Unseen flaws, fatal results
By Alex Wayne,
News & Record
died after his family moved across a county line - and out of sight
of social workers. Joanie Appleman lost her life to a drunk driver
- her mother, who hid drug and alcohol problems from social workers.
Ivan Burks died after his mother, angered during a potty-training
session, slammed the toddler to the bathroom floor with such force
she broke a blood vessel in his brain.
Since 1999, 120 children have died within a year after North Carolina
social workers investigated their families for abuse or neglect.
In at least 80 of those cases, a News & Record investigation
has found, system failures contributed to the death.
The paper did not include in its analysis 28 deaths the state has
yet to review.
The deaths of Christian, Joanie and Ivan demonstrate the many ways
the child-protection system can fail to detect and correct problems.
Their deaths also show that in North Carolina, the child-protection
system looks and acts unevenly.
This constant remains: Often, social workers operate in a fog of
incomplete data and misinformation. Clarity sometimes emerges in
death, when state and local officials try to piece together what
Eddins, (Feb. 7, 2000 - June 26, 2001)
Christian's life began in a trailer park off Groometown Road in
Guilford County. It was there, in March 2000, that a neighbor called
the Department of Social Services to tell the agency about a fight
between Christian's parents.
James Eddins Jr. had hit his girlfriend, Christie Kennedy, while
she was holding her newborn son, Christian. James had been drinking,
the neighbor said.
A social worker visited the house. What she found was a newborn
too small for his age. The worker took the whole family to the hospital,
where doctors found that Christian was underweight and "failing
to thrive." His older brother and sister were behind on their
shots. Because of their poor health, a nurse suggested that DSS
take the children from their parents, records show.
The children spent the summer with their grandparents, Danese and
James Eddins Sr. At first, James Eddins Jr., now 28, and Christie,
now 23, were eager to do anything to get their kids back. James
got treatment for alcohol and drug abuse and passed all his court-ordered
drug tests. Both parents completed parenting and domestic-violence
"These were two people who loved their kids," said Don
Moody, appointed by District Court Judge Wendy Enochs to represent
the children in court. "And boy, I'll tell you what, the kids
doted on Mommy and Daddy. The bonding, the real bonding in the family
Social workers and the court were pleased by the family's progress.
In August 2000, the children were returned to their parents.
During the next eight months, however, James' and Christie's lives
Christie became pregnant with her fourth child, James Dan, who would
be born in the spring with birth defects.
Both parents had trouble keeping jobs.
James failed two drug tests. He was arrested in the spring on charges
of breaking into a car and drug possession. The parents displayed
a dangerous lack of common sense and parenting skills, problems
that went unaddressed by DSS. In March 2001, the family moved to
James' parents' house in Randolph County and then to a Thomasville
trailer park for lower rent. Guilford DSS officials sent a letter
to their counterpart agency in Davidson County, asking it to help
"monitor" the family. But Guilford County kept responsibility
for the Eddins children.
Both agencies say that their social workers continued to visit the
home. Records from Guilford DSS show that a social worker checked
on the kids at least once before each quarterly court hearing on
the case. But workers from private nonprofits, contracted by DSS
to help families like the Eddinses with parenting skills and other
services, stopped visiting.
Moody, on the other hand, visited several times a month.
Moody is a retiree who volunteered for the county's guardian ad
litem program. With a caseload of three or four families, far less
than a social worker, he had more time to visit the Eddins home.
He criticized DSS for not sending social workers more often, particularly
at night, when the parents were more likely to be home.
Even more key, Moody said: The county would not pay for a worker
from a nonprofit, Family Services of the Piedmont, to help Christian's
parents with life skills, such as home cleaning and nutrition. Without
that help, Moody said, the family's home was a mess.
On April 16, 2001, Moody visited their Thomasville trailer. He arrived,
unannounced, at 11:05 a.m.
No one immediately answered the door, but Moody knew the parents
were home. "I could pretty well picture Mom and Dad with the
covers pulled over their heads - a 'just be quiet and he'll go away'
type of thing," Moody recalled.
Christian's older brother, Zachary, opened the door. His clothing,
hands and fingernails were dirty. The trailer was filthy. Both parents
were still in bed. They were out of work and were "flat broke,"
A month later, the tenor of Moody's reports to the court became
grave. Christie Kennedy, he wrote, "appears to be overwhelmed
by (the) situation." James Eddins "does not seem to accept
the gravity of his situation" and had "hit bottom."
"How we manage this situation now might well predetermine the
ultimate outcome for these children," he wrote.
Moody recommended that Guilford County judges order the parents
to meet more stringent goals, including James keeping a job, staying
off drugs and alcohol, and continuing domestic violence and alcoholism
counseling. And he persuaded a judge to order DSS to pay for Family
Services to visit the home.
