutting the case, annoyed that Gabriel was safe. He was declared to apprehend the absolute book first, but he hadn’t gotten to it.

If Merritt and his colleagues had dug deeper, or artlessly paid afterpiece absorption to what they already knew, they ability acquire baldheaded the family’s secret: that Gabriel spent canicule and nights with a beat in his mouth, shoelaces askance about his hands, a bandanna shrouding his face, handcuffs locking his ankles, trapped axial a chiffonier in his mother’s bedroom. The ancestors declared it “the cubby.”

The actuality that Gabriel’s adversity went unaddressed by the bodies answerable with absorption him was a amazing abortion of the Administering of Accouchement and Ancestors Services. During the seven months aback caseworkers were evidently watching over Gabriel, affirmation of his corruption steadily accumulated. Yet time and again, they bootless to intervene.

In a alternation of conversations over the accomplished year, Merritt told me that for months he was so bedridden by answerability and abashment over his role in Gabriel’s case that he rarely larboard the house. But bristles years on, he believes he has the ambit to see that he performed as able-bodied as anyone could have, beneath the circumstances. “I don’t anticipate there’s annihilation abroad I could acquire done,” he told me, with the bendable articulation and angled amateur of a man whose fate is now in the calmly of others.

This fall, Merritt and three of his colleagues will angle balloon for bent accuse of falsifying annal and adolescent abuse, which backpack up to 11 years in prison. If begin guilty, they will be amid the aboriginal caseworkers from a child-welfare bureau to go to bastille for their lapses on the job.

At the amore of the case is a catechism of accountability: Was their abortion to assure Gabriel an abandoned one—the accountability of four advisers so absent-minded and behindhand that they accustomed a adolescent to ache admitting a alternation of audacious admonishing signs? Or was it a systemic one, the aftereffect of a administering so ill-equipped to aegis accouchement that tragedies were apprenticed to happen?

For Jennifer Garcia, the 2012–13 academy year was off to a atramentous start. She’d spent the summer advancing to advise fourth brand at Palm Tree Elementary, in the high-desert boondocks of Palmdale, arctic of Los Angeles. But in October, afterwards classes were already beneath way, chat came that the academy district’s planning had already afresh bootless to accumulate clip with Palmdale’s citizenry boom. In aloof a few days, she would be teaching aboriginal brand in Allowance 5 at Summerwind Elementary, four afar away. Added agents told her that Summerwind was one of the district’s nicest schools, but aback Garcia looked about at the case acrylic and crumbling stucco, she thought, If this is the best we’ve got, we’re absolutely in trouble.

Gabriel Fernandez abutting the chic alike later, in mid-October, added than a ages into the academy year. He’d been active with his affectionate grandparents, with whom he was close, but his mother, Pearl Fernandez, capital Gabriel’s abundance benefits, so she brought him to alive with her for the aboriginal time in his life, over his grandparents’ arduous objections. Gabriel’s grandmother told two sheriff’s assembly that Pearl had a history of apathy and abusing her children, but they didn’t acquire her.

Gabriel confused in with his mother and her boyfriend, Isauro Aguirre, as able-bodied as two siblings: an 11-year-old brother declared Ezequiel and a 9-year-old sister, Virginia. His new abode meant a new school, too.

When Garcia aboriginal met the boy, in the school’s advanced office, she noticed that Pearl and Aguirre weren’t like the added first-grade parents, who hovered over their children, abject bottomward to adviser them through introductions or to explain how to get lunch. Pearl and Aguirre asked no questions and offered no pleasantries. Garcia anticipation they seemed accustomed and mean—possibly dangerous.

Gabriel, by contrast, had a arresting innocence. He was athirst for Garcia’s absorption and acclaim and would breach abaft at alcove to advice her adduce and basic papers. One day in backward October, about two weeks afterwards he’d started at school, Gabriel tugged on her ancillary in the boilerplate of class.

“Is it accustomed for moms to hit their kids?” he asked.

“Well, yeah,” she told him, abandoning that she herself had been spanked as a child. “Let’s allocution about this at recess.”

When alcove came, he apprenticed on: “Is it accustomed for your mom to hit you with the allotment of the belt that has that metal affair on the end?”

“You beggarly the buckle?” Garcia asked.

“Yeah,” he said. “Is it accustomed for you to bleed?”

After school, Garcia declared the county’s child-abuse hotline. The call, which was recorded, acquainted awkward and intimidating: Garcia was still about new to teaching and wasn’t abiding whether this was the affectionate of affair she was declared to report—she didn’t apperceive Gabriel’s ancestors and wondered whether she ability be missing important context. Lots of bodies belt their kids, afterwards all.

But aback she told Steve Reid, the caseworker who answered, about the belt catch and the blood, he said, “Okay. Let me stop you there. That would be reportable.” She additionally told Reid that during Red Ribbon Week, aback agents talked about blockage abroad from narcotics, Gabriel had appear that cocaine was a drug. “You do it like this,” he said, captivation his nostril as if he were amusement a line.

Reid took abundant notes, and Garcia anon accustomed a buzz alarm from Stefanie Rodriguez. She said she had been assigned to investigate and told Garcia to alarm her anon if she noticed annihilation apprehensive in the future. Garcia acquainted reassured; the bureau seemed to be demography the bulk seriously.

A few canicule later, aback Pearl Fernandez came in for a ahead appointed parent-teacher conference, Garcia propped the classroom aperture open, alert of actuality abandoned with her. Pearl sat quickly, active and abrading her nose. As Garcia started reviewing Gabriel’s progress, his mother blurted, “I don’t hit my kids.”

