Kids Dying Under State Watch -- Last Year, Over 100 Died While Being Monitored DSHS

Copyright 1996, Seattle Times Co.

Children who were supposed to be kept safe by Washington's child-protection programs died at a record rate last year, a study by The Seattle Times reveals.

The publicity surrounding the child-abuse deaths of Eli Creekmore and Lauria Grace in recent years might suggest that such tragedies are rare. But in fact, more than 100 children died in 1995 while under the watch of state social workers or shortly thereafter..

Such children were four times more likely to die than the state's other kids, the study found.

They were crushed, burned, suffocated or starved. Some were deprived of medical care. Others were hit by cars or drowned in pools when they wandered out of sight. And in one case, twin babies died of overheating after they were bundled next to a vent in a room where the temperature soared over 100 degrees.

Nearly all these deaths were officially ruled natural or accidental. However, The Times study concluded that at least a third of them may have been preventable.

At least 52 of these children were in open case files at Child Protective Services (CPS) when they died. The rest had received attention from CPS, Child Welfare Services or Family Reconciliation Services within a year of their deaths or lived in state-licensed care such as foster homes.

In most of the cases, parents or guardians had been reported to the state for dangerous acts of neglect and abuse - some as many as

18 times, over as long as a decade, and one as recently as an hour and a half before the child was found dead.

The findings are `kind of the ultimate measure," of the state's failure to adequately protect children, said state Rep. Kip Tokuda, D-Seattle, a former CPS worker.

Some of the difference can be explained away by poverty. But some of it is due directly to the actions - or inaction - of parents and guardians. In many cases CPS made mistakes, too.

Jeff Norman, a CPS official in Seattle who has studied child deaths, said he would expect a higher rate of child death on CPS caseloads but was surprised it was so much higher.

"It just really makes you wonder how this occurs and what can be done for prevention," Norman said.

Social workers might have prevented some of the deaths with actions as simple as providing smoke detectors, as basic as insisting that drug-abusing parents take fragile infants to medical appointments, as decisive as removing children from dangerous homes.

Like Eli Creekmore, a 3-year-old Everett boy kicked to death by his father in 1986, and Lauria Grace, a 3-year-old Tukwila girl suffocated by her mother in 1995, many of these children had previously been reported to authorities as being in dangerous situations.

Some examples:

-- In Seattle, CPS caseworkers left two toddlers in their crack-addicted mother's house despite nine validated complaints of neglect and abuse lodged against her. One of the children, a 21-month-old boy, drowned in a neighbor's pool in January 1995. He slipped outside while the mother was sleeping off a cocaine binge.

-- A 3-month-old girl suffocated in Spokane in February 1995 when her mother fell asleep with her on the couch and then rolled on top of her. "I guess I picked a bad night to get drunk," the mother reportedly told a friend. The crib was filled with debris and soiled diapers. The state had fielded eight complaints in six years about drug and alcohol abuse in the family, but pulled services from the home a month before the death, leaving the baby, a 3-year-old and a 6-year-old in the mother's care.

-- A 2-month-old boy died in Kent in August 1995, four days after a day-care worker phoned CPS to complain that the mother of the sick baby wouldn't take the infant on a bus to the doctor's office.

Invisible victims

The Times study identified many factors that contribute to the rising death rate, beyond the decisions of individual caseworkers. Those range from a shortage of money and staff in CPS to the political pressure to keep troubled families together.

The study is the first public accounting of how many children die under state watch. Several states review every unexpected death of a child; Washington does not. Many states require an annual public report on the numbers and causes of child deaths under state care; Washington does not.

The official quietness has made the children - a disproportionate number of them African-American and low-income - virtually invisible victims of a fatal epidemic of child abuse and neglect.

The newspaper's study, done over 20 months, was based on DSHS child-death reports, CPS referrals, police reports, court records, death certificates, interviews, and standards of "preventability" developed in Colorado and Oregon.

The 1995 death toll continues an upward trend: 44 children on state rolls died in 1991, then 40, 58 and 98 in subsequent years before the record 112 deaths in 1995. No figures are available for 1996.

