A chance to learn
Some death reviews in Washington led to sweeping policy changes affecting the care of children across the state.
Others found nothing.
In the past five years, Idaho's CPS fatality teams produced one recommendation.
Shirley Alexander, Idaho's child welfare program manager, defended the state's evaluations.
"A recommendation for a change in policy and procedures is just one part of the review process," Alexander said.
Idaho officials denied a public records request for the fatality reviews, but did release the recommendation.
The solitary change suggested was simple and similar to changes enacted by Washington just a year earlier.
The recommendation stemmed from the 2002 death of Elizabeth "Lizzy" Goodwin, a 6-year-old autistic girl who drowned after her guardians left her unattended in a bathtub in Coeur d'Alene, according to court documents.
A background check would have revealed that the guardian, Denise Whittle, had a criminal history including domestic battery, misdemeanor battery and passing bad checks. Whittle, who is now charged with involuntary manslaughter, had also been charged in Nevada with child abuse and endangerment in 1993.
The team investigating Elizabeth's death recommended that the state adopt background checks for guardians. The recommendation was sent to a state subcommittee, where it remains under review.
In Washington, CPS reviews the cases of children who received services in the year before their death. A new state law will require CPS to review all deaths of children referred to the agency.
A Spokane fatality review team convened after the death of infant Angela Lynn Biotti in December 2002.
The state had little time to intervene in Angela's life. She lived just 35 days.
But it had a chance.
Five days before Angela's death in 2002, a nurse dialed a state hotline and warned of her father's temper.
Angela's 14-year-old mother, Tasha Jones, feared leaving the child with Casey Biotti, 18, who "hits the wall" when the baby cried, the nurse reported.
There were other red flags. Social workers had received complaints concerning the families of both parents.
The state also had a file on Biotti's father, Jeff Richards, with whom the young family was living.
Richards said he gave up parental rights to two older children from a previous marriage because he was caring for too many children.
Despite the family history, the state coded the report "information only." That meant CPS did not investigate the claims but kept them on record in case more complaints were received.
On Dec. 8, in the early morning hours, Casey Biotti climbed out of bed, awakened by Angela's crying. According to Biotti's statement to police, he slammed Angela's head against a windowsill, then laid her back in her crib.
She died of blunt force injuries to her head and neck.
After her death, the state discovered that chest X-rays showing Angela's broken ribs were taken weeks before she died. They weren't read by a radiologist until three weeks after her death.
The fatality review offered few answers.
State officials say they don't remember why a radiologist didn't read the X-rays, even though they spoke with Angela's pediatrician. They say no record was kept of the conversation.
The review recommended that the details of the complaints "should be accurately reflected in the referral."
Mary Meinig, Washington's ombudsman for children and families, has pushed for more reviews and for more consistency from one review to the next.
"We should be able to learn from every child's death," Meinig said. "It behooves everyone for the agency and the people who are involved to conduct a critical review."
Washington currently does not have a clearinghouse of the regional reviews and their recommendations where they can be examined by other regions.
Ahluwalia, director of child welfare in Washington, said the state plans to overhaul its child fatality review teams in the wake of the federal review. The new system will consolidate fatality reviews and try to create more accountability.
A statewide practice assessment team will critique the regional offices' work, Ahluwalia said.
Idaho officials said they have plans to improve the review system through internal reviews and through outside reviews of the deaths. A statewide committee will review the findings of each regional death review.
`I'll never get over this'
As the states try to improve the child welfare systems, families struggle to reconstruct shattered lives.
In a quiet subdivision in Post Falls, a civil engineering technician named Don Buss Jr. lives each day with the memory of his son, Alex, who died nearly nine years ago.
"I'll never get over this," Buss said, staring at pictures of Alex that still hang on the walls of his home. "I don't think you ever come through it."
By his father's recollection, Alexander Buss was an energetic 2-year-old who loved toy trucks and tools. When Don and his wife separated, Alex split time between their homes.
On a summer day in 1995, Alex was left in the care of his mother's boyfriend, a man distressed by his role as a baby sitter, according to court records. Despite police investigations and a lengthy trial, what happened that day remains unclear.
Kevin Merwin, the boyfriend, said the boy fainted and fell from a bed. At Merwin's trial, a pediatrician testified Alex would have had to fall 30 feet to suffer the injuries that killed him.
Alex died after his brain swelled. Blood vessels in his eyes burst. Bruises covered his lips, stomach and back.
Merwin went to an Idaho prison for two years for felony injury to a child. He has since been released.
Alex went to a grassy cemetery along a busy street, where his father fusses over the flowers on his grave. • Benjamin Shors can be reached at
(509) 459-5484 or by e-mail at firstname.lastname@example.org.