How abuse warnings failed to save a little boy

EPHRATA — Four days before Maribel Gomez became the only suspect in her 2-year-old son's homicide, her state social worker offered a testimonial to her "sound, dedicated" parenting.

She was in full recovery from drug addiction, "raising neatly dressed and well-adjusted children, and literally spares no effort to do whatever she considers to be a benefit to her family," social worker Murray Twelves wrote on Sept. 5, 2003, in helping Gomez resolve an old drunken-driving charge.

Rafael Gomez's death Sept. 10 ended a disturbing pattern: suspicious injury and removal to foster care, then, with the strong backing of Twelves and other state social workers, a return to Maribel Gomez.

That cycle was repeated three times, until Rafael, at age 25 months, joined the list of tragedies that have occurred after children were returned to their parents by the state child-welfare system — Eli Creekmore, Lauria Grace and Zy'Nyia Nobles.

But a review of thousands of pages of police, medical, and Department of Social and Health Services records released by the Grant County prosecutor's office this week shows that, unlike previous tragedies involving children who tumbled through the child-protection safety net, Rafael Gomez had intense and continuous attention.

As Rafael went between his mother and foster homes, independent Child Protection Teams reviewed his case at least five times, following a protocol intended to prevent bad decisions. Each time, the teams, whose decisions are important but not binding, endorsed a recommendation by DSHS to send him home.

Despite the attention in the Gomez case, DSHS staff made critical errors. Twelves, the primary caseworker, admitted in court testimony he never read the family's huge file after it was transferred to him in 2002, a year into Rafael's life.

And the agency's recommendations largely ignored the concerns of three of Rafael's doctors; foster parents; school officials; police, and one of Gomez's ex-roommates. All suspected the boy's injuries — two broken legs, two skull fractures, severe burns, cuts and bruises — were caused by abuse.

Twelves and other DSHS officials declined to comment, citing a review of the case that is not expected to be completed until May.

The Grant County prosecutor is considering charges of homicide by abuse against Maribel Gomez. Deputy Prosecutor Stephen Hallstrom said a decision is expected next week. Rafael's father, Jose Arechiga, was at work at the time of the death and is not a suspect.

According to police reports, Gomez said the boy's injuries were self-inflicted, caused when Rafael repeatedly slammed his head onto a hard kitchen floor after slurping a bowl of soup noodles.

She testified in a February hearing in Ephrata that she never abused Rafael or his siblings, who were placed in foster care after his death. She pleaded to have the four children — ages 11, 7, 5 and 1 — returned.

"They are my life," Gomez said, according to a transcript released this week. "They are the only treasure that I have. And if you want to send me to classes or whatever you feel I need to be better, do that, but please return my children to me."

But according to medical experts, whose testimony was also released this week, Rafael's injuries at the time of his death were too numerous and severe to have been caused by a tantrum. His shoulders had been nearly yanked out of their sockets, and a fresh fracture creased his skull.

Pooled blood squeezed his brain from front and back from an injury that Dr. Kenneth Feldman, a child-abuse expert at Children's Hospital & Regional Medical Center in Seattle, compared to whiplash. "It would have to be extremely hard to do all this," Feldman said in court testimony.

A foster child from birth

Rafael came to the attention of DSHS even before he was born, when Maribel Gomez tested positive for cocaine during a third-trimester prenatal checkup.

According to DSHS records, a Child Protective Services worker soon faxed alerts to all area hospitals, and Rafael was immediately placed in foster care after he was born Aug. 7, 2001, with cocaine and amphetamines in his blood. The other children remained with Maribel Gomez.

Gomez and Arechiga initially resisted CPS demands that they get drug treatment, failing drug tests through December 2001. But Maribel volunteered for inpatient treatment a month later, and hasn't failed a drug test since.

After a few months of clean drug tests, DSHS social workers came to view Gomez and Arechiga as "exceptional parents" to the other children, and, deciding that "Rafael has been in foster care too long," pushed for reunification.

In late April 2002, after Rafael had been in foster care nine months, a Child Protection Team backed a DSHS plan to send Rafael home for the first time. Around the same time, Arechiga, the father of Rafael and his youngest brother, moved in with Gomez.

Soon after that, a woman named Alicia Estrada told CPS she had frequently seen Gomez slap Rafael and tell him she "hated" him. Although Estrada lived with Gomez for two months, the complaint was never investigated, DSHS notes show.

The optimistic view DSHS held of Maribel Gomez was tested in the following months. She began missing group treatment sessions. Then Rafael suffered a small fracture just above his ankle, an injury that was quickly ruled accidental.