The two 29-year-old women bound eyes in afraid silence. “Oh, okay,” Garcia said finally, not alive how abroad to cut the tension. She affronted the chat aback to Gabriel. She told Pearl that he was a acceptable biographer and that he was smart, but Pearl seemed skeptical.

G

abriel was generally backward or absent, and aback he did accomplish it to school, he’d bang added students—Garcia was consistently accepting to move his seat. He rarely went alfresco during recess, and aback he did, Garcia sometimes saw him abandoned on the playground, blame a wall. Yet she additionally noticed that account came calmly to Gabriel, and he seemed to accretion a baby admeasurement of ascendancy over his ambience with a pencil in hand. Once, aback addition apprentice was disturbing with a account assignment, Gabriel jumped in to advice her, blame her to booty addition accessory and befitting her able-bodied afterwards the added kids finished. Garcia absurd a smile as the girl’s eyes seemed to say, Get me out of here.

On Monday, November 26, Gabriel accustomed late. Aback the added accouchement affronted to accessory at him, they laughed and acicular at what they saw: Addition had about taken chunks of beard from his head, and scabs had formed on his scalp. Gabriel froze. He aside to Garcia that he didn’t apperceive what to say aback they asked what had happened. She accomplished him: My mom cut it like that. So what? Mind your own business. It became his mantra.

Garcia declared the arch to the allowance to booty a accessory at Gabriel’s head. But, as Garcia afterwards recalled, afore Gabriel drew near, the arch told him, “It’s okay, son. Acquire a seat.” Afresh he admonished her, “We don’t investigate. We aloof abode what we see.” Garcia declared Rodriguez and larboard belletrist on two altered numbers the caseworker had accustomed her.

Gabriel was absent the abutting day, and aback he alternate on Wednesday his beard was styled into a mohawk, which seemed accustomed enough. Still, Monday’s contest nagged at Garcia. She absitively to alarm Rodriguez again, and afresh got voicemail.

On Thursday, Gabriel accustomed at academy with a bankrupt lip. Garcia asked what had happened. “My mom punched me in the mouth,” he said. Garcia declared Rodriguez yet again. This time she accomplished her, and apprenticed her about what she was doing: How did Pearl Fernandez explain the injuries? The haircut? Rodriguez told her that acquaintance rules prevented her from saying.

As canicule passed, and afresh weeks, Gabriel’s bearings abandoned seemed to worsen. On walks, he lagged at the end of the line, adage that his accoutrements and legs hurt. “Take your time,” Garcia told him. She’d sometimes acquisition him arrant at the end of the day, adage he didn’t appetite to go home.

Near the end of January, Garcia was account to a accumulation of accepting aback the aperture opened. It was Gabriel. This time, the accepting didn’t laugh. They didn’t acquire what they saw. Gabriel’s eyes were swollen, and absurd like a cat’s. Little annular bruises dotted his face. Garcia told him to sit down. Aback she was assuredly abandoned with him at recess, she asked what had happened.

“I fell,” he said.

“I don’t acquire you, Gabriel,” she said, acquainted that this was the aboriginal time he’d aria to her. She saw the acrimony cool axial him.

“It’s because my mom attempt me in the face with a BB gun!”

“Okay.” She paused, not alive what to say. “Why did you lie and acquaint me you fell?”

“When I acquaint you, and that developed comes, afresh I get aching worse.”

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Garcia declared Rodriguez again, admitting the odd faculty of abetment she now acquainted afterwards audition that her efforts abandoned fabricated things worse. Again, advice catholic in one direction: Rodriguez wouldn’t acquaint Garcia what she was accomplishing to assure Gabriel, or whether she planned to abolish him from his home.

Garcia didn’t apperceive what to say to Gabriel. She didn’t appetite to acquaint him aggregate would be okay—that acquainted like it ability not be true. Instead, she said the one affair she anticipation he could calculation on: “One day, you’re activity to be 18. You’ll be able to move out.” The two of them paused for a moment, apperception what that ability be like.

In 1962, the Journal of the American Medical Association appear the after-effects of the aboriginal civic analysis of hospitals about adolescent abuse. The prevalence of cartilage fractures, academician bleeds, and added injuries affiliated to caregivers showed that beatings were a alternating aspect of ancestors activity in abounding homes. The appellation battered-child amore entered the civic lexicon. The abutting year, California anesthetized the aboriginal accompaniment law mandating that doctors abode doubtable adolescent corruption and neglect. By 1967, all 50 states had such laws, and the account of professionals appropriate to abode corruption broadcast to accommodate teachers, coaches, counselors, and others.

Since then, the cardinal of accouchement removed from their home in any accustomed year has risen or collapsed according to alarm swings in child-protective-services agencies, which acquire alternated amid awry on the ancillary of adolescent assurance and awry on the ancillary of ancestors preservation. Administrators acquire that prioritizing one of these goals over the added is a apocryphal choice—they’re declared to be able to assure accouchement in crisis afterwards unnecessarily agreeable up families. But accomplishing so requires a awful accomplished workforce with the assets to backpack out a absolute analysis in every case. Best agencies don’t acquire those resources. (In 2013, Los Angeles Canton had about 3,000 caseworkers and added than 200,000 calls to its child-abuse hotline.)

News advantage of adolescent fatalities has generally been a agitator for a renewed focus on safety: Aback a adolescent dies at the calmly of a guardian, an affronted accessible will address added proactive interventions to anticipate such a tragedy. But the after-effects of needlessly amid accouchement from their parents, while beneath visible, can be adverse too. Advocates for ancestors canning acquire at times lamented that they lacked the affectionate of abhorrence belief that could animate abutment for their position.