The climbing rate is "very troubling," said Peggy West, a Seattle-based consultant with the U.S. Public Health Service and member of a state team on child deaths.

And the situation is actually worse, West said, because every state that has looked closer than Washington does has found a lot more children dying of preventable causes related to parental neglect.

The Times' findings are consistent with a report published in 1992 showing children under CPS care between 1973 and 1986 had a threefold greater risk of death than other children in the state.

"That's just the tip of iceberg," said Dr. Robert Davis, a University of Washington pediatrician who co-authored that study. "The rest of the iceberg is the ongoing abuse against the children who don't die."

More than half the dead were younger than 2 years old, their caskets the size of bassinets.

An unreleased internal DSHS report, covering deaths in state care during 1993 and 1994, acknowledges: "Many child fatalities may, indeed, be preventable." Yet the report has languished in draft form for more than a year.

Rosie Oreskovich, DSHS Assistant Secretary for Children and Family Services, said she was not surprised by the record number of children dying. She blamed more violence, drug abuse and better reporting of child deaths.

"The people CPS deals with are the most high risk, vulnerable people that there are," Oreskovich added.

One particularly troubling statistic in The Times' study was the rate of infants who were said by investigators to have died of sudden infant death syndrome (SIDS) - eight times more likely on open CPS caseloads than among other infants.

SIDS, once called crib death, is a medical explanation for what is essentially an absence of a detectable fatal condition. In homes where caretakers had been previously cited for abuse or neglect, such a diagnosis raises questions.

Again, in some cases, danger signs abounded.

During the 11 weeks of one child's life in Vancouver, Wash., his teenage parents were reported to CPS three times for drug and alcohol use and domestic violence. A caller said the mother was "always stoned or drunk" and the father beat her up.

CPS could have removed the baby from the home, but didn't. He was found dead in bed with his parents in January 1995. The cause was ruled SIDS.

Few questions asked

According to DSHS' own records, 17 of the 112 deaths in 1995 were directly related to abuse or neglect by caretakers or family members. Of those, only about half resulted in prosecutions, and some did not even result in the removal of other children from the home.

Parents who cause a child to die are nearly always anguished and never meant to be so violent or so careless. In sensitivity to that pain, investigative files are quickly closed on scores of suspicious deaths of children every year, with few questions asked.

Particularly common are cases where parenting decisions might have contributed to deaths, but they are simply labeled accidents. For example:

-- A Mountlake Terrace woman had already lost two children when tragedy struck again. In May 1995, her 6-year-old daughter ran in front of a car and was killed.

Six complaints of abuse and neglect already had been filed with CPS against the mother, and officials suspected she'd been criminally negligent in this case. But the death was ruled an accident, and the woman's remaining two children were left with her.

-- In Bremerton last December, a 7-year-old boy was killed in a car crash with his mother behind the wheel. He wasn't wearing a seat belt and was thrown from the car and crushed. The mother, who'd previously been reported to CPS for substance abuse, was prosecuted for vehicular homicide but acquitted by a jury. CPS closed the case as an accident and left two other children in her care.

Why are so many children dying right under the noses of state workers? Reasons abound:

Problem: Lack of resources

State agencies were swamped last year with 76,342 complaints of child abuse or neglect. The average workload was 35 active cases per CPS social worker, double the number suggested by the Child Welfare League, the nation's oldest and largest association of public and nonprofit children's agencies.

"I can't deal early on with prevention, so problems build to crises," says CPS supervisor Karen Gunderson in Mount Vernon.

A new study of infant mortality in King County from 1992 through 1994 faulted CPS for ineffective action in 14 infant deaths. The study, released last week, said CPS failed to remove some infants from dangerous homes and returned others too soon.

But with a shortage of money to help parents, build cases to remove children, or recruit good foster homes, CPS workers know better than anyone that they are leaving thousands of children in danger.

So they talk about "publicly acceptable" levels of injury and death - the level elected officials and the voters can tolerate.

