Missteps left child in extreme danger.

Byline: Bill Bishop The Register-Guard

People who watch over the community's children detected the bruises, diagnosed the anxiety and documented the declining mental health of 5-year-old Lacey Folenius.

But they did not remove her from danger.

Lacey died two days before Christmas 2004 from a blow that tore her intestine in three places. She bled to death before her father's girlfriend, Nicole Rafael, summoned help. Rafael is serving a 17-year prison sentence for Lacey's death. Her projected release date is March 4, 2021.

While state child protection workers did not kill Lacey, they failed to save her from a family torn by drugs, abuse, neglect, chaos and deceit.

Although seven agencies were addressing the family's problems, no one critically examined the explanations that Rafael gave for Lacey's injuries. This happened even though Rafael was on probation for felony assault, had a long criminal history and four poor psychological evaluations.

Instead, Department of Human Services officials discounted abuse reports by Lacey's bus driver and at least one relative.

A review of Lacey's case by the state Department of Human Services, a routine followed whenever a child dies of abuse, listed the following mistakes in Lacey's case:

No one addressed Rafael's inability to parent the six children in her household, in spite of psychological evaluations of her that expressed serious reservations about her ability.

Caseworkers did not consider Lacey's safety. They did not look at parent conduct, but instead focused on the behavior of the other children in the household.

Social workers failed to talk to children removed from Rafael's care to learn about conditions in her household, and failed to follow up on abuse information they did receive from one child.

Agencies that provided services to the family produced conflicting reports for the chief DHS caseworker about the care of the children and the parenting ability of Rafael and of Lacey's father, Aaron Folenius - leading to decisions to support the parents' desire to keep all the children.

Ongoing injuries to Lacey were reported by Head Start and others to the family's DHS caseworker, who investigated. Instead, the reports should have gone to a separate child protection worker for investigation.

DHS lacked a comprehensive strategy to involve outside agencies and family members to meet Lacey's needs.

DHS should have enlisted an outside consultant with expertise in complex and difficult cases to advise front-line workers and review results.

While Lacey's suffering reveals glaring mistakes, it also underscores the urgency of changes that are under way - some as a direct result of her death.

Lacey's records - along with records acquired by The Register-Guard outside of official channels, inferences from the incomplete documentation and interviews with people who knew Lacey - convey a home that was in constant chaos.

It was a blended family of six children ages 9 months to 11 years. Lacey was the youngest of the four children of Aaron Folenius, then 30. Rafael, then 23, had a child from a previous relationship and another with Folenius.

Early in their lives, the children were neglected by drug-abusing parents and developed emotional and behavioral problems as a result. Even so, Rafael apparently exaggerated their bad conduct in order to conceal her own.

Three of the Folenius children were removed periodically to foster care throughout 2004 for treatment of aggressive behavior toward one another. Lacey was made a ward of the state, but was kept in her father's - and thus Rafael's - custody.

The chaos, and bureaucratic confusion over what to do about it, concealed Rafael's treacherous abuse of the children.

State records and interviews with her relatives show Rafael to be a chronic liar and manipulator, a product of the state foster care and juvenile corrections systems, a violent offender on probation for felony assault - a person whom the social workers nonetheless believed whenever they sought an explanation for one of Lacey's many injuries.

In the aftermath of Lacey's death, Rafael's deceit became all too clear to them.

"She lied a lot and deceived people," said Albertine "Joyce" Mitchell, mental health consultant for Head Start. "She would do things that made her appear to be a super mom."

Even so, the signs of Lacey's abuse were abundant, and obvious - at least to Head Start bus driver Ellen Shaw.

Shaw recorded and reported dozens of Lacey's black eyes, bruises, cuts and scrapes.

Head Start officials passed along those reports to DHS, in accordance with Head Start and DHS procedures, according to Head Start Director Carol Lynn "Annie" Scudder Soto.

But Head Start documents also indicate that agency workers may have violated Head Start policy by speaking to Rafael about possible incidents of abuse before the incidents were investigated - thus affording Rafael an opportunity to concoct a lie to cover the injury. Shaw believes that this happened, and that it caused Head Start workers to lose their objectivity and become vulnerable to Rafael's manipulation.

"This went on and on and on," Shaw said. "They didn't listen to me. They didn't listen to Lacey."

Abuse reports went to DHS social service specialist John McClure, the lead caseworker for the Folenius family. McClure, who at the time had 10 years of experience in child welfare services, declined to be interviewed for this article.

