BY RACHEL COOK Californian staff writer firstname.lastname@example.org
On the afternoon of Feb. 3, a Bakersfield man and his wife were out of the house, doing their taxes, when the kids called.
One said that their brother, who had been quite ill, had passed out. The boy had been shivering and had said he was having trouble breathing. Then one of his siblings noticed that the 13-year-old looked like he was sleeping with his eyes half-open.
"When the nurse attempted to clean him, she scrubbed his skin with soap and water and he would not come clean. His body is so dirty that the filth seems to be ground into his skin."
-- Child Protective Services report
"The presence of pneumonia in (the child), when caught early, could have been prevented and is a very treatable disease."
-- Coroner's report
The parents instructed the children to call 911. They got home the same time the ambulance arrived.
Four days later, the boy was dead. And now, six months later, investigations into the death have been closed with no charges brought.
The case illustrates the difficulty social workers and others face when they come across suspected child neglect. In fact a Feb. 24 report by the Kern County Department of Human Services concluded the child died because of severe neglect. Five months later, that conclusion was retracted.
The case also raises questions of parental responsibility, the ability of parents to take care of their children and how public agencies can intervene before disease or neglect becomes fatal.
In this case the family had no health insurance, didn't immunize their child, didn't send their children to school and seemed to have granted their son's request to not bathe. The family also was unable to connect successfully with agencies that could have helped.
Because the boy's parents were not charged with a crime, The Californian is not naming the boy or his survivors.
His father, reached by phone in July, cited the pneumonia finding and said, "I loved my son and we took as best care of him as we could."
When paramedics arrived and the parents got home, the boy was in cardiac arrest, according to medical records. He was stabilized at a local hospital, then taken to the children's hospital in Madera.
He was found to be extremely dirty. He had "thick brown debris over his entire body" and a nurse spent approximately an hour and a half bathing him, according to records.
"When the nurse attempted to clean him, she scrubbed his skin with soap and water and he would not come clean," a Child Protective Services report recounts. "His body is so dirty that the filth seems to be ground into his skin."
Hospital staff had to put warm towels on him for 20-minute intervals three times to clean the boy.
The hospital's report also notes an ulcer on the boy's tailbone, bruising and redness on his chest and a lack of muscle tone in his lower extremities and the contraction of his fingers, signs they hadn't been used. According to the coroner's report, the child had lice and his parents admitted he didn't want to bathe.
Fears that he had been neglected arose at the children's hospital.
After four days, the boy was declared brain dead.
In July, investigators concluded the boy's death was natural. No criminal charges were filed against the family.
The Californian obtained documents that detail the boy's case, including that his health problems had begun years earlier. The Kern County Sheriff's coroner autopsy determined the boy died of pneumonia and that there was "no evidence of trauma or foul play."
But the report also said the boy's death was preventable.
"The presence of pneumonia in (the child), when caught early, could have been prevented and is a very treatable disease," the coroner's report said.
A social worker's report concluded the boy had been "neglected and left untreated to the point of being near death." But Bakersfield Police detectives determined "there was not criminal negligence on the part of (the boy's) parents," a spokesman said.
Fifteen months before the boy's death, fears for his health were reported to CPS. In 2010, the boy's condition had become such a concern to one woman that she reported his parents for failing to seek treatment for him.
The woman reported the child couldn't move his legs or push himself in his wheelchair and that his parents had not taken him to a doctor to find out what was wrong, according to CPS reports. The woman said the boy was taken to a doctor once, while he could still walk, and given corrective shoes to wear for flat feet but his parents took the shoes off when he complained they hurt.
The woman told CPS that she had given the child's parents information about the benefits they could seek for the boy but that they didn't follow through.
She gave the family a deadline: Take the child to a doctor by Nov. 1 or she would call CPS.
"The parents became hostile and basically disowned (her)," the CPS report said.
When a CPS worker interviewed the boy's parents in November, the couple said a muscle disorder was causing him to "slowly lose his muscle abilities," but that they did not know what was causing the disease, the report said. The couple told the CPS worker they were in touch with Kern Regional Center, a private nonprofit that works with people with developmental disabilities, and the worker confirmed their claim, according to the report. The CPS worker's report ultimately concluded that the allegations of general neglect against the family were unfounded.
Candis Gibson, ombudsman for the Kern County Department of Human Services, said a CPS worker might check to find out if a family has followed through with a referral to another agency during an investigation.
"Once verification is established and there is no further concern regarding the safety and well-being of the child, the investigation and referral are closed and no further contact is required, unless another referral is made," she said.
Jeffrey Popkin, associate director of Kern Regional Center, could not disclose whether the boy's family had been or is receiving services from the agency.
Popkin said the center provides diagnostic services, which can include medical reports, to determine whether someone is eligible for the center's services.
Income isn't taken into account in deciding if a family is eligible for the center's services, Popkin said.