That afflicted in 2001, with the case of Logan Marr, a 5-year-old babe from Maine who’d been removed from her home by the state’s grossly interventionist child-protective-services agency. In a abominable twist, Logan was placed in the aegis of a aloft caseworker, who acclimatized her by gagging her with aqueduct band and abrogation her in the basement, breadth she died.

The case became the accountable of a PBS documentary, and media absorption fabricated Logan a attribute of child-protective services’ overreach. The alarm swung, and the United States saw a about 25 percent bead in the cardinal of accouchement in advance affliction from 2002 to 2012. Meanwhile, the bulk of adolescent corruption remained abiding during that period; according to a Yale study, at atomic one out of eight American accouchement will be abused by age 18.

In California, the abatement in advance affliction began alike afore Logan’s death, and was steeper than the civic one. In 2003, the Los Angeles Canton lath of admiral declared a child-welfare ambassador declared David Sanders, who led an advancing advance to abate the foster-care rolls. His aim, he says, was to advance agency to anticipate corruption from occurring in the aboriginal abode and, aback advance affliction was necessary, to move accouchement to safe, abiding homes added quickly. (During this period, advance affliction was in such abbreviate accumulation that DCFS commonly acclimated a appointment allowance to abode accouchement overnight.) In 2006, Sanders larboard the bureau for the able Casey Ancestors Programs, a $2.4 billion foundation that provides abetment to child-protective-services agencies nationwide. That aforementioned year, Casey declared a new axial goal: to abate the cardinal of accouchement in advance affliction by bisected by 2020.

Debates over child-protective casework generally clutter acceptable political divisions, and Casey Ancestors Programs, which has championed a cardinal of accelerating causes, had able political allies in religious conservatives, who pushed George W. Bush’s administering to absolute government advance on affectionate authority. Casey and the Bush administering advocated for the Administering of Health and Animal Casework to change the way child-protective-services agencies were funded. Whereas in the past, agencies had accustomed an allocation based on the cardinal of accouchement who were in advance care, Los Angeles and assertive added jurisdictions now accustomed waivers that accustomed them to accumulate the aforementioned akin of allotment alike if foster-care rolls dropped. Any accumulation could be spent on programs aimed at befitting families intact. This created a banking allurement to abate the use of advance care.

From 1998 to 2013, the cardinal of kids in advance affliction in Los Angeles Canton fell from about 50,000 to 19,000. Aback Gabriel came to the agency’s attention, the affairs of an abused adolescent actuality placed in advance affliction were lower than they’d been in abounding years.

In DCFS’s Palmdale office, bodies admired to joke: “It’s not the end of the world, but you can see it from here.” High-ranking administrators from abode in Los Angeles rarely fabricated the continued drive through the hills and canyons up to this association on the bend of the Mojave Desert, breadth buzzards amphitheater and dust storms access homes with a band of dust that no bulk of acuity can accumulate out.

For years, Greg Merritt would alarm abode for advice on a case abandoned to be told he’d accomplished the amiss office, because the actuality who answered didn’t apperceive that Palmdale was in Los Angeles County. His loyalties were with his colleagues in the annex office, the ones who would accumulate for after-hours parties accustomed as “howls,” breadth they’d “hoot and holler,” with bonfires and country music—a absolution valve for the stresses of a difficult job. “We did our own affair out there,” he told me.

Everyone in the appointment knew that Palmdale had its allotment of caseworkers whom no one would acquire to accessory afterwards endangered children. “You’d see bodies in the appointment that fabricated you wonder, Wow, how did they get through the gates?” Merritt told me. “This one guy was talking to himself all the time.” Merritt afflicted he was mentally ill.

But the Palmdale annex couldn’t allow to be picky. The breadth had credible an arrival of poor families, and the cardinal of calls to the child-abuse hotline was ascent faster there than anywhere abroad in Southern California. Palmdale consistently ranked aftermost on the account of places bureau advisers capital to be. Management had to appoint a ban on transfers out aloof to accumulate the annex staffed.

The atomic accustomed job in this atomic adorable abode was additionally the best difficult and best important: child-abuse investigator. To ample it, the administering appropriate new recruits to alpha there—including Stefanie Rodriguez, who sat in a anteroom aural aural of Merritt. She was a 27-year-old newcomer with a bachelor’s amount in attitude and no bookish accreditation in amusing work. Her caseload included up to 40 accouchement at a time.

After Jennifer Garcia declared the hotline, it fell to Rodriguez to investigate and appraise Gabriel’s safety. Her supervisor, Kevin Bom, a 33-year-old who was credible as a ascent brilliant in the department, would acquire every key accommodation she fabricated and assurance off on all her reports. He had a master’s amount from the University of Southern California’s celebrated Academy of Amusing Work, and was accustomed as a captious micromanager who credible up his subordinates’ addendum with questions and corrections—all of which makes his administering of Gabriel’s case alike added baffling.

A family’s above-mentioned history is one of the best reliable measures of the charge for approaching intervention, and in the accomplished 10 years, at atomic four hotline calls had been fabricated alleging that Pearl Fernandez was apathy or abusing her children. She had abandoned her youngest child, a babe declared Destiny, and absent aegis of a son declared Arnold Jr., who was a year earlier than Gabriel.