On June 23, Christian became ill. He vomited and had diarrhea. His
parents rushed him to the emergency room at Thomasville Community
General hospital, where he was treated for dehydration.
The hospital pumped him full of intravenous fluids and released
him after eight hours - still with a 102-degree fever, his parents
say. Police said that doctors ordered the parents to return Christian
the next day for a checkup.
But what James and Christie say they heard from doctors was to bring
Christian back only if he couldn't keep food down.
On June 26, James Eddins sat at the kitchen table in their mobile
home, trying to feed Christian a can of tomato soup and crackers.
The boy started vomiting - "like a faucet," James recalled.
He ran with his son to the bathroom, where "he just lost every
bit of his body fluids there in the toilet."
Christian's eyes rolled up into his skull. His dad ran into the
living room, laid him on the floor and yelled out the door.
"Please help me! Please help me!"
He started CPR. "I was scared to do it on his chest because
he was a little bitty fellow."
An off-duty fireman from next door came over and helped.
Christian was dead before he got to the hospital.
The investigation by police and the Davidson County District Attorney's
Office took more than a month. Davidson County sheriff's deputies
said Christian appeared malnourished and had bruises across his
body - on his forehead, thumbs, left foot and lower back. His family
said those injuries were the result of the hospital's IV needles.
James Eddins Jr. and Christie Kennedy were arrested July 30 and
charged with involuntary manslaughter. After interviewing doctors
at the hospital, police said the parents ignored the hospital's
orders to bring Christian back for a checkup because their car broke
The parents pleaded guilty on Aug. 1, 2002. Superior Court Judge
Kimberly S. Taylor sentenced each of them to five years' probation
and forbade them from having custody of any children in that time.
But Taylor did not think that James and Christie alone were responsible
for Christian's death. Health and social workers failed Christian,
If any of the doctors and nurses who treated Christian had suspected
that he might be neglected, none said so.
State law requires anyone who suspects child abuse or neglect to
call their county DSS. But there is no penalty for not calling.
"The medical providers were not following the law," Taylor
said in an interview last summer. "The problem is, there's
no sanction (for not reporting abuse and neglect) other than a civil
lawsuit. Maybe there should be criminal sanctions for that."
Spokespeople for the hospitals said they could not comment on Christian's
Taylor also believed that social workers lost track of the family.
She had requested Guilford DSS to send representatives to the parents'
sentencing to answer her questions; the agency declined.
Guilford DSS Director John Shore said in an interview that in hindsight,
there were warning signs that the family was in trouble. But that
was not clear at the time, he said, and he does not believe Guilford
DSS made mistakes in the case.
"Families don't make a smooth curve in their parenting,"
Shore said recently. "It's fits and starts. At what point does
that become an unacceptable risk to the children?"
Since Christian's death, James and Christie have been battling Guilford
DSS in court. The agency wants to put their three remaining children
up for adoption, they say. They want the kids back.
"I didn't lose one young'un," James said. "I lost
four of 'em."
Appleman, (Oct. 29, 1986 - May 31, 2000)
The first tip about trouble in Joanie Appleman's home came from
a guidance counselor at Shelby High School. That counselor called
the Cleveland County Department of Social Services in October 1999
with a story from Joanie's sister, 17-year-old Joann Appleman. She
had seen her mother pull a gun on a third sister, 15-year-old Melissa.
Social workers soon learned that the Appleman home was a troubled
place. There had been 20 911 calls from the home that year. Thirteen
of them, records show, were for domestic disputes. No one was ever
Domestic violence between parents is considered by child advocates
to put children at risk for abuse or neglect. If adults are violent
with their spouses, it is reasoned, they have the capacity to hurt
their children. But police never called DSS.
Melissa and Joanie confirmed for social workers that their parents
fought. Their mother, they said, drank and abused drugs and made
"suicidal gestures'' and "statements.'' Joann, the oldest
sister, was living with a cousin, too afraid to come home.
Social workers concluded that Frank and Annette Appleman were neglecting
their children because they had created an "injurious environment''
through their fighting and because Annette was abusing drugs and
alcohol. Melissa and Joanie were taken from the home Nov. 3 and
sent to live with relatives. On Feb. 8, 2000, they were returned
to their parents.
Cleveland DSS officials believed at the time that the home had improved.
Annette Appleman had been treated for depression and was attending
anger- and stress-management sessions at Pathways, the local mental
health agency. Frank Appleman met weekly with a social worker to
discuss domestic violence and parenting.
On April 11, 2000, a social worker paid a routine visit to the home.