In Aberdeen last year, a 7-year-old boy and his 2-year-old sister died in a fire in a household that had been the subject of 14 CPS complaints. The house didn't even have an operating smoke detector. Had this been Ohio, they might have lived: That state provides smoke detectors to every CPS-monitored family.

Problem: The family-preservation movement

Washington state law was changed after Eli Creekmore's death to say "the best interests of the child" are more important than "family preservation."

But some of the 1995 deaths and interviews with CPS workers show they are increasingly reluctant to remove a child from a home - even when the circumstances seem to scream for it.

Pro-family groups are pushing in Olympia and Washington, D.C., to narrow the definition of child abuse and cut the powers of CPS.

"I believe that oftentimes the family is not as broken as CPS would have us believe," said state Rep. Val Stevens, R-Arlington.

On occasion, Stevens has taken her fight against CPS from the halls of Olympia into her constituents' living rooms, joining parents to resist when a CPS worker shows up to try to remove a child.

Media focus groups have shown that some parents believe - erroneously - that CPS will seize their children if they spank them for disciplinary purposes. And campaigning politicians point to the agency as a symbol of government's intrusion on personal freedoms.

All this adds up to strong public sentiment - and pressure on social workers - to leave children in their original homes.

"The pendulum might have shifted back a bit too far in the direction of keeping families intact, with the outcome that children are exposed to high risk," said Dr. James Kreiger, director of the King County infant mortality study.

At a workshop last year in Bellevue, Richard Gelles, a national expert on child abuse, said he's changed his mind about trying to save families. Now, he said, he realizes that a lot of people just aren't meant to be parents.

"Get the child out," Gelles told caseworkers.

"I thought, `Oh, thank you!' " CPS caseworker Katie Carrow said later. "I needed to hear that."

But when DSHS recently sought a national grant, officials didn't promise to do a better job getting children out safely. Instead, the agency promised a "family-focused philosophy with a greater emphasis on prevention and family-preservation services."

Problem: Lack of review

One of the best ways to prevent deaths of children is to examine deaths that have already happened.

" `Accidents' are not random, unpredictable, and uncontrollable events," says a 1995 report by the state Department of Health. "Rather (they occur) in predictable patterns, with recognizable risk and protective factors, and identifiable high risk populations."

The state looks into some but not all deaths of children under its care, using a mishmash of procedures. When deaths are investigated, DSHS uses at least five different forms in different parts of the state.

"We're still trying to figure out exactly what we need to be reporting," says Rick Winters, program manager with the Division of Children and Family Services.

Another agency is involved, too, and it's unclear who is in charge. Last year, the Legislature unanimously told the Department of Health to "develop a consistent process for review of all unexpected deaths of minors" getting state care or services.

"The law says to identify a process, not to initiate one," said Lori Grevstad, staff director for the team assigned to the task. She is surveying other states and says it will cost a lot of money to study child deaths. Meanwhile, she is assigned to spend three-fourths of her time on other projects.

Two DSHS workers are trying to write a report on child deaths in the agency during the past 10 years, but they have other jobs. Dee Wilson is a training manager; Linda Redman is a public-records and training officer.

"Washington state has made some strides around child deaths in recent years," Redman said. "I cannot tell you it's perfect, but we are doing some things better."

DSHS promised the federal government it would adopt rules by June 1994 to review more cases where children die while on state rolls. The rules were finally adopted last April.

DSHS death-review teams are operating in Tacoma and Yakima but not in other parts of the state.

Jill Cole, director of social work at Children's Medical Center in Seattle and a member of the state child-death team, said she and others would help review every death of a child receiving services in King County if the state would organize the effort.

Cole said there are "more than enough" volunteers for one or two standing child-death-review teams.

"We're puzzled by it, that the law's there but it's not happening," Cole said.

State Sen. Pat Thibaudeau, D-Seattle, pushed a bill through the Senate earlier this year requiring DSHS to review every unexpected child death, but the bill died in the House on the last day of the session.