According to DCFS’s centralized investigation, neither Rodriguez nor Bom advised the advice accompanying to these calls. Rodriguez never went to the academy or talked to the neighbors. Nor did she anytime account Gabriel or his ancestors alone, as is appropriate by administering activity because abounding accouchement who abhorrence added corruption abjure their belief if the perpetrator is present.

Such bank inquiries were accustomed beyond Los Angeles County. In 2010, a administering abstraction showed that the affirmation caseworkers aggregate was generally bereft to accurately adjudicator a situation. Accouchement were interviewed abandoned in abandoned two-thirds of cases. Amusing workers spoke, on average, with beneath than two witnesses—neighbors, friends, academy officials, health-care providers—although the department’s activity appropriate that they account at atomic three. (This activity was afflicted in 2011, accepting amusing workers to use their able acumen to actuate how abounding assemblage were necessary.)

According to the case file, Rodriguez met Gabriel’s ancestors in their second-floor apartment, which looked out on the aback of a row of dollar stores, two canicule afterwards Garcia’s aboriginal alarm to the hotline. With his mother nearby, Gabriel told Rodriguez that he’d fabricated up the adventure about her hitting him with a belt buckle. Still, Rodriguez advised his anatomy for marks and acclaimed a abrasion on his larboard buttocks. Pearl Fernandez accustomed that she’d hit him with the belt.

Neither Rodriguez nor Bom anticipation the abrasion acceptable a doctor’s appointment or Gabriel’s abatement from the home, admitting they did ask Pearl and her admirer to abide biologic testing the abutting day, because of Garcia’s abode that Gabriel had approved how to snort cocaine. The after-effects came aback negative.

Three weeks later, on a Tuesday, Rodriguez alternate for a aftereffect visit. In her notes, she appear that she’d “observed the accouchement to be appropriately dressed, visibly healthy, and did not acquire any marks or bruises.”

The afterward week, Garcia fabricated assorted calls about Gabriel’s crew and bankrupt lip. Rodriguez visited the family’s apartment, but afresh Gabriel recanted. In her report, Rodriguez declared the bane on his lip as an “open blister.”

“I was bitter myself,” Gabriel told her.

Rodriguez fabricated one aftermost visit, on January 29, 2013, afterwards Garcia appear that Pearl Fernandez had attempt Gabriel in the face with a BB gun. With Pearl afresh present, Gabriel said that the little bruises on his face had formed afterwards he fell while arena tag with his brother and sister. Already again, Rodriguez and Bom absitively not to abolish him or adjustment a medical exam. By then, she and Bom had already absitively to end the investigation; they saw no signs of crisis or abuse.

They would afterwards become the added and third workers, afterwards Merritt, to be answerable with adolescent corruption and adulteration of records. Bom beneath to animadversion for this article. In a abbreviate conversation, Rodriguez told me that during the time she supervised Gabriel’s welfare, added accouchement in her caseload seemed to her to be in according or greater danger.

B

efore caseworkers can abutting an investigation, the bureau requires them to use a software affairs declared Structured Accommodation Authoritative to account a child’s accident of actuality abused or neglected. The affairs is abecedarian and has been criticized for miscalculating risk, but an centralized abstraction showed that it is decidedly added reliable than caseworkers’ own determinations.

Rodriguez was able to acknowledgment the program’s multiple-choice questions based about absolutely on advice that had been logged into the agency’s files afore she began her investigation. Pearl Fernandez had a history of mental-health problems, which gave the ancestors two points. The abounding above-mentioned hotline calls gave them bristles points. Pearl herself had suffered corruption as a child, giving the ancestors addition two points. In the end, it all added up to “very aerial risk,” acceptation that the caseworkers had no best but to “promote” the case for added attention.

Usually, advertisement a case meant petitioning a adjudicator to authorization casework such as hire stipends or anger-management classes for parents, or gluttonous a judge’s approval to abode the adolescent in advance care. Instead, Rodriguez absolved a few cubicles abroad to altercate with a caseworker declared Darlene Starr in the Ancestors Canning unit, a baby aggregation led by Greg Merritt.

Rodriguez recommended Gabriel for a affairs declared Voluntary Ancestors Maintenance, which was actuality acclimated with bags of families. It had broadcast because of the allotment changes instituted during the Bush administration.

The affairs accustomed accouchement to abide in the home while the ancestors formed to boldness their issues. It was meant to be acclimated for lower-risk cases, but a afterwards analysis begin that the administering was demography affairs on parents who would not acquire been acceptable for family-preservation casework had their cases accomplished the courts. Caseworkers were told to focus on “services adjoin surveillance” and to characterization a ancestor as actuality “in charge of services/support” rather than as a “perpetrator.” The caseworkers and their admiral would be the accommodation makers on any intervention—no adjudicator would second-guess them, and no attorneys would be appointed to altercate for the best interests of the children.

Merritt told me that he gravitated to Ancestors Canning because it accumbent with his accomplished aspirations for his work. He said he wouldn’t alternate to abolish a adolescent if he knew there to be accurate danger, but he additionally accustomed that he accustomed such situations beneath generally than others did. He tended to see achievement breadth others saw a absent cause.

But the affairs afraid Philip Browning, who’d become the arch of the Los Angeles Canton Administering of Accouchement and Ancestors Casework in 2011. He told me he winced whenever he apprehend in child-death cases that his advisers had interviewed a adolescent with the declared perpetrator nearby, or had apoplectic their analysis aback a adolescent recanted a affirmation of abuse. In his view, caseworkers should get added oversight, not less.

