DCFS says it shouldn't be held responsible for children who die under its watch, but its own inspector general wonders if these lives had to be ... cut short.

In the middle of the night, 12-year-old DeMario nudged the only adult in the apartment and told him that his baby sister, Chloe, wasn't breathing. But the man barely responded, suggesting that the baby was fine and the boy should go back to sleep.

The boy's mother was nowhere to be found. At 8:30 that night, she had told him she was going to the store for milk, but she had not returned, and would not until dawn. As he waited for her, the boy spent the night praying and rocking his lifeless 6-week-old sister.

The state system that is in place to protect children had already spent a year trying to get the boy's mother to stop using drugs and leaving her kids to fend for themselves for nights at a time. Caseworkers even warned her that the state would take custody of her children. But it would not be until May 19, 2003--five days after Chloe died--that the Illinois Department of Children and Family Services would reach in and ask a Cook County Juvenile Court Judge to remove the children, demanding that the boy's mother get help for her drug addiction to regain custody.

Every year, dozens of children die months after DCFS looks into their family lives. And the number of these deaths went up by almost 50 percent between the fiscal years 1999 and 2003, from 82 to 122, according to the annual report issued in January by DCFS Inspector General Denise Kane. The inspector general is mandated to review the deaths of all children who, within the past year, were in foster care or whose families had received services from DCFS or had been investigated by the agency. "Is it reasonable for us to inquire if it is possible to lower the mortality rates of these children?" Kane asks in the report. Then she answers her own question, concluding that it's not only reasonable, but also prudent.

Kane describes several cases in which obvious failures by investigators and social workers left children at home, where they were later killed by their parents or parents' partners. And she also notes several deaths attributed to accidents or natural causes that might have been prevented if workers had been more diligent. DCFS does not allow Kane to be interviewed, and officials wouldn't comment on specific cases.

Master Sgt. Richard Roderick, who is the head of the Illinois State Police's 6-year-old Child Homicide Task Force, is often disturbed by the number of children who die after DCFS has had prior opportunities to intervene. "It happens again and again and again," said Roderick, a member of a group of experts who review child deaths in Cook County. "Sometimes I just want to stop the [review] meeting and stand up and say, 'What is going on here?'"

DCFS Director Bryan Samuels, who was appointed in May 2003, wouldn't comment for this article. Other officials wouldn't acknowledge the increase in child deaths shown in Kane's reports. "Those are not our numbers," said Gailyn Thomas, DCFS deputy director of child protection. "I don't have any numbers of my own. Keeping count is not important to me."

"Our mandate is to keep kids safe. But just because a child dies I can't say we didn't meet our mandate," Thomas continued. "We have no control over certain circumstances of families, but we try to provide the appropriate services to ensure the safety of kids."

Still, Thomas and DCFS spokeswoman Jill Manuel said the department takes Kane's recommendations seriously. Samuels and a group of his deputy directors meet monthly with Kane to consider making changes based on Kane's findings. In response to some of Kane's recommendations, DCFS recently started to require child protection investigators to make sure homes are meeting safety standards such as having smoke detectors, Manuel said. "The [protocols] at the end of the day will probably save some lives," Manuel said. But she said DCFS is just one of many government agencies responsible for educating parents on ways to keep their chiddren out of harm's way.

Although Kane works closely with DCFS, her annual report is addressed to elected officials. The governor is required by law to get it, as are key Illinois House and Senate leaders. Yet the report mostly gets buried amidst other material in these politicians' files.

Rebecca Rausch, a spokeswoman for Gov. Rod Blagojevich, said the governor is aware of the report, but she couldn't say whether he'd read it before The Chicago Reporter made inquiries. "The governor thinks it is a tragedy every time a child dies," Rausch said. The governor continues to have confidence in Samuels, she added.

Other lawmakers, including Sen. Barack Obama and Rep. William Delgado, the Democratic chairmen of the Senate and House committees that handle child welfare legislation, said they hadn't read the report before the Reporter asked for their response to it. An additional group of 14 lawmakers who, according to DCFS, specifically requested the report said they could not comment until they had the chance to "dig it up" or "find it in the volumes of information they get," in the words of two members. Many of the lawmakers couldn't remember why or when they requested the report.

Delgado, who is from Chicago's Northwest Side, said he was upset to hear about Kane's data because it runs contrary to the picture of success the department offers to lawmakers. "DCFS has a strong lobby in Springfield, but it seems to me that they are always so reactive rather than preventative," he said. "It is all about damage control and creating fluff. They are so concerned with putting sugar on lemon drops that changes will never be made."