"These things take time," Thibaudeau says, promising a funding proposal in the 1997 legislative session.

Oregon provides a nearby model. Its Legislature budgeted $500,000 plus staff time to study every death of a child. Result: A 1995 report saying maltreatment deaths had been drastically undercounted in Oregon.

Meanwhile, critics say DSHS isn't the agency that should be investigating these deaths anyhow, because the agency can't realistically be expected to be objective.

"They almost always investigate themselves and find themselves innocent and have no liability," says Gary Roth, a Bellingham man whose foster daughter's baby died in state care.

Problem: Secrecy

When a child in its care dies, DSHS faces a conflict: privacy rights of the family vs. accountability of the agency.

DSHS fought The Times in court to conceal the identities of families whose children died under state workers' watch. Assistant Attorney General Lee Ann Miller said the state could lose $54 million in federal funding if it revealed any information about any DSHS clients, including caretakers of the dead children.

Thurston County Superior Court Judge Christine Pomeroy sided with the state.

In one case, DSHS gave The Times a report on two children who died in May 1995 and did not disclose the fact the mother had already lost her parental rights to two other children.

"I think it should be an open book after the child dies," said Karil Klingbeil, director of social work at Harborview Medical Center in Seattle. "Now all of a sudden they're protecting the parents? The only way to get corrective action is to open things up."

In another response to a public-records request, state officials gave The Times a 16-page report detailing CPS complaints about an unidentified family whose child had died. Asserting privacy rights, they blanked out all 16 pages.

"It is incredible how they keep this stuff secret," said Stu Jacobson of Washington Parents for Safe Day Care.

Before releasing information, DSHS deleted all identifying information about the children and their parents. The newspaper used other sources, including interviews, death records and published news articles, to further research cases.

Other states are much more open with detailed information on child deaths.

New York used to withhold information, but the law was changed after public outrage over the beating death of 6-year-old Elisa Izquierdo. "Elisa's Law" now requires release of a yearly report on child deaths, invites audits of the system by comptrollers, and allows officials to release information about abused children after they die.

Dr. Michael Durfee, chairman of the California Child Death Review Board, told Washington officials at a conference in Bellevue in April that they need to be especially open in reviewing the cases that fail.

He told caseworkers they have "a moral obligation to break that so-called law" on confidentiality after a child dies.

Problem: Inadequate investigation

When a 3-month-old boy died in Buckley, Pierce County, in April 1995, a police investigator who checked the apartment wrote that he saw "nothing out of the ordinary when making a cursory look."

He might have given the scene more than "a cursory look" had he known the family's history: Two older children had been taken away by CPS after chronic abuse and neglect by their mother. Relatives said the baby never should have been left there. A CPS complaint said the mother's sister was living in the home and taking care of the baby even though she had lost custody of her own children.

The word "cursory" comes up again and again on reports describing police investigations of the deaths of children.

Despite some improvements in recent years, CPS and police still don't communicate in the early hours of many cases. Sometimes, police don't find out about family history until an investigation is over. Often there appears to be a rush to close cases.

"It's very rare for law enforcement to take an interest in the neglect-type of deaths," said Wilson, one of the women working on DSHS' own report on child deaths. "The police, a lot of times they close them out within a day or two. I think they feel the parents are suffering a lot at that time."

In a 1995 report titled "A Nation's Shame," the U.S. Advisory Board on Child Abuse and Neglect said, "Many police, prosecutors and judges viewed such deaths as a strictly social problem, not a criminal issue."

A 1993 national study found 85 percent of childhood deaths from abuse and neglect were systematically misidentified as accidental, disease or other causes.

A study of 72 cases of fatal child abuse in Ohio said: "It is relatively simple for a parent or caretaker to kill a young child without criminal consequences since the crime can be committed in virtual secrecy and isolation."

"Most adult homicides are stab wounds, gunshots, things like that, so when you roll up in your car you know you're investigating a murder," said King County Police Detective James Corey.