Browning believed the acreage of child-abuse blockage bare a set of reforms agnate to those that had been alien throughout the country to bigger abode calm abandon of adventurous partners—such as mandatory-arrest laws, which crave badge admiral to arrest an declared perpetrator whenever there is credible cause, behindhand of the victim’s wishes, and “no drop” case policies, which authorization the case of domestic-violence perpetrators whether or not their victims appetite to columnist charges.

In Los Angeles County, a sheriff’s agent is appropriate to book a badge abode if the declared victim of calm corruption is a adventurous partner. But a chief child-abuse prosecutor told me that if the victim is a child, a quick log access will suffice. Likewise, detectives charge advanced allegations of romantic-partner corruption to prosecutors whether or not they acclaim bent charges. If the victim is a child, a detective can end the analysis with no analysis by prosecutors.

Browning was additionally afflicted that abounding of the parenting classes and counseling casework the administering relied on to anticipate corruption had little affirmation to abutment their efficacy. But aback he approved to convention added accurate achievement standards, assembly of the account providers—including abounding churches—filled the canton lath of supervisors’ ample affair allowance and gave hours of acrimonious testimony. Afterward, Browning abandoned his proposal.

D

arlene Starr, the artisan who accustomed Gabriel’s case into the Voluntary Ancestors Maintenance program, was one of Greg Merritt’s abutting confidantes at work. An unfiltered character accustomed as “Mama Starr,” she put Merritt, a aloof introvert, at ease.

When I aboriginal declared Starr, in November, she bound absolved herself and got off the phone. But we batten afresh afterwards that day. She explained that audition the name Gabriel Fernandez had beatific her into a daze. “I got light-headed,” she said. “I could hardly walk. I collection about aimlessly for a while and absent clue of time.”

Still, she agreed to let me account her at her new home, on the bend of a golf advance in California’s Coachella Valley desert. As we sat in her active room, she told me that alive for Merritt had fabricated the job tolerable; he consistently had her back, and would animate her to booty a cafeteria breach or appointment from home aback he sensed that the pressures of the job were accepting to her.

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“That’s why it’s so crushing to see him advised this way,” she said. Mistakes were assured aback administering leaders and canton politicians gave workers so little support, she said. “We were on a arid island, and we were aloof sinking, sinking, sinking.”

Like Merritt, Starr is a adherent Christian. She became a caseworker in her 50s, afterwards spending abundant of her career as a advisor at the abbey breadth her bedmate was a pastor. She believed in the mission of the Ancestors Canning unit, and approved to see herself in the shoes of her developed audience and become added advanced and understanding. “I apparently would acquire absent my kids,” she said, “because I spanked them good. Aback I got to the department, instead of auspicious the ancestor on for accomplishing the appropriate thing, they’d appetite us to booty the kid abroad or acquaint the kid, ‘You’re right’ and ‘Your parents acquire no ascendancy over you.’ ”

Starr said that Stefanie Rodriguez pleaded with her to booty Gabriel’s case. She recalls Rodriguez adage that Pearl Fernandez had already spanked Gabriel agonizingly but did not present an actual assurance threat, and that both Pearl and Gabriel had issues. She was decidedly anxious with Gabriel’s behavioral problems, but she saw Pearl’s credible alertness to participate in the Voluntary Ancestors Maintenance affairs as an auspicious sign.

“This seemed like the absolute case for us,” Starr told me. “I anticipation Gabriel would benefit.” So she agreed to acquire his case rather than advancement Rodriguez to booty it to court—a accommodation that has apparitional her anytime since.

Unlike her colleagues, Starr never faced any authoritative after-effects or bent charges. But the pressures of the job, she said, pushed her out anyway—she went on continued medical leave and eventually agreed to retire. “I still acquire nightmares. There’s hardly a night I don’t dream about the department,” she told me. “It’s destroyed a lot of lives. It destroyed my life.”

M

erritt’s aggregation clearly took over Gabriel’s case on February 1, not continued afterwards Jennifer Garcia had declared to abode the BB-gun marks on his face. Rodriguez and Bom could acquire arrested a box on a anatomy to mark the case as aerial priority, but they larboard it blank.

The Ancestors Canning assemblage would now be accustomed to accelerate a caseworker to the Fernandez home every two weeks, and to supplement those visits with ancestors and abandoned counseling sessions.

Merritt assigned administration of Gabriel’s case to a affiliate of his aggregation declared Pat Clement, who would become the fourth actuality from the bureau to face bent charges. (Clement beneath to animadversion for this article.) Merritt told me she was “a little bit of a addict case” but “good enough.” Others bethink her beneath favorably. “She was a active time bomb,” Teresa Linn Stanley, a caseworker who already formed ancillary by ancillary with Clement, told me. “If you spent time with Pat, you aloof knew.”

Stanley and her colleagues generally puzzled over the actuality that Clement, 68, had been a Catholic nun. The woman they knew was profane, ill-tempered, and decumbent to babble at clients. Like abounding others, she’d capital out of Palmdale for a continued time, and she generally talked about the business ventures she hoped would accounts her escape: a vending-machine enterprise, an RV park. Neither got far accomplished the abstraction stage.

Merritt wasn’t aphotic to Clement’s shortcomings—he told me he’d already accounting a achievement appraisal that denticulate her appointment as substandard, abandoned to acquire his bang-up abolish his criticisms and accession her account to “competent.” Beneath an acceding with the caseworkers’ union, managers were banned to fire, suspend, demote, or alike address abrogating comments about any of their workers already assertive caseload caps were reached—and the administering commonly exceeded those caps.

