(This is a copy of the original story on the AJC site.)
Reprinted with the permission of the Atlanta Journal and the Atlanta Constitution.

[The Atlanta Journal-Constitution: 12.05.99]

State law requires local experts to review unexpected deaths of children. But many counties ignore the law without penalty.

By Jane Hansen
Atlanta Journal-Constitution Staff Writer

Doctors say Raymond Ellis was neglected in life. In death, he was forgotten.

The Legislature had just this kind of case in mind in 1990 when it set up a child fatality review process. A team of experts would convene whenever a child died unexpectedly to see whether government agencies had done all they could and to recommend appropriate changes.

But no lessons were learned after Raymond's death, although doctors, educators and others believed Raymond could have been saved. The review team never met to go over his case.

The boy's suffering began when he was 19 months old and was struck by a car, leaving him paralyzed below the waist and in need of constant medical care. 

By the time he was 3, public health officials reported to Sumter County DFACS that the toddler's mother had knocked Raymond and his brother to the floor with her fists. Two months later, another caller said Raymond had suffered second-degree burns in his bath. 

For the next 14 years, many people reported their concerns about Raymond's treatment by his mother, at times pleading that the agency move him to a safer place. But Raymond remained at home, state records show, even as allegations mounted:

May 1986: Raymond is burned on his thigh and leg.

June 1987: Raymond is "covered in burns" and old burn scars. 

December 1987: Raymond comes to school with a clean diaper over a dirty one.

January 1988: Raymond is left at the bus stop in a cold, wet wheelchair. 

February 1991: Raymond's mother wants to remove him from the hospital against medical advice. 

Raymond's mother consistently denied hurting him. The burns in the bathtub, she told caseworkers, occurred when Raymond, then 2, turned on the hot water. And he caused the burns covering his body, she said, as he got in and out of his wheelchair. The mother at one point told caseworkers she was a "good mother" and did not need them in her life.

Caseworkers concluded the family was under a lot of stress because of the child's medical problems, and they believed she didn't fully understand their severity. 

By March 1994, a caller alleged that Raymond's mother removed him prematurely from a hospital after surgery, case records show. As a result, doctors said, he developed a massive infection that forced them to amputate his left leg. Physicians pleaded with the agency to get him out of his house. 

"His life expectancy will be jeopardized without proper care," one physician wrote.

Another doctor expressed similar concerns. But caseworkers assured him that they would "monitor" the situation. 

By May 1996, the same doctor notified the agency that Raymond had developed more sores as well as psychological problems. He urged that Raymond be hospitalized in Atlanta. "I think this is a serious matter that is potentially life-threatening and ...clearly limb-threatening." 

Two months later, the physician again pleaded with the department to take custody. 

"He is dying from his pressure sores," he wrote. "I fail to understand the basis and justification for inaction." 

Although a number of child welfare workers knew of Raymond's plight, the agency later concluded they rarely held his mother accountable and may have feared her growing hostility. 

By June 1997, doctors were forced to amputate Raymond's other leg. A third physician asked DFACS to take immediate custody of Raymond. 

"I am extremely concerned about Raymond's home situation, especially the obvious lack of compliance and care his mother exhibits," he wrote. He said Raymond was "extremely malnourished and clinically depressed." 

The surgery would be risky, the physician wrote, but it was "the only way we can save his life." 

By then, it was too late. On July 7, 1997, Raymond died from massive infection. He was 16.

An internal report by the state DFACS office, never distributed outside the department, said the agency had "failed to protect a very vulnerable child from maltreatment." 

"One can only imagine how much Raymond suffered throughout the years of neglect," it said.

Lulean Laster, director of Sumter County DFACS, said Raymond's death led to the dismissal of one employee and stronger oversight by supervisors. But she insisted her staff had tried hard to find a program that would take him. 

"The resources for any fragile child, not just Raymond, are really truly not available," she said.

Under a 1990 law, local teams representing police, prosecutors, child welfare workers and others are to review all suspicious, unusual and unexpected deaths of children under 18. 

But the law has lacked enforcement power, and in the last three years, about half the deaths of children that should have been reviewed under the law were not.

The Sumter County team never learned the details of Raymond's life and death. That's because Sumter County District Attorney John Parks, then the team's chairman, refused to review the case, says Eva Patillo, director of the Office of State Fatality Review. She called three times urging his committee to look at Raymond's death and make a report to her office.

Raymond "could have lived, he should have lived had he been taken care of properly," Patillo said.

Parks says at the time he considered child fatality review an unfunded mandate from the state. "Hopefully we've straightened that situation out," said Parks. "We don't have more funding, but we're participating more fully."

Even if the Sumter team had reviewed Raymond's death, the public wouldn't have known what it found. Under state law, those findings are considered confidential, and are not even shared with DFACS. 

At the least, Patillo said, Raymond's death should have prompted a review to determine what needed to change. "I don't understand," she said. "People are making poor decisions and administrators are signing off. When it's all said and done, what's done to correct it?" 

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