Unseen flaws, fatal results

9-7-03

By Alex Wayne, Staff Writer
News & Record

Christian Eddins 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 went wrong.

Christian 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 classes.
"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 was unbelievable."
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 steadily unraveled.
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," Moody said.
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 down.
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, she believed.
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 case specifically.
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."

Joanie 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 arrested.
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 father.
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 laws.
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 said.
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.''

Ivan Burks, (April 25, 1998 - Sept. 12, 2000) ONSLOW COUNTY
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 Ulana.
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 Ulana.
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 were brief.
"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 to probation.
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 abusers.
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 DSS.
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 her nothing.
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 her.
So she picked up her 29-pound son and threw him to the bathroom floor.
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 killing him.
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 well.
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.''

Contact Alex Wayne at 373-7098 or awayne@news-record.com