"But with children - you smother a child, at the time of autopsy they're going to have the same findings as a SIDS death. Same with skull fractures. They might say, `Johnnie fell off the counter when they turned to get his bottle.' So you're not in a position to be very accusatory.

"Obviously if you're wrong, you accuse a grieving parent. So you give the parents the benefit of the doubt until you know otherwise. We rely on the Medical Examiner's Office a lot."

Most coroners have no special training to identify child abuse. Some of the doctors who perform autopsies in Washington's smaller counties lack pediatric expertise.

King County's medical examiner, Dr. Donald Reay, is nationally renowned. But even he admits that doctors can't tell between natural or suspicious deaths much of the time based on medical findings alone.

"There's a constellation of other findings that you like to see," Reay said. "Historical and circumstantial information carries the weight."

In the Buckley case, the infant wasn't declared dead until he got to a hospital. Investigators from the Pierce County Medical Examiner's office never looked at the mother's apartment, which CPS had described as filthy.

The medical examiner ruled it sudden infant death syndrome, even though pathologist standards say SIDS should be declared only after a thorough investigation of the circumstances and the scene.

Problem: Lack of prosecution

Fewer than a dozen people were prosecuted for child abuse in the deaths of children in Washington last year. But - as in previous years - there were no prosecutions for fatal acts of neglect.

By their count, state officials say neglect is a factor in four to six child deaths per year in families with open CPS cases. The internal reports obtained by The Times suggest the number is at least double that.

Yet prosecutors say only one case for neglect in a child's death has been successfully prosecuted in the past 10 years in this state.

"It's very time-consuming to investigate and prove," said Pierce County Deputy Prosecutor Tricia Malone, who prosecuted the only neglect case.

That 1991 case brought the convictions of a Puyallup couple who went out to buy beer and left two children sleeping in a mobile home that caught fire. The trailer didn't have a smoke alarm. The parents, who had been the subject of 11 child-neglect complaints in five years, were given 2 1/2-year sentences for manslaughter.

A "homicide by abuse" law, passed after Eli Creekmore's death, gives special consideration to abuse deaths of children younger than 16, but there is no similar law for deaths arising from parental neglect.

Detective Corey said he would like to see the law changed to punish a parent whose child is injured or killed partly as a result of illegal drug use, drunken driving or other types of criminal activity. A CPS review panel also called for such a law.

Corey investigated the death of the Seattle child whose mother was sleeping off a cocaine binge when the child slipped outside and drowned in a neighbor's pool. The mother, 37, had been a cocaine user since age 19.

"You know it's neglect all the way, man," one friend told police. "That child would have never got out that window if she wouldn't have been higher than a kite every night. She stays up all night and neglects the care of her children."

But Corey said there wasn't any law to cover the case.

"Here's a case of obvious neglect that resulted in a death of a child, but there was nothing in the statute to say that she had committed a crime," Corey said. "This would be one of your most classic examples of homicide by neglect."

Prosecutors have talked a lot about whether to propose changes to the law, but they don't agree on whether it would help.

Becky Roe, longtime King County prosecutor on child-abuse cases, now in private practice, said she thinks existing laws are fine.

"I think when a child dies by somebody's negligence, whether they're in the care of the state or the care of their parents, that's already a crime," Roe said.

Kathy Goater, head of the King County Prosecutor's Special Assault Unit, and Barbara Corey-Boulet, a Pierce County prosecutor, said some cases might be easier to attack if there were more specific laws against parental neglect leading to the death of a child.

"That's something we've gone around and around on," Corey-Boulet said. "And there's no simple answer."

Postscript

On a cold night last December, a Spokane woman bundled blankets around her twin babies, put them in their crib and turned up the heat in the room. The hot air blew directly on the 7-week-old girls.

By morning, they were dead of hyperthermia and the temperature in the room was over 100 degrees.

"I worried about them so much," the sobbing mother told police, "and I finally just made them too warm."

Most children under the watch of state social workers are living with two strikes against them. Many are poor, and their parents face challenges of inadequate income, education and support.