He learned that Annette Appleman had chased her husband with a knife
the previous Sunday. Police had been called but again didn't report
the incident to DSS.
Annette Appleman agreed to check herself into a psychiatric hospital
for 10 days. Joanie and Melissa were allowed to stay home with their
What social workers didn't know was that Annette Appleman was again
abusing alcohol and drugs. Pathways knew. But the agency wouldn't
share that information with DSS, citing federal confidentiality
Doctors diagnosed and treated Annette's bipolar disorder, but she
returned home with her alcohol and drug problems intact, her ex-husband
and Melissa said.
Joanie's last day alive was bookended with car trips. First, her
father dropped her off for her final day of middle school.
She was about to hop out of his Ford truck when Joanie turned and
said, "Daddy, you got $2 I can have?''
"You know I don't have no money,'' he said. She looked dejected.
So Appleman pulled out his wallet and gave Joanie two bucks. She
slid across the seat and hugged her father. She told him she loved
him. Then she got out and went to school.
Annette had made a habit of using Joanie as a chauffeur when she
drank too much. That night, she had Joanie drive her to a party
at an uncle's home. About 11 p.m., Joanie insisted on leaving and
tussled with her mother over the car keys.
Annette won, angrily grabbing her daughter by the arm and shoving
her into the back seat. But she soon decided she was too drunk and
gave Joanie the wheel.
Then the 13-year-old missed a turn. Annette insisted they stop the
car. She slid behind the wheel.
On curvy, two-lane East Zion Church Road outside Shelby, about two
miles from home, Annette lost control of the car. Traveling about
80 mph, she swerved into the left lane, toward an oncoming car.
She swerved back to the right and went off the road.
No one was wearing seatbelts. The medical examiner figured that
Joanie was thrown from the car, which then rolled on top of her
head. She was killed instantly, the examiner told her father. Annette
Appleman suffered a broken back.
Annette Appleman, 42, was charged with second-degree murder and
death by vehicle but pleaded guilty to a lesser charge of involuntary
manslaughter. She was sentenced to five years' probation.
Frank and Annette Appleman separated the night of the accident;
Frank divorced his wife in September 2001.
Annette Appleman now lives in Asheville, Melissa Appleman said,
and occasionally calls her daughter collect from a pay phone. She
could not be located for this report.
Cleveland DSS officials are comfortable with the way they handled
the case. Without knowing about Annette Appleman's drug problems,
they believe they would not have been able to take Joanie from her
parents before she was killed.
"You couldn't get all the pieces of the puzzle,'' said Karen
Ellis, director of Cleveland DSS' child-services office.
The director of Pathways, Karen Andrews, said in a phone interview
that her agency's attorney advised against giving Cleveland DSS
information about Annette's drug abuse without a court order.
"I think that the position that we took as an agency was one
we thought in the best interest of the consumer (Annette),'' Andrews
Ellis said her office now takes two or three complex abuse and neglect
cases a month to the county's Community Child Protection Team. The
team - every county has had one since 1991 - can obtain records
from all agencies involved with a child.
"You get a community recommendation (for the case), not just
a Pathways recommendation or a DSS recommendation,'' Ellis said.
"That's good decision-making.''
Burks, (April 25, 1998 - Sept. 12, 2000) ONSLOW
Lance Cpl. Ulana Burks had just given birth to her first child,
Ivan, and she was worried.
"When will my maternal instincts kick in?'' the 21-year-old
Marine asked a social worker at Camp Lejeune's base hospital. Her
husband, Tyrone Burks, wouldn't change diapers or even hold Ivan,
Ulana told the worker. Ulana said she was a heavy sleeper, and might
sleep through the baby crying.
Those things would come naturally, the worker, Lori Nardo, told
But medical records suggest that Ulana may have beaten her son nearly
from his birth.
Ivan first showed up in a hospital when he was less than 3 months
old. Doctors found an oblique leg fracture, a break often associated
with child abuse.
He also had a freshly broken arm. And doctors found a skull fracture
that appeared older than the other two breaks.
Ulana told doctors that Ivan had slipped while she was pulling him
out of the tub nine days earlier.
Doctors told DSS that the leg fracture was at most two days old
and could not have been caused by a fall.
Ulana denied hurting her son. Her husband, Tyrone Burks, said he
didn't know how the injuries had happened either. He refused to
believe that his wife would beat Ivan.
As social workers investigated, a discomfiting picture emerged of
The Marines were investigating an adultery charge against her, and
she faced discharge. A base chaplain told a social worker that she
was a "chronic liar.''
Onslow County DSS decided Ivan couldn't stay with his parents. But
the agency did not ask a judge to order the child removed, which
is the typical procedure in other counties. Agency staff members
felt then - and now - that they should first try to work cooperatively
with families to find a safe place for children to live.
