Risk factors: the Office of the Inspector General faults DCFS for missing warning signs that turned deadly.

A patron of a bowling alley is so disturbed when he sees a boy getting hit and kicked by a man that he calls police. Staff members at a public health clinic are alarmed after overhearing a girl's father order her, in Spanish, to tell the doctor that her black eyes were the result of falling down the stairs. A mother, recently released from the foster care system, has self-destructive thoughts and high levels of stress and anxiety.

Each of these incidents was a sign that something in a family was awry, but none set off enough alarms for the Illinois Department of Children and Family Services to take definitive action. And, within weeks or months, children were killed by the very person previously suspected of abuse.

"In an alarming number of cases ... death and serious injury could have been prevented had professionals involved with these cases acted more knowledgably about risk factors for violence and strategies to prevent it," wrote DCFS Inspector General Denise Kane in a special report on violence that she included in the appendix of her 2004 annual report, which covers fiscal year 2003.

Each year, the Office of the Inspector General, the independent watchdog over DCFS, examines a number of cases in which a child was murdered after state child abuse investigators or social workers had involvement with the family.

Murders by parents and their partners represent 20 percent of all the death cases.

They include cases like Demitri H. Kozup's. On Nov. 4, 2001, the 2-year-old was allegedly pulled out of a bathtub and violently shaken to death by his mother's live-in boyfriend, 30-year-old Jermayne Thomas, who is expected to stand trial this summer for first-degree murder.

Demitri's mother, Sharon Kozup, said she is now left to wonder how not only did she miss the signs that her boyfriend was too rough with her son but also how trained investigators did, too.

"Everyday I ask myself this," she said.

From July 1, 1999, to June 30, 2003, 57 children were murdered after DCFS had some involvement with their families, Kane's reports show. Seven of the homicides were committed by current or former foster children, some of them inside DCFS housing programs.

In a number of cases, investigations were underway at the time of the deaths, while, in others, abuse allegations were ruled unfounded.

In the special report, Kane faults child protection investigators and private agencies that provide services to families. She writes that they failed to collect sufficient information to grasp the level of risk each child faced, consider other factors such as domestic violence, or appreciate that children are more vulnerable when parents refuse to participate in services. In several cases, Kane recommends that some state workers should be disciplined or fired.

Gailyn Thomas, deputy director of child protection for DCFS, said she will not respond to the inspector general's broad criticisms and recommendations about mistakes in these cases. "Each family has unique circumstances," she said.

However, she said that, when a death occurs, her office reviews the case to make sure that the department's policies and procedures were followed. "We do have to go back and assess what we should have done--did we do it?" she said. "Not what we could have done. We could have done a lot in certain cases--maybe."

Demitri's story is one of the cases Kane highlights in her special report on violence. Kane doesn't include names in her report, but, using dates and details of the incidents, The Chicago Reporter was able to identify the parties.

Seven months before Demitri was killed, a patron of the Stardust Bowl III in Dyer, Ind., called police after he reportedly saw Thomas hitting and kicking Demitri. The boy was huddled against the wall with a coat over his head.

Thomas was charged with battery to a child.

Kozup said she rode with Demitri from the bowling alley to the hospital where he was examined by a doctor. At the time, she said, she was upset that the police had been called. And, when the doctor found no bruising or other signs of injury, she said she felt somewhat vindicated. "I was in denial at the time," Kozup said. "I did not want to believe it."

Since the family lived in Illinois, the police contacted that state's child welfare agency. According to Kane, a child protection investigator talked to the arresting police officer, Kozup and her 5-year-old daughter. Demitri's sister told the investigator that Thomas hit her little brother.

But Kozup told the investigator that Thomas was simply playing peek-a-boo with Demitri, and that the police didn't believe her because they were biased against Thomas, who is black.

Within a few days, Kozup said, she received a letter from DCFS, telling her the department believed the allegations were untrue. Satisfied, she let her family settle back to normal. While Thomas didn't hit her, he believed in corporal punishment as suitable discipline for Demitri.

"At first, I thought that, being that this was my first son and I was young, this is how you discipline boys," said Kozup, who was 23 at the time. "Every time I brought it up to Jermayne, he said that this is how you keep boys in line."

Kozup was confused by Thomas' behavior. While Thomas punished Demitri, he also was attentive to him, helping him tie his shoes and playing with him. And Demitri, she said, was a happy, energetic child, who loved the children's TV show "Blue's Clues" and had a wide smile with big, bright eyes. "He was just a great kid," she said.

After her son's death, Kozup said she was catapulted into a state of regret and anger. "I was lost. I still am lost," she said.

Things got even worse for Kozup. On the same day Demitri died, DCFS took her 5-year-old daughter to place her in foster care with Kozup's mother. And, four months later, when Kozup gave birth to a baby boy fathered by Thomas, DCFS took the child from the hospital and placed him with Thomas' family. "They say I have to prove to them that I won't put my kids in harm's way," she said.

Kozup is especially critical of the fact that the child protection worker did not tell her that Thomas had a long criminal record, including charges for domestic battery. "After the first incident, they called me and said they were sorry for any inconvenience," she said. "They completely closed the case and just walked away. If they'd have pushed a little more or told me about the criminal history, it would have helped me open my eyes."

In her extended write-up of the case, Kane echoes Kozup's sentiments. Kane points out that the south Cook County unit that investigated Demitri's case completed 95 percent of its investigations in fewer than 30 days, which is half the time allowed by law. She writes that DCFS should pay attention to such statistics and review all unfounded cases for the past year.

Kane also criticizes the investigator in this case for closing it without doing a background check. And, though Kozup said Thomas was never violent toward her, Kane implies that she thinks it is at least an underlying issue in this case. Kane reiterates a recommendation she made two years earlier that child protection supervisors should be able to consult with domestic violence experts. The department responded that it is in the process of developing guidelines to deal with domestic violence issues.

While Kane's criticisms focus mostly on DCFS' handling of cases, others note that physicians, police and state's attorneys can add to an investigator's confusion by failing to recognize abuse. "Sometimes they don't want to believe that a mother or father would hurt their own child," said Master Sgt. Richard Roderick, who runs the Illinois State Police's Child Homicide Task Force, which assists local law enforcement in determining whether abuse has caused the death of a child. "I know enough now to sit a parent down and look them in the eye and say, 'Your story is bullshit.'"

Dan Leonhardt, a pediatrician at Children's Memorial Hospital, notes that other social issues besides DCFS' control help create the dangerous mix that leads to children's deaths.

"It has a lot of roots in domestic violence, drug abuse, socioeconomics. But there is also something very preventable about these deaths," he said. "The No. 1 reason people kill their children is because they're crying. We have to teach people what is normal child behavior, and that it's okay to be frustrated."

But Leonhardt said he's often left with the impression that the child welfare system and the state, in general, could be doing more to support families in precarious situations. Every couple of minutes his pager beeps, alerting him to another suspected case of child abuse or neglect. Too often, he sees children with old injuries and old DCFS reports, he said.

"DCFS comes into contact with people who we know have problems dealing with stress," he said. "We don't help them deal with stress. Instead we think time alone will change the situation. Getting families extensive help doesn't seem as important, and it is expensive and difficult."

Contributing: Nicole Drummer.

Demitri's older sister (right) told an investigator that her mother's boyfriend hit bet brother seven months before his death.