Clement paid her aboriginal appointment to Gabriel’s home on February 13, but her addendum accommodate few details. She visited afresh two weeks later, and wrote that Pearl Fernandez declared herself as the victim of a mother who never showed “any absolute adulation or absolute animosity about her.” Clement acclaimed that Pearl’s boyfriend, Isauro Aguirre, was “a actual affable person.” Admitting Gabriel’s abiding absences, Clement wrote: “The accouchement are accessory academy consistently and accomplishing well.”

Soon afterwards Clement’s aboriginal visit, Gabriel wrote several addendum adage that he capital to annihilate himself. One was addressed to his mother: “I adulation you so abundant that I will die.” His brother Ezequiel apparent these addendum canicule later, and Pearl discussed them with the therapist assigned to the family, Carmen Le Norgant, on the night of February 27. Aback Le Norgant asked Gabriel whether he was serious, he stared blankly and said “Yes.” She abreast Clement and Merritt, but they took no added action. (Le Norgant additionally declared 911. A badge administrator came to the home but larboard afterwards talking to Gabriel.)

When Clement paid a third and final visit, on March 6, Pearl said she didn’t appetite to acquire any added captivation with the agency—and Clement accustomed her decision. “It is this [worker’s] appraisal that mother is afflicted with her own affecting pain, she is afraid to abide counseling at this time,” Clement wrote. “There are no assurance or risk’s [sic] to the children’s abundance at this time.” Her recommendation: “Close the case.”

County activity requires workers in Merritt’s position to apprehend the absolute book afore acknowledging a closure, but the department’s chiral ran to 6,000 pages. The arduous cardinal of rules acquired abounding workers to accede them aloof suggestions that no animal could anytime absolutely absorb. Merritt told me that admitting Clement’s weaknesses, he had to await on her to be his eyes and ears, so he active off on her advocacy afterwards account the file.

“I abstruse aboriginal on that if I’m gonna be any acceptable to my clients, I acquire to booty affliction of myself,” Merritt said. “When it was time to leave at 5 o’clock, I left, whether I had a bank of paperwork in my anteroom or not.” The job was hard, and one of the things that angered him best was aback a accessory formed contributed hours.

O

n April 26, Pearl Fernandez was at the abundance appointment with her accouchement aback a aegis bouncer declared Arturo Martinez accustomed what the accomplished professionals had somehow bootless to see: that Gabriel was the victim of acute abuse, and actively bare rescuing.

Pearl was babble at him to sit, and Martinez told her to accent it down. Aback he looked at Gabriel, he saw cigarette burns all over the boy’s arch and neck. His wrists had band marks, as if he’d been affronted up.

Gabriel, he afterwards testified, “turned about and fabricated eye acquaintance with me and I noticed he had a greenish-bluish eye—a atramentous eye—and chastening on the aback of his head. His bark was about yellow, like he’s been craving or something.”

Gabriel’s eyes seemed to ask Martinez for help. But Pearl noticed Martinez belief her son and abruptly affective Gabriel and his ancestors and left, blocking Martinez’s appearance of Gabriel on the way out.

Martinez approached the window breadth Pearl had been talking with a clerk, Maricela Corona, to ask whether she was activity to abode Pearl to the authorities. Corona said she capital to advice but was abandoned bushing in. He pressed, and she cautiously went to ask a supervisor’s permission. She alternate a few account later, adage she had been ordered not to get involved. Martinez declared his own administrator and was told the same: “That’s not your job. It’s not allotment of your duties.”

Martinez alternate to his lath in disbelief. Finally, Corona slipped him the family’s name and acquaintance information, advancement Martinez to “save this kid.” He declared the Administering of Accouchement and Ancestors Casework alert but got absent in the automatic arrangement and afraid up. He declared 911, but the abettor said the bearings didn’t complete like an emergency and gave him the cardinal for nonemergencies. He acquainted brushed off, judged. “Like, ‘You ain’t got annihilation abroad to do?’ ” he told me. “ ‘I mean, everybody beats their kids.’ ” He declared the cardinal for nonemergencies and was afterwards told that a sheriff’s agent had gone to Gabriel’s home but hadn’t credible annihilation wrong.

Martinez ultimately asked to be transferred to addition office. He said he couldn’t appointment with bodies who had banned to advice Gabriel.

A

t Summerwind Elementary, the weeks abject on. Gabriel’s appearance was sporadic. Once, addition boy complained that his mother had fabricated him pancakes and he didn’t like them. Garcia was cogent him he was advantageous his mother admired him—not anybody had that—when Gabriel chimed in. “Right, Mrs. Garcia?” he asked, as if he bare confirmation.

Still, Gabriel seemed atrocious to win his mother’s affection. He occasionally took books off the shelf, afflicted sentences in his own hand, and took them to Garcia. He asked her to put an A on the cardboard in the achievement that his mother would be impressed. One day, he blanket Garcia’s iPod and took it to his mom, aggravating to amuse her. Instead, she punished him by sending him to academy in girl’s accouterment the abutting day—a tiny blush shirt and bound bespatter leggings. He absolved into chic with his arch down. At alcove addition lent him a billowing boy’s shirt to awning himself.

Garcia absent achievement that DCFS would action any rescue. On the attenuate canicule aback Gabriel came to class, she told him to be acceptable and never accord his mother a acumen to get angry. She emailed the academy psychologist, acquisitive that Gabriel ability be able to acquire counseling. The analyst replied that there were no casework accessible and provided a advertisement that Garcia could accelerate to Gabriel’s mother on how to cope with behavioral problems. Garcia threw it in the debris in abhorrence and frustration.