South Side Democrat Mary Flowers is one of the few lawmakers who had seen Kane's most recent report. "It angers me because we are talking about children's lives," she said. "If there are fewer children being taken into the system and more children are dying, then they need to rethink what they are doing."

In the opening letter of the latest report, Kane points out that the increase in deaths occurred during the same time that the number of families getting services from the system had decreased by 16,000 and the number of children placed into foster care went down by 7,500.

Kane fails short of drawing a direct connection between the declining caseloads and rising child deaths, but others, especially pediatricians, teachers and social workers, say they see a correlation.

"I think it is a double-edged sword," said Sarah E. Powers, a licensed social worker at Children's Memorial Hospital and also a member of a team of doctors and social workers who assesses abuse and neglect in Cook County. "It is a good thing that less kids axe going into foster care, but the assumption is that they're getting better services, and I don't think that is true. Kids fall through the cracks."

Like many of the cases reviewed by Kane, Chloe Palmer's death received little attention. Chicago's two daily newspapers wrote briefs about it, both less than 100 words, and in one it was mentioned at the end of a short story about a suburban boy who died after allegedly being pummeled by his father.

But, in 1993, in lengthy articles, the newspapers recounted the horrific death of 3-year-old Joseph Wallace. Two months before Joseph's death, a judge had returned him from foster care to his mother. She ended up hanging him with an electrical cord. Juvenile court judges, caseworkers and their supervisors were harshly criticized. And the system that seemingly put parents' rights before children's safety was rebuked.

These revelations sent the state's child welfare system into upheaval.

Within months, lawmakers changed the law to make the "best interests of a child paramount" in deciding whether a child should stay at home or be placed in foster care. They created the Office of the Inspector General to be an agency watchdog. Child protection workers also became worried about making a mistake that would not only result in a child's death, but also in public admonishment. The pressure caused the foster care caseload to skyrocket. In 1995, the number of children placed in foster care reached a 20-year peak at 15,254, pushing the overall caseload up to 51,000. Illinois suddenly had the nation's highest per capita rate of children in foster care.

By the late 1990s, child advocates were proclaiming that the state was removing too many children from their homes and that too many of those boys and girls were languishing in foster care. Not only was it expensive, but it also was bad for children, most of whom longed to be with their parents, they said.

Growing discontent over the size of the caseload, along with a new federal law and a consent decree calling for improvements, gave then-DCFS Director Jess McDonald the momentum needed to start downsizing the system. In addition to working with the courts to get children adopted, he implemented "front-end redesign." This standardized the way investigations were done and changed some of the definitions of what was considered abuse or neglect. It also was supposed to provide more services to troubled families to prevent their children from being removed.

Since then, the number of children placed in foster care has dropped by more than 68 percent, to 4,830 in fiscal year 2003.

Current and former DCFS officials say that they've been able to achieve this decrease without compromising children's safety. They point to internal figures showing the number of children re-abused in their homes went down by 37 percent since 1997.

But Roy Harley, executive director of Prevent Child Abuse Illinois, an advocacy organization, said the rise in child deaths "runs counter to what you would expect.... If the ultimate measure of our improvement is how many children die, then we have not improved as much as the other statistics indicate."

Kane provides narratives of every child death she reviews in her reports. The Reporter analyzed the 419 cases in Kane's reports for fiscal years 2000 through 2003. Kane's report didn't provide race or ethnicity of the children. According to her report, 60 percent of the children died in Cook County. Black children make up 82 percent of the children in foster care in Cook County and 40 percent elsewhere.

Some of the deaths recounted by Kane during the four-year period are as dramatic as Wallace's, with state social workers missing signs of volatile caretakers or failing to remove children before they were killed.

In those four years, 17 teenage foster children were killed by someone other than their caretakers--eight within the last fiscal year. Many were victims of gang or relationship violence. Six had run away from their placements at the time they were murdered. Samuels has made one of his priorities the well-being of teenagers in the system. He was particularly worried that too many of them were runaways.

But most of the deaths outlined in Kane's reports are not the result of aggression. About 44 percent were from natural causes. Many were due to Sudden Infant Death Syndrome. Others were born with various medical problems. Those who died of natural causes were more likely to be born substance-exposed than others.

Another 25 percent of the deaths reviewed by Kane were accidental, including children who died in fires and car wrecks.

While these deaths seem out of the control of DCFS, after digging a little deeper, Kane concluded that at least some of them could have been avoided.

