On May 3, 2019, an 11-year-old boy in Denver County, Colorado, refused to go home from a neighbor’s house. He said his mother and stepfather beat him and hit him with belts.
The neighbor’s grandmother called the police.
The boy had scars on his face, his arms and his back. When officers arrived, the boy still refused to leave. The grandmother feared for his safety. The police were concerned what would happen to the child if he returned home.
What happened next would, according to state investigators, reveal an all-too-common fracture in a system that is supposed to ensure the safety of the state’s most vulnerable children: Child-protection caseworkers who miss appointments and deadlines to meet with children face-to-face, unable to adhere to baseline measures of effective case management.
This boy’s case is far from unique. Despite years of efforts to reform the child-welfare system in Colorado, some counties still struggle to respond promptly to reports of abuse and neglect. In an analysis of Colorado Department of Human Services documents and data, the NYCity News Service found instances time and again where caseworkers did not show up promptly.
When initial reports of maltreatment are investigated further, caseworkers are required to interview or observe reported child victims in an assigned time frame. Failing to act quickly can leave children in harmful situations. Sometimes, the consequences can be deadly, as was the case in the deaths of a 5-year-old boy in 2010 and a 2-year-old girl in 2015.
State data covering October 2019 through September 2020, shows five Colorado counties were late more than 20 percent of the time, below the state’s standard.
In addition, a News Service review of recent reports by the Office of Colorado’s Child Protection Ombudsman and the state’s Child Fatality Review Team documented delays that were a factor in the abuse and neglect of children.
The pandemic has only made things worse. Stephanie Villafuerte, the state’s child protection ombudsman, testified Dec. 17 before a state legislative budget committee that the agency was witnessing “an inconsistent response by child welfare agencies” as safety protocols make home visits even harder.
Calls to the state’s child-abuse hotline dropped dramatically in the early months of the pandemic as schools and businesses were closed and it became more difficult for teachers, social workers and coaches to notice signs of child abuse.
“There’s a lot of concern about [children] we’re not seeing,” said Ned Breslin, CEO of the Tennyson Center for Children, an organization that provides services for children who have been abused or neglected. “Schools sort of lost track of them with COVID and the switch to virtual learning.”
How a delay hurt one boy
The May 3, 2019 report wasn’t the first report filed with the Denver Department of Human Services about abuse suffered by the 11-year-old boy. Four days earlier, on April 30, a caller said the boy’s parents were mistreating him.
The department assigned a caseworker. Agency workers decided there were no immediate safety concerns and that a visit should be done within five working days, by May 7.
When the May 3 call came in, police contacted the department.
The boy’s mother told police that the parents had only spanked the boy for discipline. Despite the report of scars and officers’ concern for the child’s safety, caseworkers decided that since a visit was due within days, a quicker response was not warranted.
The delay led to more abuse.
On the morning of May 6, the boy and his parents showed up at the county’s Family Crisis Center. The boy disclosed that, following the May 3 incident, his parents took away most of his clothes, leaving him in just underwear. They made him sleep on the kitchen floor for the rest of a weekend when temperatures in Denver dipped to 40 degrees. His parents also shaved his head.
Officers interviewed the family and arrested the mother on child-abuse charges.
The state Department of Human Services Child Fatality Review Team, which examines investigations of egregious child abuse and deaths, documented the missteps that led to continued mistreatment. The name of the family was withheld in the report, and Denver Police declined to release further details.
The 11-year-old, later placed in the care of relatives, had recounted a history of abuse. The review team also examined the boy’s medical report, which concluded that the parent’s treatment met the “diagnostic criteria for torture.”
The review labeled the case “egregious.”
The failures went beyond the decision by caseworkers to not deem the boy’s case as urgent, and to not respond quicker despite the scars on his body: They did not interview his siblings within the assigned five working-day time frame and did not make a timely assessment of the family.
Denver Human Services officials declined to comment on the case. In the state review, the agency acknowledged shortcomings and said it was making efforts to do better.
The state review also recommended the county agency interview reported victims faster. Data at the time showed the interviews were prompt only 62 percent of the time. The county agency responded that it is “working to improve,” that it does better than elsewhere in Colorado and that delays are a “statewide systemic problem.”
Craig Wells, a Denver Human Services spokesman, told the News Service that a variety of factors can contribute to delays: Families miss appointments or do not respond to calls, contact information is out of date and information is reported to multiple professionals. Historically, Wells said, the agency has performed at or above the state goal for timeliness.
“Working with human beings rarely results in perfect regulatory compliance,” Wells said via email. He said when the agency finds systemic problems, it works to improve.
One county’s repeated stumbles
In Montezuma County, tucked into Colorado’s borders with Utah and Arizona, the state’s Child Protection Ombudsman learned in 2018 that a child was sexually assaulted. But county caseworkers did not contact the child for more than two months and police were not notified.
The case, along with other complaints, triggered a nine-month investigation into Montezuma’s child-welfare department. One of the most serious findings exposed the county’s pattern of being slow to respond to abuse, despite performance data showing the county was meeting state goals.