"There is no means test, so we don't look at the family income," he said.
The center creates a plan for qualified people, monitors to make sure it works, and looks for ways to pay for the help. Cerebral palsy is one of five eligible conditions.
The boy's 2012 medical records indicate his parents said the boy was diagnosed with cerebral palsy at Kern Regional Center about seven or eight months before his death. However, the parents told a social worker they tried to get services through Kern Regional Center but didn't follow up with the agency when their application for Medi-Cal was denied, according to a CPS report.
The next time Child Protective Services was called to investigate the boy's parents, he was already hospitalized.
His parents said he'd had a cough and congestion for several days, an illness they treated with over-the-counter medicines because they didn't have insurance, CPS reports said. The cough was so bad the child couldn't sleep, according to a coroner's report.
It was at the children's hospital that nurses dealt with the filth on his body, and staff noted the ulcer and the lack of muscle tone in his limbs.
Reports on the boy's earlier medical history are inconsistent. One record shows the parents said he developed normally but started having trouble walking about three and a half years earlier. But another medical report said he had "substantial gross motor and physical delays" that his parents said appeared when he was a toddler.
The parents said they had trouble getting help when their child had difficulty walking a few years earlier and were "unsuccessful" finding care for him, a hospital report said.
A hospital report listed concerns for "ongoing medical neglect and possible non accidental trauma" and worries that the parents didn't look for "adequate medical support" when the boy first had trouble walking. Kern County CPS was alerted.
The parents told a CPS social worker about their attempt to connect with Kern Regional Center, a report said. A friend gave them a wheelchair and the boy had been using it ever since, they said. They bought a La-Z-Boy recliner because he could no longer sleep in a regular bed, the CPS report said.
"(The couple) did not seek regular medical treatment for the child because they do not have insurance and are on a limited income," the social worker's report said.
The CPS worker concluded allegations of general and severe neglect against the parents were true and believed the boy's two siblings were also at risk. A hold was placed on the boy at the hospital and his siblings were taken into protective custody.
When asked about the current custody of the boy's siblings, Gibson, the DHS ombudsman, wrote in an email that California law "does not provide for information on the siblings (of) a child who dies."
Dr. Todd Peterson, an emergency room physician at San Joaquin Community Hospital who was not involved in this case, said it was "crazy" for a family not to get medical care because of a lack of insurance. Everyone has access to health care, Peterson said, and an emergency room would not turn away a child who couldn't walk.
While pneumonia crops up among children every winter, Peterson said, by far most do not die from it. Many children can weather the illness without hospitalization, but for those whose bodies are already concentrating on battling other maladies, it is harder to fight, the doctor said.
"It just sounds to me like medical care was sought too late," he said.
De McCormick is a medical coordinator for Safe Harbor, a multi-disciplinary program in Ventura County that interviews and examines child and adult victims of sexual assault and children who have been physically abused. She was not familiar with this case, but when told about it, said there were signs the boy was neglected.
"The child being so dirty number one is neglect, that's obvious neglect," she said. "The fact that he has the bed sore is another form of neglect."
McCormick said the family might have benefited from more instruction on how to care for their child if they didn't have the education or drive to seek it. She hoped someone is monitoring the boy's family to make sure the home is appropriate for the other children if they are still in it.
"Maybe it's true, maybe the (cerebral palsy) kid was just too much for (the parents) but if those other two have any medical issues, it's just going to be too much for them," McCormick said.
On Feb. 5, the boy appeared to have serious brain injury caused by a lack of blood and oxygen and a "significant" lung injury caused by pneumonia, according to a medical report. He did not respond to stimulation the next day and he was pronounced brain dead on Feb. 7.
Whenever a child dies -- or comes close to death -- because of abuse or neglect, the county is required to submit a form to the California Department of Social Services reporting the death.
About two weeks after the boy died, the Kern County Department of Human Services finished that form for the boy's death. The document indicated CPS had determined the boy died from "Severe Neglect." That designation opened the door for public access to CPS reports and medical records in this case.
But the department reversed that finding in late July after taking the coroner's completed report into account.
Sharon Chun Wetterau, California Social Work Education Center project coordinator and a faculty member at UCLA's Department of Social Welfare, said the boy's situation shows the complexity of these cases. It is tempting to point fingers and to find someone to blame after a child dies, Wetterau said, but it is impossible to know what precisely happened because of confidentiality issues.
"It's hard to know who exactly is responsible when we don't have all the facts of the case," she said.
Jennifer Johnson, a nurse practitioner who coordinates a forensic program at Shawnee Mission Medical Center in Kansas, said cases like this one boil down to every agency doing its part.
"When you have a bad outcome then it becomes overwhelmingly apparent that something didn't happen," she said.
When something goes wrong, who will call attention to it, Johnson asked.
"Who then is the one that's going to say, 'Wow, this is really bad and the system didn't work for this situation and what are we going to do to make it better?'" she said.