Social workers met with 11-year-old hours before he hanged himself, but lacked access to key information on his case. Tablet computers sit unused and a database linking county agencies remains spotty.
By Garrett Therolf, Los Angeles Times
July 25, 2010
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On a still night last month, a Montebello fifth-grader walked to a bedroom closet, pulled out a jump rope and hanged himself — apparently to end the abuse that had tormented him for years.
Just hours earlier, Los Angeles County mental health and child abuse investigators had visited the drab apartment building to examine 11-year-old Jorge Tarin. He had told a school counselor that day that he wanted to kill himself. After speaking to Jorge privately, the county workers left.
A review following his June 8 suicide uncovered evidence that persistent communication breakdowns at the county Department of Children and Family Services may have contributed to the tragedy, according to county records reviewed by The Times.
When county workers decided not to hospitalize or detain the boy, they were unaware of key pieces of information, according to documentation about the case. The social worker did not have one of the portable tablet computers that the department uses to pull case records in the field.
The department paid $5.9 million for about 2,400 tablets in 2007, but purchased only 400 wireless cards to allow them to connect remotely. As a result, in a department with about 7,300 employees, the overwhelming majority of the tablets gather dust on social workers' desks. Many field workers instead rely on personal cellphones to connect to the office.
It was not until after Jorge killed himself that the workers learned that the stepfather who answered the door had a long history of drug abuse and domestic violence. He was there when county officials visited, even though a court order barred him from living in the home.
Although county workers had visited Jorge in disheveled homes since his infancy — noting drugs, violence and neglect in the households — the complete history was not available to the officials who interviewed him that day. Without remote access to the department's computer system, the social worker at the scene was unable to fill in some blanks that may have changed the decision to leave Jorge at the home.
"This was a very difficult case and we're still trying to determine what happened," Supervisor Gloria Molina said.
Communication breakdowns have long been blamed in the deaths of Los Angeles County's abused and neglected children. The Times reported last year that top county leaders knew of a dozen reports dating back almost two decades that concluded county agencies were not exchanging vital information that could prevent children's deaths and injuries.
In a 2008 case involving a severely abused 5-year-old boy, a review revealed that eight separate agencies had more than 100 contacts with the boy's family, but those findings were not shared. When the child was finally removed from the home, he was so malnourished that his kidneys were failing, his hands burned so badly that he could barely unclench them.
In Jorge's case, county records indicate that he spent 15 months in foster homes beginning in 2008 before social workers decided to reunite him with his mother last year. She and other family members declined to speak to The Times about his death.
On the day Jorge hanged himself, he spent the morning at La Merced Intermediate School emotional and crying. He told the school counselor that life was "unbearable," county records show.
Jorge said schoolmates were bullying him, and his mother repeatedly struck him with a hanger and a shoe while his stepfather held him down. He said he wanted to kill himself "because I'm tired of people hitting me all the time," according to the records.
By noon, the school counselor had called emergency workers from the county Department of Mental Health and filed a child abuse report with the Department of Children and Family Services. The counselor told mental health workers that Jorge threatened to use a gun to kill himself, and that he had spoken in the past of using a rope, according to county documents.
School officials and mental health workers thought Jorge was well enough to go home. He boarded a school bus with a note for his mother to call them.
Not long after he got home, a social worker arrived, accompanied by police.
After his stepfather opened the door, the social worker took Jorge to his mother's bedroom to interview him alone. He sat playing with an object, occasionally throwing it up in the air. Asked the last time his mother struck him, he shrugged his shoulders. Asked if he feared her, he said no, records show.
The social worker was told by mental health officials about the boy's threat to shoot himself, but found no weapon in the home. The social worker did not search for a rope, unaware of the school counselor's warning.
The social worker also did not know that the stepfather was limited by court order to visits at the home and was not allowed to live there. Unaware of the order, the social worker did not try to determine whether the man was staying there full-time.
The department's chronic communication issues appear to have hindered the social worker's access to such information.
In addition to the thousands of mothballed portable tablet computers, the county's Family and Children Index, a database where other agencies should have reported encounters with the family that might indicate abuse or neglect, continues to be problematic. Although the social worker sent to evaluate Jorge checked the index and got a positive hit for some kind of problem, phone calls to those agencies were not immediately returned, records show.
After a push last year to make the database more complete, county efforts have stalled while officials pursue state legislation to loosen legal restrictions on the flow of information.
Without access to complete records, the social worker was left to evaluate Jorge's case largely on interviews.
When the social worker spoke with Jorge's mother, she denied hitting him with a hanger or shoe, and she appeared genuinely concerned for his welfare, according to records. Based on the mental health workers' assessment that Jorge did not pose an immediate suicide risk, the social worker left him in the home but kept the investigation open in order to gather more information over the following days.
Hours later, as the family gathered to watch the Lakers play the third game of the NBA finals, Jorge slipped away to his mother's bedroom. He closed the door. When his mother went to call him for dinner, Jorge's stepfather heard a scream. He went to the room and found her holding Jorge's limp body in her arms, according to county records.
The next day, after lingering on life support at Long Beach Memorial Medical Center, Jorge died.
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