An East Tennessee grandmother said she tried in vain to get the Department of Children's Services to intervene when she feared her newborn grandson was living in an unsafe environment.
DCS already had opened an investigation in March 2012 after the baby was born with symptoms of drug withdrawal. He also was born prematurely with a severe birth defect: the infant's intestines were outside his body, but he underwent surgery before going home.
By June, he was dead at just 9 weeks old.
The grandmother's call for help is not noted in DCS records.
"I just said I was worried because of the situation that (my grandchildren) were living in," said the grandmother in an interview with The Tennessean on Saturday.
"They called back two weeks later for an update and the thing was, they hadn't had quote, 'time to follow up on it.' And then before you know it, (my grandson) passed away."
It is unknown what steps, if any, DCS took to protect the baby and his two older siblings between his birth and when he died June 2, 2012.
Details about the death of the infant boy, identified only as "Case # 9" in DCS records, emerged over the weekend after the release Friday afternoon of 1,600 pages of internal DCS documents chronicling the 2012 deaths and serious injuries of 42 children who had some interaction with the state's child welfare agency.
The limited and redacted documents were released after a protracted legal battle between DCS and a coalition of media groups led by The Tennessean.
Records show the baby's mother said she awoke to find him not breathing, could not find her phone and drove him to two separate homes before finding someone to call 911.
The mother later told investigators she and her boyfriend had snorted a "roxy" - the street name of the powerful narcotic Roxicodone - and used marijuana before putting the baby to sleep in bed with them. She said they later moved the baby to his bassinet.
An autopsy report obtained by The Tennessean is inconclusive, noting the boy died of "sudden unexplained infant death" that may have been the result of co-sleeping.
This was not the first time DCS had interactions with the family.
DCS records show that the agency had contact with the family before the baby was born and had investigated a report of "drug-exposed children" involving the baby's two older siblings in January 2012. A caseworker noted: "no services needed."
His grandmother is still angry, believing DCS should have done more. At her request, The Tennessean is not identifying the baby or the family. The grandmother said she wants to protect the privacy of her surviving two grandchildren, who now live with their father.
Governor to review
In reviewing the files before releasing them to the media, Davidson County Chancellor Carol McCoy noted they were "very hard" reading.
She said the records revealed lapses at DCS in the protection of children and in record keeping. And, she said, failure to follow through on some cases may have hindered criminal prosecution of child abusers.
In a brief interview with The Tennessean on Saturday, Gov. Bill Haslam said he had not had a chance to review the judge's assessment, but planned to do so.
The governor also said he is reserving judgment about the agency's conduct in these cases.
"I think in a lot of these cases you have to go back and look at the family situations, what exactly had DCS involvement been in the past, before I can jump to a conclusion," Haslam said.
Last fall, the governor said he had spent a weekend reviewing child deaths from the first six months of 2012 and had come to the conclusion that DCS had "acted appropriately."
On Saturday, the governor said his assessment was based on a review of five files. A spokesman for the governor later clarified that the governor had reviewed five complete files and summaries of the remaining child death histories.
Among the 42 children's records released were 33 child deaths and nine "near deaths" in which children suffered critical injuries or illnesses but still survived.
Although the judge had ordered 50 case files to be made public, attorneys for DCS said they could not produce records on eight child deaths, noting that the agency may have closed a case on those children and not been alerted to their deaths afterward.
The files released show that children died from abuse, neglect, health problems, car accidents, drowning and a house fire.
Half of the files released involved children under a year old. Not all records listed a child's age.
A 3- or 4-month-old infant girl - identified as "Case # 1" - died after being whipped with a belt by her father to stop her from crying.
"Case # 33" describes a 14-year-old boy who died when his parents delayed seeking emergency care for shortness of breath.
A 2-month-old boy - "Case # 28" - died after suffering a brain injury.
In that case, and several others, DCS records reveal the agency drew no conclusions about whether child abuse or neglect led to the death, noting only the cause of death was "undetermined" and a perpetrator was "unknown."
"There are some instances in which there should have been criminal prosecution and these poor children have died and no one is going to be prosecuted," McCoy said Friday.
DCS had been alerted to concerns about all but six of the children before their deaths. Five children were in DCS custody at the time of their deaths, either with foster families or in a DCS-run institution.
Many of the cases involved drug abuse on the part of the children's parents or caregivers, a growing epidemic that DCS chief Jim Henry has said is behind the increasing number of children being taken into custody by the agency.
At least nine cases involve very sick children - children born with birth defects, suffering from cancer, or alcohol and drug withdrawal symptoms.
Some of those files raised questions about what steps the agency did or did not take to ensure the children were receiving adequate medical care.
At least a third of the records detailed thorough and persistent efforts on the part of individual caseworkers to investigate allegations, connect surviving family members with grief counseling, work with police and prosecutors and find secure living situations for surviving siblings.
Henry said Saturday the agency had no plans to review the 2012 cases for signs that criminal prosecutions should have been brought or to re-assess whether DCS caseworkers ensured that surviving siblings were safe.
The agency is already revamping the way it investigates child deaths going forward and has created a detailed plan of action that agency officials believe will set a national standard for such work.
"We have not talked about going back and doing any investigations prior to January" of 2013, Henry said. "We kind of have our hands full with what we're trying to do now."