So social workers asked the Burkses to suggest caretakers for Ivan.
The Burkses picked Irving Duffy, a gunnery sergeant in Ulana's unit,
and his wife, Gilma.
The Duffys and the Burkses were not particularly close, Irving Duffy
said in a phone interview. He was Ulana Burks' superior officer
at work but not her direct supervisor. The Burkses did not have
any close family or friends in the area.
Ivan spent most of his life with the Duffys. That caused tension
between the families. Once, Ulana told her husband that Irving Duffy
had made a pass at her. Tyrone Burks made an angry phone call to
Duffy, who denied the charge. Ulana later recanted.
As the child-abuse charge against her was investigated, Ulana attempted
suicide several times and spent time in a mental hospital, according
to court records.
After the confrontation with Irving Duffy, Ivan's father refused
to visit his son at the Duffy home, records show. Ulana's visits
"She didn't even talk to him,'' Irving Duffy said. "She'd
just look at him, and then she'd get up and leave.''
The Duffys fell in love with Ivan. Parents of three children already,
they wanted to become official foster parents and adopt the boy.
But Duffy said he couldn't make time in his military schedule to
complete foster-parenting classes that Onslow County DSS required.
Ulana was charged with felony child abuse and pleaded guilty on
Jan. 6, 1999. She was discharged from the Marine Corps and sentenced
But the treatment she received for her mental problems was limited,
a state review said. Unlike larger counties, Onslow does not have
a broad range of nonprofit agencies that provide services to child
Attorneys for Onslow DSS said the agency told the Duffys to return
Ivan to his parents when Ulana's psychiatrist said it was OK. And
with that, the agency closed its case in October 1999.
"We would not close the case unless the child was safe at the
time we closed it,'' said Ed Blackwell, the attorney for Onslow
Months passed. There is no public record that Ulana's psychiatrist
pronounced her cured.
Irving Duffy was in Peru on a mission for the Marine Corps when
his wife called him one day in February 2000. Tyrone Burks had called
Gilma Duffy and told her that DSS was sending Ivan home. Ulana was
on her way to pick Ivan up, Tyrone told Gilma.
Gilma demanded paperwork reflecting DSS' decision. The Burkses gave
DSS officials wouldn't return her or her husband's frantic phone
calls, they say. The agency's attorneys say that there is no record
that the Duffys called.
Gilma Duffy said she called Ulana's parole officer, who said he
would deliver some paperwork to the home. Nothing ever arrived,
she says. That day, Gilma Duffy handed Ivan over.
On Sept. 10, 2000, Ulana tried to potty train Ivan. He somehow irritated
So she picked up her 29-pound son and threw him to the bathroom
Ivan stood back up and "appeared unremorseful,'' according
to a medical examiner's report.
Ulana picked him up and slammed him down again.
His head hit the floor, rupturing a blood vessel in his brain and
Ulana Burks laid Ivan's body on the dining-room table. Her husband
found it there when he came home from work that night.
Ulana Burks was charged and convicted of first-degree murder. She
is serving a life sentence at the N.C. Correctional Institute for
Women in Raleigh. She declined a request for an interview.
The state report on Ivan's death suggests that Onslow DSS was unaware
that the Burkses took Ivan back.
Blackwell said Ivan was returned to the Burkses "without formal
DSS involvement.'' Blackwell and his staff, in written responses
to follow-up questions, did not elaborate.
Onslow DSS leaders say that they have taken steps to prevent another
similar tragedy. They now go to court whenever they keep children
out of their homes for more than 30 days, Blackwell said. That means
that judges supervise the placement.
Even that, though, is atypical. Most county social services agencies
ask for a court order every time they remove children from their
homes, regardless of the duration.
Onslow DSS hired two social workers to monitor children who are
removed from their homes to make sure they don't return until DSS
and the court permits it.
Ivan's death ruined not just the Burks family but the Duffys' as
Irving Duffy had just retired from the Marines and accepted a job
as a consultant at Baltimore-Washington International Airport in
Maryland when Ivan died. But his wife, who visited Ivan's grave
every week, was not ready to move. Their children, who had considered
Ivan a sibling, were devastated, the Duffys said.
"It's really put a toll on my family,'' Irving Duffy said.
"As time went on, we just drifted apart.''
Irving and Gilma Duffy separated. He lives in Maryland now, she
in Jacksonville. She continues to visit Ivan's grave often.
"Still now,'' Gilma Duffy says, "my kids, they talk about
(Ivan) and they'll be crying.''
Wayne at 373-7098 or firstname.lastname@example.org