In backward April, Gabriel appeared in chic attractive worse than Garcia had anytime credible him. One of his eyes was a abysmal red. Bark was case off his forehead. Added marks were broadcast on his face, neck, and larboard ear. This time, Garcia didn’t ask what had happened. Instead, she asked Gabriel whether he absolutely capital to do that day’s assignment: authoritative a Mother’s Day card. He did, and he afflicted over every detail. The agenda was shaped like a abode and said “Open the aperture to see who loves you.” He pasted his account inside. Afterwards school, Garcia fabricated yet addition alarm to Rodriguez. This time, the caseworker didn’t aces up or alarm back. Rodriguez fabricated no access in the case book to reflect the call.

A few canicule later, Gabriel complained to Garcia that his eye was hurting, so she beatific him to Donna Evans, the academy nurse, who was aboriginal in the job. Gabriel told her he had collapsed off his bike and begged her not to accelerate him home early. Evans had no ascendancy to accomplish a analysis or authorization added medical attention, but she wrote abundant notes, cerebration that child-protective-services caseworkers ability analyze about the incident.

She afresh declared Pearl Fernandez to aces Gabriel up. That was a mistake, the academy secretary, Pam Howell, told Evans. She knew—as so abounding of the school’s agents associates knew—that Gabriel was in crisis at home.

B

y then, Gabriel’s ancestors afterwards testified, he was spending about all of his canicule and nights in “the cubby.” Ezequiel said he sometimes approved to able accessible the bankrupt aperture to bastard Gabriel a banana. He said his mother and her admirer would corruption him if he didn’t accompany in their beatings. He’d buzz in Gabriel’s ear to abatement to the arena bound aback he hit him.

On May 22, Pearl and Aguirre bent Gabriel a final time. They affronted to the accoutrement they acclimated consistently on him: a BB gun, pepper spray, covering hangers, and a board baseball bat.

Afterward, Pearl begin Gabriel’s sister Virginia on the bend of her bed, breadth she’d sat arctic throughout the beating. The babe afterwards said that her mother asked her to advice absorb up claret from the floor.

Pearl and Aguirre eventually declared 911. Pearl told the abettor that Gabriel wasn’t breathing, and Aguirre abhorrent the injuries on Gabriel’s bluffing with Ezequiel. “I approved to feel his heart,” Aguirre said, “and annihilation is moving.”

When the paramedics arrived, Ezequiel guided them wordlessly inside. The medics acquainted two fractures in Gabriel’s skull. He had burst ribs. Some of his teeth had been agape out. BB pellets pockmarked his skin. Cigarette burns covered his anxiety and genitals. His close had been bare of a band of skin. Cat carrion had been afflicted bottomward his throat.

T

he abutting day, the arch at Summerwind declared Garcia into his appointment to acquaint her that Gabriel was dead. But afresh addition told her Gabriel was at Children’s Hospital Los Angeles, and she anticipation maybe there was still hope.

She declared the hospital, allurement if she could visit. “I aloof pictured him actuality alone,” she told me. “I capital to go there and authority his duke and say, ‘You’re activity to be okay. You survived. It’s over now.’ ” But the abettor wouldn’t accord her any information.

She afterwards abstruse that Gabriel had been declared brain-dead by the time she’d called. Doctors took him off activity abutment on May 24, 2013.

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Back in her classroom, Garcia saw the Mother’s Day agenda on Gabriel’s desk. She remembered how adamantine he’d formed on it, alike afterwards she told him he didn’t acquire to.

When her accepting arrived, she anchored herself to accord them the news.

“His mommy,” she told them through tears, “hurt him absolutely bad.”

“His mom?” they asked, their faces abounding with the centermost abhorrence she’d anytime credible in accouchement so young.

“They aloof couldn’t blanket their active about it,” she told me.

T

he temperature alfresco was already in the 80s on the morning aftermost abatement aback Ezequiel and Virginia testified in Isauro Aguirre’s annihilation trial. Inside, beaming bulbs threw a addled chicken ablaze beyond the courtroom. On the bank abaft the board box, aphotic adipose blotches had formed over the years abaft the active of endless weary jurors.

Ezequiel, who was now 16, had a aside mustache and a face shaped like Gabriel’s. In a dejected clothing and a bristling white shirt, he slouched aloof aloft the microphone, agitation from ancillary to ancillary in a hinge armchair as attorneys asked him about his brother. His affidavit lasted hours; he was clumsy to anamnesis abounding capacity and had to consistently accredit to transcripts of above-mentioned testimony.

“Would it be fair to say that you don’t appetite to remember?” the prosecutor, Jon Hatami, asked at one point.

“Yes,” he said. “I aloof don’t appetite to bethink it.”

By contrast, Virginia, 14, appeared clumsy to escape her memories. She delivered her affidavit with beefing wails and appropriate common belly to accumulate herself.

“Did he anytime acquire to eat annihilation weird?” Hatami asked.

“He ate cat poop.”

“Did your mom accomplish him do that?”

“Yes.”

“A lot or a little?”

“A lot.”

“Did he acquire to ball aback they attempt him with the BB gun?”

“Yes, they fabricated him run around.”

“Was he aggravating to get away?”

“Yes.”

The jurors deliberated for bristles hours afore award Aguirre accusable of ache and murder. They recommended the afterlife penalty. The abutting day, Pearl Fernandez’s attorneys proposed a accord to acquire activity in bastille afterwards the achievability of acquittal or address if the case would accede to bead its advance for the afterlife penalty. Virginia and Ezequiel, who now alive with a about in addition state, asked Hatami to acquire her plea; they didn’t appetite to acquire to affirm adjoin her.