In one case, an 8-year-old who had no plan for treating his asthma died of an asthma attack. In another, a toddler drowned in a bucket of Lysol while his drug-addicted uncle slept nearby. The boy's parents had promised state workers they would not leave the child in the uncle's care. And more than two dozen babies fell asleep on couches or adult beds--many because they had no cribs--and never woke up.

The night Chloe died, she was left by her mother to sleep between cushions on a sheet on the floor of a South Shore apartment. The medical examiner was never able to conclude exactly how she died. Her death was among the 10 percent of those examined by Kane that were labeled "undetermined."

Those intimately involved in the case, however, say Chloe's death not only illuminates how children are allowed by DCFS to be left in perilous situations, but also the way the state's policies and procedures play in the lives of vulnerable children.

"What I told the inspector general was that this was a time bomb waiting to happen," said Toni Lay, the supervisor of the caseworker who was assigned to work with Chloe's mother. Lay works for Chicago Commons, a South Side social service agency.

At the moment, family members don't know where Chloe's mother lives. After years of leaving her children but being pulled back to take care of them, she is suddenly untethered, said her cousin David Brown. One child is dead. The other two were sent by a juvenile court judge to live with relatives. Her case files say she's filled with grief, but her family has become hardened to her. "[Chloe's mother] has burned every bridge," her mother told her caseworker.

Brown is adamant that the situation didn't have to turn out like it did. First, he blames Chloe's mother's drag addiction and lack of concern for her children. When Chloe's mother had her first son at age 19, Brown said, she only smoked marijuana. But, by the time the little boy turned 4, it was obvious to the family that Chloe's mother was being swallowed by an addiction to crack cocaine.

Brown said Chloe's mother should have extricated herself from the drugs and men who clouded her ability to care for her children. But he also believes some culpability lies with the state's child welfare system. "We told them she was in trouble and we just could not believe that they wouldn't do anything," he said.

Brown was the first person in the family to call the child abuse and neglect hotline. Back in 1999 when DeMario was 9, she dropped the boy off at the Hyde Park home Brown shares with his grandmother. Without telling anyone of her plans, she left him for more than five months, occasionally stopping by but never leaving money or taking him with her. Frustrated by the expense of raising a child and suspicious that Chloe's mother was collecting benefits for him, Brown called the hotline. "Anyone could see it was a clear case of abandonment," Brown said. "I told them that she was on drugs, running from man to man, and that she wasn't taking care of her child."

The response shocked him. Under "front-end redesign," leaving a child with a relative who was able to care for the child was considered acceptable.

"The lady told me that because she didn't leave him by himself, because she left him with responsible adults, it wasn't a case of neglect," he said. Brown, incredulous, called back several more times over the next couple of days hoping to get someone who would understand the family's position, but he was unable to get anyone to take a report. Of the 300,000 calls to the state child abuse and neglect hotline each year, about one-fifth of them prompt operators to take a report. Only once a report is taken does DCFS investigate the situation.

Eventually, Chloe's mother came back and got her son. Brown said the family was worried about where the two would go, but they had no right to tell her she couldn't take him.

A year later, in March 2002, Chloe's mother gave birth to a boy at Jackson Park Hospital in South Shore. "This baby was a crack baby," Brown said. The family was sure that the child welfare system would finally see what was going on and take the children into state custody, Brown said.

Officially, the baby was substance-exposed, according to court documents. As required by law, the hospital called the hotline, and a report was taken. And DCFS investigated.

If an investigator determines abuse or neglect occurred but the child is not in immediate danger, the child will typically be allowed to remain at home and his parents will be referred for services, usually provided by a private social service agency.

Giving birth to a substance-exposed infant is, on the surface, a substantiated case of neglect, but the state does not routinely place these children in foster care, said Teresa Aversa Maganzini, chief of the child protection division for the Cook County State's Attorney's Office. In Cook County, her office is the gatekeeper for which DCFS cases are brought before judges to determine if a child should be placed in foster care.

Maganzini said the mother of a substance-exposed infant will usually be told to go to treatment. This is especially true after a woman gives birth to her first substance-exposed infant, but, even if she has several and never gets treatment, her children still might not get removed. In an earlier report, Kane noted that the department should review its policy of leaving children with their mothers after they give birth to a third substance-exposed infant.

But some addicts can be good parents, Maganzini said. "Some parents can take their children to grandma's house and get high and then come back and get their kids," she said.

Powers is skeptical of this reasoning. "Imagine having to deal with a child when you are coming down from a high or in withdrawal," she said. "I think these are the most dangerous times for children."