Given that, the reality is that there is a limit to how much the state can protect these kids.

Sometimes, it seems, all the necessary services are provided, and children end up dead anyway.

The 24-year-old Spokane mother had struggled with raising young children and with a drinking problem. Less than a month before the twins were born, she had turned up at the hospital drunk and badly beaten by the father.

He went to jail. She accepted help from CPS and from a public-health nurse. She enrolled in alcohol treatment and parenting classes.

But there was a limit to what anyone could do - making it essential to do everything that was possible.

"It's always a traumatic thing," said Sandra Oldren, a CPS manager in Clark County. "There isn't anything we can do to help bring a child back to life, obviously. So one thing we hope we can do is look at things later, examine our practice, and make sure we didn't miss anything."

----------- CASE FILE 1 -----------

The 10-year-old Yakima boy was left a quadriplegic after nearly drowning as an infant. He could cry, smile and wiggle, but little else.

After his mother had a nervous breakdown, his father was left in charge of the boy and three siblings. There were problems, as evidenced by eight detailed complaints of neglect and abuse between Aug. 2, 1994, and Aug. 1, 1995.

"The kids are losing weight because dad is on drugs. Dad is also violent," a 1994 report said.

"Father uses marijuana daily," Child Protective Services (CPS) reported in early 1995. "Verbally abusive. Makes statements like, `I'll kill you.' On 2-2-95, he pushed (another son) out the door, dragged him by his hair. Three to five days ago he kicked (a daughter) in the side and punched her in the head."

Another complaint said the quadriplegic boy was suffering seizures and wasn't getting his medicine.

In July 1995, police found the boy living in squalor. They reported to CPS: "Child has a feeding tube into his stomach. Bag was empty. The room child was in had clothing and garbage covering the floor. . . . Father was sleeping in adjacent bedroom. . . . In the living room was an adult male who was passed out. There were numerous beer cans on the floor."

Yet all the complaints were ruled unfounded for lack of proof of harm to the children.

In early August, the boy's 14-year-old sister moved out, saying she hated having to take care of all the other children.

Three days after that, the boy's grandmother reported, the father was ranting that he couldn't find the boy's feeding tube.

A day later, the boy was dead.

A medical exam found signs of a seizure. Police found no evidence of a crime. CPS judged it a natural death and left the other kids in the home.

----------- CASE FILE 2 -----------

In Spokane, a 26-day-old baby died in September in the care of parents who'd been named in six CPS complaints the previous year. They had long histories of drugs, drinking and domestic violence.

A state worker had tried to visit the home the day before the baby died, but no one answered the door. The worker left a card.

It took a Spokane police detective only 106 minutes, paperwork included, to wrap up the death investigation.

The medical examiner ruled the baby had accidentally suffocated in soft blankets in the crib.

A 13-month-old sibling was left in the parents' care.

----------- CASE FILE 3 -----------

Child Protective Services fielded three phone calls in three months about a neglected baby in a South Everett apartment.

The 16-month-old girl was malnourished and ignored, observers complained. Her mother, 19, was a methamphetamine addict and dealer. The mother's friends said the baby was so hungry that they fed her a fast-food hamburger while the mother was passed out.

A CPS worker visited the apartment once and said it looked OK. Social workers screened out two subsequent complaints without investigation.

The girl died of starvation after her mother and a male friend were shot to death Feb. 5, 1995, and nobody checked on them for the next eight days.

Apparently, the baby kept quiet as she was dying. Neighbors in the apartment complex said they did not hear a thing.

"It surprised me that nobody heard the baby crying," Snohomish County Sheriff's Detective Gregg Rinta said. "Maybe they did hear it, but they'd heard it crying so much before they didn't pay attention.

"A lot of people knew what was going on, that the baby was being neglected, but they didn't do anything about it."

----------- CASE FILE 4 -----------

Three children were left in an Aberdeen home even though friends, neighbors and social workers had filed 14 complaints of child neglect and abuse against their mother over four years.