In response to the number and severity of the children's problems, DHS coordinated a multiagency response in 2004. The agencies planned to provide intensive home-based services, case management, family therapy, individual therapy and on-call support, according to agency records. They also obtained psychological examinations of Rafael and Folenius.

The DHS approach satisfied no one - not the parents, not the social workers. Head Start officials were particularly critical of how it failed to address Lacey's problems.

`We heard `budget cuts' a lot. `We don't have the money for this.' They kept saying that,' Aaron Folenius said. "That's ridiculous when you've got a family asking for help. That's not what you want to hear when you go to your government, your state, for help."

By late May 2004, Head Start's Mitchell was documenting her frustrations in Lacey's Head Start file. She complained of a lack of follow-through on promises of counseling for Lacey and wrote, "They (the family) have not been serviced effectively for the past six months, only to be told that now they are out of funds and their case will be transferred (to another counseling service)."

Mitchell offered to use Head Start money to pay for counseling for Lacey because other agencies had not provided it, according to Head Start records. Lacey died before her first scheduled counseling session. In a recent interview, Mitchell and Soto said Head Start employees had been so concerned about Lacey before the summer break in 2004 that they requested extra steps be taken to monitor her condition until school started again in the fall.

Arrangements were made to step up home visits by McClure, and he did 12 of his 21 home visits in this four-month period, according to DHS records.

In spite of their concerns, in November, two Head Start officials - Mitchell and a family advocate who worked closely with Lacey's family - wrote letters to a judge in support of McClure's recommendation that Lacey not be taken into foster care.

Soto said those were the first and will be the last letters of advocacy that Head Start will write to Juvenile Court.

In the aftermath of Lacey's death, Soto said, Head Start officials came to realize how shrewdly Rafael deceived them.

"There were so many agencies, and so much government money spent on this family," Soto said. "And it still happened right in front of our eyes."

She said her staff did nothing wrong in Lacey's case and no staff discipline resulted from Lacey's death.

The agency's child abuse reporting policy was revised to clarify reporting procedures and to emphasize that no staff member is to discuss a potential case of abuse before it is investigated by DHS, according to Head Start records.

At DHS, Lacey's death generated a vigorous internal review in which people were asked "tough questions," said John Radich, DHS manager for the Lane County area.

He said the many needs of the children in Lacey's family - including those who had been taken into foster care - clouded the picture of what Rafael was doing to Lacey.

"Some people got so focused, looking at placement moves (for the other children), they weren't looking at the current placement (of Lacey)," Radich said.

The tragedy changed how DHS handles new reports of abuse in families that already are involved with DHS and have a caseworker, he said. In Lacey's case, new reports of abuse went to the family's regular caseworker.

Today, new reports go to a caseworker other than the one already assigned in order to bring fresh eyes to the situation, he said.

Also, when abuse is investigated, caseworkers no longer can close the case without review and approval of a supervisor to ensure that the inquiry was thorough, he said.

The agency's case review did not turn up any egregious errors on the part of DHS workers, Radich said.

"People do get asked tough questions," he said.

"Our staff feels like they are under a microscope. The community and the Legislature want accountability."

Lane County DHS, along with DHS offices statewide, are in a continuous "fine-tuning" process aimed at putting child safety at the forefront of every decision social workers make in trying to help troubled families, said Una Swanson, DHS child protective services manager.

The state agency is challenged by staff turnover, which creates a younger work force requiring clearer rules and tighter supervision in doing what is a tough job for even the most experienced caseworkers, she said. Dwindling resources are another challenge.

"We need to stay focused. Our job is child safety," Swanson said.

"There is always something we can improve. There is always a lesson to be learned. There will always be situations where people make choices that may cause great harm or the death of a child. There will be a part of that which will be out of our control."

- Bill Bishop

CHILD ABUSE: In Lane County, DHS has 108 workers and 1,011 children in foster care. They get 800 to 1,000 abuse reports each month. Job turnover for DHS caseworkers is 16 percent annually, for a job that requires three to five years to gain proficiency. Up to 40 percent of local caseworkers have less than three years of experience. Statewide in 2005, DHS got 55,114 reports of suspected abuse, up 18.5 percent from 2004. Of those, 11,255 reports were confirmed, up 6 percent from 2004. Child abuse reports statewide doubled in the past 10 years. The number of victims in 2005 was a 10-year high. Half are under age 6. Over the past decade, an average of 19 children have died annually from abuse and neglect. The high was 34 in 1997. Eight, including Lacey, died in 2004. - Oregon Department of Human Services