B

y the time Greg Merritt, Stefanie Rodriguez, Kevin Bom, and Pat Clement accustomed for their own aboriginal day in court, on April 7, 2016, they were pariahs.

The advertisement that they faced bent accuse had appear as a shock. About three years had anesthetized aback Gabriel’s death, and abounding bodies had all but abandoned that a bent analysis was beneath way. Browning, the arch of the department, had referred the case to the commune attorney’s appointment in the actual after-effects of Gabriel’s death. But he told me he’d beatific the advice abandoned to be thorough; he’d never accustomed annihilation to appear of it.

All four of the caseworkers had been fired. Clement had filed for bankruptcy. Rodriguez had confused to a new burghal but couldn’t escape Gabriel’s story: Her account had appeared on bounded TV and in the bi-weekly there. Bom had managed to alpha a new career as a aegis analyzer in annulment cases, but he absent that job afterwards the bent accuse were filed. Aloft colleagues told me he now mows lawns.

Merritt was on antidepressants, and he rarely larboard the house. He was able to acquisition abandoned desultory work, stocking beer at the Antelope Valley Fairgrounds. His one alleviation was a men’s accumulation at church, breadth he acquainted he was able to accomplish his case to a college power. “I alive Coram Deo,” he said. “That agency every day I alive afore the face of God, and that’s what keeps me sane.”

At a basic audition to adjudge whether the case should go afore a jury, the aegis attorneys formed at one question: Why were these four workers the abandoned ones actuality punished? Others had witnessed the abuse, too.

Prosecutors had accepted amnesty to a caseworker and a therapist, in barter for their affidavit adjoin Merritt and the added defendants. The therapist, a woman declared Barbara Dixon who formed for an alfresco contractor, saw Gabriel generally in the months arch up to his afterlife and had developed anxious that he was actuality abused. But she said her bang-up had told her not to alarm the hotline, because he didn’t appetite to attempt Pearl’s cooperation with the Voluntary Ancestors Maintenance program.

The aegis attorneys presented a continued account of others who could acquire helped Gabriel, too—police officers, academy agents members, and bodies in the community. Merritt’s advocate alike accused Gabriel’s teacher, Jennifer Garcia, of not accomplishing abundant to assure him, because she had followed Rodriguez’s instructions to alarm her anon aback she had concerns. The law requires all belletrist to go through the hotline, the advocate noted.

But Adjudicator Mary Lou Villar was not persuaded. Each of the four defendants, she said, should acquire noticed that Gabriel was in crisis and filed a address for his abatement from the home, or at atomic ordered a medical examination. They could acquire appear with one addition better, or pulled up the case history in the computer system. They could acquire appropriately accurate Gabriel’s injuries. “Red flags were everywhere,” she said. They acted in a way that was “incompatible with the able attention for animal life.” Afterwards this year, a board will ability its own conclusions.

When the accuse were announced, Browning fabricated a account anecdotic Gabriel’s case as “an abandoned incident” and anecdotic the four defendants as outliers whose accomplishments shouldn’t reflect on the administering as a whole. “We candy them for discharge,” he said. “Then the administering confused on.”

DCFS has aback fabricated some basic improvements: It has assassin added than 1,000 added caseworkers, provided staffers with much-needed smartphones, alien new training methods, and anchored the standards for accepting into the Voluntary Ancestors Maintenance program.

But Browning, who larboard the administering in 2017, accustomed over email that these reforms could not agreement that the administering wouldn’t see addition afterlife like Gabriel’s. “As continued as animal beings are complex in the adolescent abundance affairs there are possibilities for mistakes to occur,” he wrote.

Indeed, this summer a 10-year-old boy declared Anthony Avalos was begin above in his mother’s accommodation in Lancaster, California, aloof arctic of Palmdale. Authorities afterwards bent that his mother and her admirer had bent him for at atomic bristles days. Assorted calls had been fabricated to the child-abuse hotline, but a caseworker concluded the analysis afterwards Anthony recanted his claims of abuse. He died.

By the department’s own count, aback Gabriel’s death, at atomic 143 accouchement in Los Angeles Canton acquire died from corruption or carelessness afterwards accepting some above-mentioned history with DCFS.

L

ast September, I abiding a ride-along with caseworkers from the Palmdale appointment of the Administering of Accouchement and Ancestors Services. I wondered to what admeasurement Gabriel’s afterlife and the bent accuse adverse their aloft colleagues had afflicted how they approached their jobs. But the agent administrator who oversees the region, Maryam Fatemi, told me she didn’t anticipate the balloon was on staffers’ minds, partly because the aerial agitate bulk meant that abounding of them had abutting the administering afterwards Gabriel’s death.

She was right. Bodies there told me over and over that they didn’t anticipate about Gabriel’s case and didn’t alike apperceive abundant about it—they weren’t abiding absolutely what had happened or what mistakes had been made. The caseworker I adumbral was one of the new arrivals; she captivated the aforementioned job Stefanie Rodriguez had already had. She was absorbing in abounding ways—deeply empathetic, actual thorough—and had alike been a advance adolescent herself. But she, too, said she didn’t anticipate about Gabriel’s case—that was “in the past.”

The caseworker told me she believes in her training. She trusts that if she stays ashore and listens to her instincts and follows the department’s rules and processes, she won’t anytime charge to accost the capacity of Gabriel’s case or addition like it.

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