Why they were left there remains a secret in state files. What happened next is public record:

One night last December, the mother and her boyfriend got to bed about 3 a.m. and woke up three hours later to the smell of smoke. They said her 3-year-old son had awakened, picked up a cigarette lighter, and started a fire in some clothes on the floor.

The mother grabbed her son and ran outside. She says she yelled at the boyfriend to get the other two kids. He didn't.

A 2-year-old boy and a 7-year-old girl died in the fire.

The fire had started directly under a smoke alarm, but it didn't have a battery.

After the two children died, a caseworker wrote that she had "cause for greater concern regarding the health and safety" of the only surviving child. But since police ruled the fire an accident, social workers left the 3-year-old boy in the mother's care.

----------- CASE FILE 5 -----------

A 2-month-old baby was suffocated by her mother in Yakima while they were sleeping together on a waterbed. By court order, they weren't even supposed to be in the same room alone.

The baby had been put in the father's custody because of the mother's drug use, mental illness and other problems. But after the death in February 1995, the mother revealed she and the father had "snuck behind the court's back so I could bond with my child. . . . I had her almost all the time. It was my secret. It was my sister's secret. Everybody helped me with that."

She said CPS workers didn't know, and they didn't check.

The death was reviewed by a team of experts picked by DSHS in Yakima County. The team faulted "inadequate communication among the many agencies involved with this family."

The team also said a change in state law could allow prosecution in cases where parents violate court orders and failed to follow instructions on safe sleep arrangements with an infant.

"Prosecution, even on a relatively minor charge, would make it easier to avoid placing other children with a caregiver who clearly does not make good judgments regarding the care of the child."

DSHS has not acted on the recommendation.

---------- WHAT TO DO ----------

Experts say these actions could help reduce the number of children dying under state watch:

-- Funding. Increase the number of Child Protective Services caseworkers, and give them more training and supervision. Increase funding for health care, drug abuse, parenting education and foster care. Make sure every CPS family has an operating smoke detector.

-- Training. Train more police, prosecutors and pathologists about child abuse and neglect.

-- Leadership. Adopt child-safety as the No. 1 goal, ahead of preservation of families. If parents cannot provide a safe home, judges should know it's OK to remove the children promptly and place them in a new, permanent home soon.

-- Information gathering. Create a standardized form to gather information on child deaths, and require police, coroners and social workers to fill it out in every case.

-- Child-death reviews. Set up teams of social workers, health workers, police, prosecutors and doctors in every county to review every death of a child, except in cases of expected, natural death. Provide funding and staffing as needed.

-- Public reporting. Report to the governor, Legislature and public on all child deaths. Revise the law to reduce secrecy within the Department of Social and Health Services after a child dies.

-- Investigations. Require police, medical examiners and caseworkers to talk to each other about child deaths before they make their findings. They should have access to one another's data.

-- Criminal laws. Adopt a criminal-neglect law that focuses on negligence in child deaths. Adopt a law to allow child hearsay (testimony by a police officer about what a child said) as evidence in child death cases.

------------------------------------- Child deaths rising under state watch -------------------------------------

A record number of children died on state roles in 1995.

Figures shown are for children with open or recently closed cases in Child Protective Services, Child Welfare Services or Family Reconciliation Services, or living in foster care or group care.

Source: Department of Social and Health Services, Seattle Times research.

1991: 44 deaths.

1992: 40 deaths.

1993: 58 deaths.

1994: 98 deaths.

1995: 122 deaths.

------------------------------------ Greater death rates for CPS children ------------------------------------

The 1995 rate was four times higher for children with open cases at Child Protective Services than other children in Washington State.

Source: Department of Social and Health Services, U.S. Census Bureau, Seattle Times research by Duff Wilson. The 1995 total deaths are estimated from recent data.

Without open CPS cases: 0.6

About 865 children died out of 1.44 million living in homes without open CPS cases.

With open CPS cases: 2.5

At least 52 children died out of 20,319 living in homes with open CPS cases. Figures do not include children under the supervision of other state agencies.