Brown said it was more than just his cousin's drug use that worried the family. It was the whole dire picture, he said. "She had no home, no job. She couldn't take care of herself, much less a newborn baby."

Still, the child protection worker allowed Chloe's mother to leave the hospital with the baby. This began a year-long dance between an emotionally involved caseworker and a mother who seemed to love her children but was overwhelmed by the strength of her addiction.

What happened when Chloe's mother frost left the hospital with her baby boy is not clear. When a case is referred for services, as Chloe's mother's was at that point, there is no court record of what happened. In August, five months later, the case was closed because the family was "inactive."

How the department should handle families that don't want to participate in services is a theme in Kane's reports. Maganzini said DCFS workers could seek a protective order--which mandates the parent participate in services-but that they very seldom do. Thomas, the DCFS deputy director, said her workers only go to the state's attorney's office when they want to take custody.

Cook County Public Guardian Patrick T. Murphy, whose office represents foster children in court, said protective orders fell out of favor because they clogged up the courts.

But, in Chloe's mother's case, DCFS was soon made aware that the family was still struggling. In October, another family member called the hotline to report that Chloe's mother was leaving her 5-monthold baby and DeMario with her 93-year-old grandmother. Once again, DCFS child protection workers substantiated a case against Chloe's mother, this time for inadequate supervision. And once again, they referred her for services.

This time Chloe's mother's case landed on Lay's desk. Sitting in her office, crowded with boxes of case files, Lay said she often gets families that need more than she can offer. But DCFS has a no-reject policy, meaning the agencies it contracts with can't pick and chose which cases it takes.

Lay said it's common for her to get mothers, like Chloe's mother, who have long-time drug problems, no jobs and no homes. Finding these women all the services they need to become functioning parents is difficult, especially in resource-starved neighborhoods in Chicago.

Most of the services to which Lay refers parents are community-based programs, and being involved with DCFS does not mean they get priority. "You can't very well tell someone who needs counseling that in order to get it they need to take two trains to Rogers Park," she said.

On top of that, many of the parents Lay works with do not want help. But she said she gets a lot of heat from DCFS workers if another hotline call about the family is placed or if Lay herself feels it is necessary to bring the children into custody. "The child protection workers are mad as hell at us," Lay said. "They look at us like we aren't doing our job."

Lay handed Chloe's mother's case to one of her workers, and that worker became entangled in the case, confidential case files obtained by the Reporter show. In October 2002, during their first phone conversation, Chloe's mother was reportedly surly and told the caseworker that she was about to be thrown out of her sister's South Holland house. In short order, she needed a place to stay and some income, she said.

The worker told Chloe's mother that finding her an apartment was not a priority because first they had to deal with her drug addiction. When the caseworker called a week later, the sister told the caseworker that Chloe's mother wasn't "going to do right so [the sister] had to let her go."

Chloe's mother went to her mother's apartment. And, for a month, the caseworker visited her often and tried to get her life in order. The caseworker typed out Chloe's mother's resume, enrolled DeMario in school, arranged for the children to have their proper immunizations and took Chloe's mother to pick up an application for WIC, a government program that provides nutritious food for low-income children under the age of 5. She also managed to get Chloe's mother to submit to a drug test.

But, in late November, Chloe's mother began to back away. For two weeks straight, she was not home when the caseworker went to see her. Finally, on Dec. 10, she appeared at the window, saying to the worker "she realized she could not hide any more."

Chloe's mother was noticeably pregnant. The caseworker also had results from the only time she had taken a drug test: She had tested positive for marijuana and cocaine.

Throughout this time, the worker wrote in her case notes that the children appeared healthy. But Brown said family members were distressed by what they saw. Her 1-year-old son was being fed sugar-water instead of milk, and, whenever he went to visit his great-grandmother, he would have diarrhea. "The baby was really little," Brown said. DeMario said many times his mother would leave to go out for the night and not come back until the next day. At these times, the 11-year-old was being left to take care of his brother. DeMario said it made him feel good to wash his brother and feed him. However, he said he was sometimes scared and hungry. Brown adds that, during this time, DeMario lost 20 pounds. "Yet they kept saying everything was okay."

Chloe's mother resisted getting drug treatment and prenatal care. The first time she saw a doctor about her pregnancy was less than a month before Chloe was born. The caseworker warned her that, if the baby tested positive for drugs, the state could remove the child.