“It definitely caught our attention when we were seeing this,” said Jordan Steffen, deputy child- protection ombudsman. “There’s a question of why issues like this can kind of live so long before they’re seen by the state and what metrics we could be doing to improve on that.”
Her office found instances in which the county did not assign the appropriate time frame for caseworkers to respond. It examined 23 cases, finding that caseworkers failed to interview reported victims by the appropriate deadline in nine. They failed to comply with state laws and regulations for timeliness 18 times.
In one case, an 11-year-old boy had been suspended for fighting at school, had threatened suicide and had been exposed to domestic violence. The county determined the child should be interviewed in person by Feb. 15, 2018. Yet that meeting did not happen until more than two months later.
In another case, a 13-year-old went missing from school for more than a month. Her family was homeless, her parents were suspected of drug abuse and the girl was often hungry and tired when she did appear at school. Still, the child was not interviewed until six weeks after the initial call came in.
The head of the Montezuma agency at the time resigned for undisclosed reasons around the time these complaints emerged. Gina Montoya, current director of the Montezuma County Department of Social Services, declined to comment on the investigation beyond what the ombudsman was told—that the agency is working to improve.
Problems persist in rural counties
State records show a number of Colorado counties with long-standing patterns of delays.
Based on data spanning 2015 through 2019, 23 counties fell short of meeting the state’s goal at the time of making initial face-to-face contact with 90 percent of victims within the assigned time frame. Three counties were well below the mark, interviewing children within the appropriate time frame less than 80 percent of the time.
In 2020, the state altered its benchmark to include followup visits in addition to initial interviews with victims. The state goal is now for these steps to be prompt 84.3 percent of the time. Eleven counties failed to meet the new goal from January through September 2020, the end of the period covered by the most recently available data.
Over the course of 12 months ending in September, five counties—Conejos, Costilla, Moffat, Otero and Rio Blanco—failed to interview victims promptly in more than 20 percent of cases. Most of these counties are among the most rural and impoverished in the state, according to census data. Officials in two—Costilla and Rio Blanco—said understaffing and ongoing difficulty in hiring workers are key problems.
Just before publication of this story, the state released data covering the last three months of 2020. All five counties that failed to interview promptly in more than 20 percent of cases remain below the state’s goal. Five additional counties—Custer, Kiowa, Ouray, Phillips and Saguache—were also below the state standard of 84.3 percent of children interviewed on time from October 2019 through December 2020, and are among the most rural in the state.
Custer, Kiowa, Ouray, Phillips and Saguache counties did not respond to requests for comment about the most recent data.
Separately, the state Child Fatality Review Team publishes reports on substantiated cases of child fatalities, near fatalities and “egregious” maltreatment, in which families had prior involvement with a human services agency.
A review of the team’s 74 public reports from 2017 to 2020 found that in half, auditors cited inappropriate or delayed response times over the course of a case’s history. Seventeen reports documented more than one instance when a caseworker failed to make timely contact with a victim.
In total, the NYCity News Service found 68 instances between 2017 and 2020 in which county agencies failed to interview or observe children by the assigned deadline and 19 instances when a county agency assigned a too-lenient response time.
Between 2018 and 2020, the Office of Colorado’s Child Protection Ombudsman, an independent agency, published 24 “letters of compliance concern”—notices that the ombudsman believes a county child-protection agency has possibly violated a rule or law. In almost a third of these notices, the ombudsman reported agencies did not respond promptly.
Mark Techmeyer, spokesman for Colorado Department of Human Services, said other factors may also contribute to delays. A county agency may get a call from a concerned citizen, he said, but not have enough information to find the family. Or caseworkers may be unable to find the family because they have moved.
Even if caseworkers don’t make initial contact with children within assigned deadlines, they are making contact with children 97 percent of the time, Techmeyer said.
Too many cases, too few workers
Colorado is one of nine states where the state supervises child-protective services while day-to-day work is administered by counties.
The result, said Steffen, the deputy child-protection ombudsman, is that counties can implement rules and reforms inconsistently. The ombudsman’s office recently found that one unnamed county failed to respond promptly in 115 different cases in the early months of the pandemic before it made changes.
Understaffing is also a perennial problem. A 2014 study that found a shortage of child-welfare caseworkers among county agencies recommended filling 574 caseworker and 122 supervisor positions. In response, lawmakers approved funding for more caseworkers and staffing increased.
Still, some outcomes did not improve. The state reported improvement on making initial contact with children between 2014 and 2018. Yet performances on other measurements, such as whether caseworkers were visiting children in person at least once a month, got worse, according to the Colorado General Assembly’s Joint Budget Committee
A task group recommended a ratio of one caseworker for every 10 cases. However information presented at a December 2018 Joint Budget Committee hearing shows that caseworkers in some counties were saddled with more than the recommended caseload. Years after the workload study, insufficient staffing has persisted, The Gazette of Colorado Springs reported.
