School nurses saw bruises. Teachers were so worried about bone-thin Lindsay Gentry that they brought her extra food and weighed her every day.
They reported their suspicions of child abuse at least 15 times to social workers, who investigated but found nothing wrong before the severely disabled girl died in 1996. On Tuesday, a jury held her parents responsible for her starvation and neglect.
"In this case, Lindsay fell through several cracks" in the county's child welfare system, said Deputy Dist. Atty. Kathleen Cady, who prosecuted the case that resulted in last week's involuntary manslaughter and child abuse conviction.
To better protect children like Lindsay Gentry, a countywide effort is underway to foster closer cooperation and better communication among agencies that handle child abuse.
The Child Abuse Protocol, a handbook being developed by prosecutors and representatives from law enforcement, child welfare, courts, public health, schools and other agencies, is designed to promote cooperation and information-sharing. Close to being finished, it is expected to be released and implemented countywide this fall.
"The protocol will be a resource that all of these agencies can go to for directions on what to do for [child abuse] cases," said Assistant Dist. Atty. Bill Hodgman, co-chair of the task force in charge of the two-year effort to draft the document.
Child abuse cases typically require the attention of many agencies, which means there is bound to be some friction among them or lapses in how they work together if the organizations are left to their own devices, experts say. An allegation may come to the attention of social workers by way of school employees, as in the case of Lindsay Gentry. The child may be treated by doctors, who can also report and document abuse. If there is a crime, law enforcement gathers evidence, and prosecutors consider charges. The case may proceed to a dependency court or to a criminal court.
At each step, one agency might fail to pass on vital information concerning the child or inadvertently do something that impedes the work of another.
"Workers in one agency may not fully understand what others can do and how they can work together," said Terry B. Friedman, presiding judge of Los Angeles County Juvenile Court. "That's a particular problem this protocol will overcome."
In Lindsay's case, despite teachers' repeated reports of abuse to the county Department of Children and Family Services, Cady said, social workers never told the girl's doctors about the full extent of the allegations.
For example, a teacher who made Lindsay drink a liquid nutritional supplement twice a day noticed that the girl would gain 1 or 2 pounds from Monday to Friday, the teacher testified during the recent trial of Michael and Kathleen "Katrina" Gentry.
But after Lindsay spent a weekend at home with her parents, she returned to school on Monday 1 or 2 pounds lighter than her Friday weight. At the time she died, Lindsay was 4 feet 6 and weighed 44 pounds.
The fluctuations in Lindsay's weight, evidence that she wasn't getting enough food at home, were not reported to her doctors, who for years were not alarmed at her extreme thinness because she suffered from myotonic dystrophy, a muscle-wasting disease. Doctors "were not even informed about the issues about her losing weight," Cady said.
And had the police been informed by county child welfare officials of the many abuse complaints against Lindsay's parents, a criminal investigation and prosecution might have been launched earlier, said Donna Wills, head of the district attorney's Family Violence Division and co-chair of the Child Death Review Team.
"Right now, people aren't communicating, and that is what's causing the gap in services," Wills said.
Those working on the protocol emphasize that while the Gentry case highlights communication lapses centering on the Children and Family Services department, the protocol is designed to improve how all the agencies interact.
"Historically, there have been failures in every agency, every department," said Deanne Tilton Durfee, executive director of the Inter-Agency Council on Child Abuse and Neglect and co-chair of the protocol task force. Creation of a protocol was recommended by a statewide report issued by Gov. Gray Davis's Office of Criminal Justice Planning.
Final approval of the protocol is but a meeting or two away, task force members said.
The protocol won't change existing law, but it will set forth "best practices for a sensitive and appropriate and effective handling of child-abuse cases," said Jane Blissert, head of the San Fernando Branch of the district attorney's office and a task force member.
For example, the protocol contains sections that encourage agencies to do a better job cross-reporting abuse allegations to other agencies.
It is a reminder of the do's and don'ts that can help or interfere with the duties of other agencies, such as how to handle and document evidence.