In the weeks before Chloe's birth, her mother's mood seemed to swing. At times she seemed desperate to find a way to keep her children, even offering once to take daily drug tests. Other times, she became angry at the caseworker, telling her to leave her alone. And a few times, she seemed hopeless and depressed, confessing to the worker that she couldn't handle it, and that her children would be better off without her.

The caseworker was always able to talk Chloe's mother down from giving up on her children, convincing her to keep trying.

Chloe was born on March 18, 2003. Because of the drugs coursing through her system, the state hotline was called again. The child protection worker initially made Chloe's mother leave the hospital without the baby.

But, a week later, after securing Chloe's mother's promise that she would go to treatment, the caseworker let her take Chloe home. Her family was shocked, as were the staff at Chicago Commons. "We tell these mothers this is what will happen if you do this. Then they do it, but nothing happens," Lay said. "It makes us look like liars." The case was kept open for services with Chicago Commons.

On the morning Chloe's mother was to go to the Women's Treatment Center, at 140 N. Ashland Ave., the caseworker from Chicago Commons showed up at Chloe's grandmother's apartment at 5:45 in the morning. Chloe's mother wasn't there. According to the caseworker's chronology of events, the caseworker began getting the children dressed to take them into protective custody when Chloe's mother ran into the apartment, breathless.

The caseworker decided to take Chloe's mother to treatment, albeit a little late. Chloe's mother was allowed to take the newborn and her 1-year-old son, but DeMario had to stay with his grandmother.

During the month Chloe's mother spent at the treatment center, she had her ups and downs as she tried to confront her past and look directly at the future. She wrote poems, something that Brown said his cousin did throughout her life. In one of them, she writes, "I see shame on this tired face."

Chloe's mother was also belligerent at times, cursing at others and proclaiming that getting better was too much. On May 4, 2003, while Chloe's mother was in the throes of a rage, treatment center staff called the police-and she was kicked out of the program.

Within a week, the caseworker was back ringing the doorbell at her mother's apartment, but getting no answer.

Officials say the caseworker could have called child protection and made a hotline report. DCFS protective services could have gotten the police to search for the mother. None of this happened.

Lay could've tried to bring the case to court herself, but caseworkers from private agencies must wait three weeks for a court date. Lay said three weeks is usually too long if a child is in danger. In this case, a three-week court date would not have mattered. By that time, Chloe was dead.

In retrospect, Lay said she would've done some things differently, such as relying more on the caseworker's notes than on her verbal reports. And she'd have paid more attention to the case had she known Chloe's mother was depressed. But Lay said she thinks what happened is indicative of a child welfare system that pushes too much off on families and does not take enough action itself. The children's grandparents and aunts and cousins might see what's going on, but, if DCFS doesn't make them official foster parents, they have no right to tell the parent what to do.

Too often, the families feel isolated and the children are left in unsavory environments.

But DCFS' Thomas said she does not believe this is true. She and Manuel said social workers and others who say children are left in unsafe situations do not know what they are talking about. Thomas said there is a difference between being at risk and being in danger. "Some children will be at risk all their lives just because of the circumstances they are born into. We cannot do anything about that. But, if a child's safety is compromised, he will be brought into the system."

Concerns about keeping the caseload down do not play into any of the decision-making, Manuel added.

Yet their boss, Samuels, knows people on the front lines are worried about some of the children who are left with their families. Before he was appointed to direct DCFS, he was chairman of a taskforce appointed by Blagojevich to examine the state of the child welfare system. As a result of the taskforce's work, he authored a report in which he noted that only five of every 100 children investigated for maltreatment became formal DCFS cases.

This rate has been declining in recent years, which, Samuels writes, is evidence to some that resources are now used more efficiently, with child welfare dollars serving only those cases in which there is documented serious maltreatment. "But the majority of those who contacted the Task Force were less certain this was the case, noting that failure to substantiate a report does not necessarily imply that a child is being well cared for or that the parent is capable of meeting the child's physical and emotional needs."

Thomas said DCFS is working to make sure it has solid links with community-based services and the Department of Human Services so that struggling parents can access all the services they need.

Advocates add that DCFS has to be careful before it takes a child from his or her parents. When this happens, children can get hurt profoundly, said Richard H. Calica, executive director of the Juvenile Protective Association, which provides services to families involved with DCFS and consults with states on how to improve investigations into child abuse and neglect.

"It is like an arm being amputated," he said. "Sometimes you have to amputate an arm to save someone's life, but it doesn't change the fact that once you lose an arm, you'll never be the same again."