In Rio Blanco County—one of the rural counties that has trouble meeting state response-time standards—Barbara Bofinger, its director of human services, said that staffing is a major problem.
“The most significant struggle,” she wrote in an email to the News Service, “is recruiting, hiring and retaining staff, not unlike many rural counties.” Hiring is difficult because there is a “limited” base of potentially qualified applicants.
“When one employee leaves [the department] it creates a huge gap,” she said.
Costilla County, also rural, has only two child-welfare caseworkers and is trying to hire a third, said Tommy Vigil, director of the county’s Department of Social Services.
Costilla had 78 reported victims of child abuse between October 2019 and October 2020. Twenty-one were not interviewed promptly. Not meeting state standards in several instances can “throw off the numbers we are expected to meet,” Vigil said.
In Moffat County, which touches the borders of Utah and Wyoming, performance data in 2019 showed the county lagged in responding to referrals in a timely manner, prompting the state to investigate. The child-protection ombudsman had also received complaints from residents who worried that caseworkers were not following up on reports of abuse and neglect.
A team of outside caseworkers assigned to look into the county’s practices discovered fraudulent casework from one Moffat worker. The human-services director stepped down the day after the Colorado Sun ran a story about the investigation in October 2020. The agency was in the midst of a lot of turnover—10 staffers quit between March and November of 2019, the Sun reported.
The problems in these counties highlight another aspect of the fraught nature of the work staffers must do every day while coping with limited resources. Child-welfare caseworkers—who face high rates of turnover and trauma from routinely dealing with troubling issues—must constantly balance the need to respond quickly while not being overly invasive, said Breslin, of the Tennyson Center for Children.
“There’s a little ‘Damned if you do, damned if you don’t’ in this,” he said, adding, “the longer we wait [to respond], we know that things compound and spiral.”
His mom saw delay as deadlyJing Tesoriero, who lives in Douglas County, south of Denver, recalled making countless complaints to the county Department of Human Services before her son Ty was killed in 2019.
She believes the county’s slow response is one factor that led to his death.
She told her caseworker and her therapist that Ty was not safe with her ex-husband, Anthony Tesoriero. County child-protective caseworkers had been aware of potential abuse since 2016.
“I begged [the caseworker]. I said, ‘I know, there’s something wrong.’ I said, ‘I really need your help.’ And [the caseworker] was just like, ‘No, we’re not investigating this anymore,’” she told the News Service.
Over a period of about three years, Tesoriero said, Ty told her that his father choked him if he was disobedient. That was just one form of the physical and emotional abuse he endured.
On Oct. 25, 2017, Jing Tesoriero’s therapist, Christine Garcia, reported similar concerns to the Department of Human Services, and documented the call in her case notes. She believed it was a “mandated call” because of possible child abuse.
An entry from this same date in the state fatality report on Ty’s death states, “Douglas County DHS received a report of concern regarding the family. The mother reported learning information from the child ‘that [the father] continue[d] to threaten [the child] with choking if [the child] [did not] do what [the father] tells him to do.’ The father also told the child ‘that [the father] [would] kill 9 of [the mother’s] friends and he [knew] their addresses.’”
According to Garcia’s notes, the caseworker said she was not going to act immediately and would follow up with Ty on her next monthly home visit.
Caseworkers said they believed they did not have enough information to launch a more urgent inquiry.
“It was determined that the referral did not meet criteria for assessment with the indicated reason of, ‘No information available from reporter of abuse and neglect as defined in law,’” the fatality report states, indicating caseworkers believed they did not have enough information to trigger an interview with Ty.
Looking back, Garcia said she believes that, since Ty’s parents complained so frequently to child-protective services about one another, the agency began dismissing their accusations as noise from a contentious divorce, “instead of investigating concerns as real concerns of abuse, neglect, safety, or risk factors.”
On Sept. 21, 2019, Anthony Tesoriero, who was on probation for a domestic-violence conviction that barred him from legally owning a firearm, shot and killed Ty and himself.
“I tried. I tried [to get] all of them to do something and nobody did anything,” Jing said. “This kid was going to suffer forever if things just kept going.”
Ty was a sociable and talkative child before the divorce. He loved to draw pictures and play games on the computer. He had a bright smile. Yet he became quieter in the last years of his life.
Both Jing Tesoriero and her therapist said they believe the Douglas County Department of Human Services was not equipped to handle child-abuse cases that stem from instances of domestic violence like hers.
“They don’t see the [obvious] signs and symptoms, you know, the power and controls,” Tesoriero said of the agency’s lack of recognition of domestic violence. “I just got a bunch of those doors slammed in my face.”
About the reporters
Maddie Kornfeld, who reported from Colorado, is a freelance journalist based in Denver. She is studying investigative reporting at the Newmark Graduate School of Journalism at CUNY and will be interning for the Seattle Times investigative team this summer.
Sarah Gabrielli, who reported from New York, is a freelance journalist based in Brooklyn. She recently received her master’s from the Newmark J-School, where she studied investigative and audio journalism. She also works as a researcher for author Barry Levine.