In December 2002, Rafael arrived at a Grant County hospital with a clean-through leg break near a hip, severe burns on one hand, a skull fracture and a burn on the tip of his tongue.

Return to foster care

Maribel Gomez had an explanation for each — a slippery floor for the leg break, a head bump for the scalp cut and fracture, hot soup for the burns. She also suggested that Rafael's in-utero exposure to drugs may have caused neurological problems and self-abuse.

But three doctors found the injuries were too numerous and severe to fit Gomez's story, and Rafael was returned to foster care.

A discharge summary for Rafael, written by Dr. David Cook on Dec. 11, 2002, found simple child's play could not cause all the injuries, leaving "no doubt in my mind that this child has been physically abused."

A second doctor, who saw Rafael nine days later, agreed. The combination of injuries was "most consistent with abuse," wrote Dr. Larry Verhage of Moses Lake.

Two weeks later, a third doctor, who saw Rafael after he got out of a body cast, agreed. "Child Protective Services is involved, although I'm told they do not believe this to be child abuse, which is rather difficult for me to understand, given the history," wrote Dr. Daniel Sloane of Moses Lake.

A fourth doctor, neurologist Richard Dickson, checked Rafael for problems that may have caused him to be abusing himself but found none.

Maribel Gomez, meanwhile, underwent a psychological evaluation at Twelves' insistence. The evaluator found that she "lacked the defenses necessary to blunt the impacts of anxiety, depression and anger. Impulse control is poor with Ms. Gomez impulsively acting out without consideration of alternatives."

Rafael's case went before yet another Child Protection Team in February 2003, as DSHS was considering sending him home again. Neither the doctors' opinions nor the results of the psychological profile were included in a case summary prepared by Twelves.

"Parental explanations of the causes of the injuries are plausible and there is no medical evidence of abuse," he wrote. He suggested that Rafael could begin to suffer psychological problems if not returned home.

After interviewing Gomez and Arechiga, the 13-member team held a vote. Nine of the members voted to reunite, convinced of Gomez's sincerity.

Ephrata Police Detective John Phillips, who investigated the December leg break and, later, Rafael's death, was among four who voted no. "I just didn't think it was appropriate," he said.

Child Protection Teams were formed after Eli Creekmore died in 1985 and were strengthened after Lauria Grace died in 1995. There is at least one in every DSHS region of the state, made up of 10 or so volunteer pediatricians, police officers and lawyers. The teams review case summaries and recommendations from social workers.

Mother's account

As is common when a foster child is returned home, a DSHS social worker began weekly visits to the Gomez home, and noticed that Rafael's arrival put enormous stress on the family.

Maribel Gomez anxiously reported to Twelves that Rafael was becoming more and more abusive to himself and siblings. "Because of the child's history, the family is fearful of anything that could go wrong. Another accidental injury for Rafael would have serious CPS consequences, and the mother doesn't feel that she can have complete control over all that Rafael does," Twelves wrote in August, a month before Rafael's death.

Gomez gave this version of Sept. 9: She had finished feeding Rafael a bowl of curly soup noodles when he suddenly threw himself backward from a standing position, banging his head twice on the linoleum floor. She fed him a second bowl, and he again threw himself backward. This time, his eyes rolled back and he passed out.

After trying to revive him with rubbing alcohol, she called Twelves in panic. "Don't take my child!" she said, according to Twelves' notes. Rafael never regained consciousness, and died the next day.

An autopsy by the Spokane County Medical Examiner concluded Rafael died of a "nonaccidental" blow to the head.

Rafael's siblings

In February, DSHS and Maribel Gomez were back in court, fighting over custody of Rafael's four siblings. A series of doctors testified that Rafael had most likely been the victim of repeated, severe abuse.

Grant County Judge Evan Sperline agreed with the medical experts, ruling that Rafael's injuries were not an accident. He decided to keep the children in foster care, but, in a decision that has baffled people familiar with the case, he allowed Gomez and Arechiga to have the children for unsupervised, overnight visits.

Sperline declined to comment Thursday because the attorney general has appealed the decision.

Doug Anderson, Maribel Gomez's attorney, said she is excited about the overnight visits, and is eager to have DSHS return the children to her care. The biggest barrier to that, Anderson said, may be her insistence that Rafael killed himself.

"Without an admission, I don't see (DSHS) supporting reunification," said Anderson. "But that's up to my client."

Jonathan Martin: 206-464-2605 or jmartin@seattletimes.com