Murphy, the public guardian, said one of the problems is that when DCFS does take a child into foster care, it doesn't mean the child will end up in a safe, nurturing haven. Murphy has filed a lawsuit charging that the foster care system is failing children: bouncing too many from place to place, and not providing them with adequate psychological services and academic help.

But Brown said his family members felt as though they were waging a war by themselves to save Chloe and her brothers. In the process, the family became weary and cynical about helping. Now they're left with the hardest task of all-trying to raise Chloe's surviving siblings. The youngest one, now 2, is with Palmer's distant cousin, Brown said. Born substance-exposed, he cries all the time and has trouble feeding himself-and talking in full sentences.

DeMario, now 13, is living with Brown. He is a good kid but somewhat mischievous at school, Brown said. He's also struggling to catch up academically. "For five years, he hardly attended school, so now doing homework is really hard for him. That is my biggest problem with him," Brown said.

Sitting in Brown's dining room in May, DeMario said he was upset because he'd been suspended from school that day. As a result, he was grounded. Like many other teenagers, he is most animated when talking about girls and playing football and video games. When he grows up, he said, he would like to play professional sports.

But, when talking about his past, he spoke in short, almost mumbled sentences with his head slightly lowered. He softly said that he didn't understand why caseworkers kept leaving him with his mother, even as she kept leaving him by himself.

He said he does not want to go back to live with her because he'd be too afraid she would leave him again. But he worries about her being "all the time on the street all alone, not doing right."

DeMario also misses his little brother, whom he has only seen four times since Chloe's death. Smiling, he said he likes to play with his little brother: "I let him beat me up."

DeMario said he doesn't remember much about Chloe, except that she had long toes and long fingers, and that she wasn't a fussy baby. He has no pictures of her. None were ever taken.

And he's never been to her grave. She's buried in Mt. Hope Cemetery in a little area, called "Babies Forever," set aside for children who are wards of the state or whose families are so poor they must depend on the state to pay for the burial. Some of the graves have small tombstones; others are decorated with pinwheels, teddy bears and balloons.

But, like many of the graves, the place where Chloe is buried is just a patch of grass. The only way to find it is to take five steps from the beginning of Row 54, which is marked by a wood stick.

"They should have put us somewhere safe," DeMario said. "Then, even if Chloe rived in another foster home, at least I could have visited her."

Contributing: Nicole Drummer. Kimberly A. Evans, Scott Krischke, Erin Meyer, Latricia J. Taylor and Paula Wills helped research this article.

THE NUMBERS

Premature Deaths

Since fiscal year 1999, more than 400 children have died within the
year after their families had contact with the Illinois Department of
Children and Family Services. In fiscal year 2003, 122 children died
under those circumstances, nearly 50 percent more than in fiscal year
1999. And, while most of the deaths have been either due to natural
causes or ruled accidents, the department's inspector general has
noted that many of the deaths could have been avoided.

CHILD DEATHS

CAUSE OF        FY     FY     FY    FY    4-year
DEATH          2000   2001   2002  2003    total     %

Accident        26     31     17    31     105       25
Homecide        20     20     16    25      81       19
Natural         34     43     51    57     185       44
Suicide          1      1      4     1       7        2
Undetermined    16      8      9     8      41       10
Total           97    103     97   122     419      100

Notes: "Accident" includes deaths by car accidents, sleeping accidents
and fire. "Natural includes stillborn children.

Sources: Illinois Department of Children and Family Services, Office of
the Inspector General Annual Reports from 2001, 2002, 2003 and 2004;
analyzed by The Chicago Reporter.

EDITOR'S NOTES:

The Chicago Reporter chose to examine the death of Chloe Palmer because, while it was not the most dramatic, her story includes many of the recurring themes in the reports by Denise Kane, the inspector general of the Illinois Department of Children and Family Services, and highlights several prevalent policy issues. Her case file also revealed the complicated and emotional decisions made in many of these cases.

The Reporter, however, elected not to disclose the identity of Chloe's mother. While DCFS found enough evidence to substantiate a report of neglect, Chloe's mother was never charged with a crime in connection with Chloe's death. The Reporter made several attempts to contact Chloe's mother, both in person and by mail, but was unable to locate her for an interview.

Much of the information in the article about Chloe's mother came from confidential juvenile court documents obtained by the Reporter and from Chloe's relatives. As is always the case, the Reporter fact-checked all information in the article with primary sources.

For more examples of cases highlighted in the annual reports of the Office of the Inspector General, visit the Reporter's website at www.chicagoreporter.com.