By the time he was rescued last year, the 5-year-old South Los Angeles boy was so malnourished his kidneys were failing. His hands were so badly burned he could barely open them.
Child welfare officials traced his history, trying to make sense of what had happened. According to documents obtained by The Times, they learned that eight separate agencies in Los Angeles County had pieces of information on the household:
One had evidence that the mother and her girlfriend were abused and neglected as children. Others knew both had committed violent crimes. Still others were aware that both women had been ordered into mental health treatment and that the sickly boy had missed appointments with county doctors.
Over the years, these agencies had come into contact with the boy or his caregivers 108 times -- yet no one had pieced together how much danger the child was in. Indeed, county social workers had closed a 2005 child abuse investigation because the evidence was "inconclusive." They might never have stepped in but for a concerned stranger who delivered the child into their hands.
It was a lesson in how poor communication had put a child's life at risk -- but it was hardly the first. For at least 18 years, Los Angeles County has repeatedly received urgent and sometimes gruesome reminders that its agencies don't share vital information about potentially abused or neglected children, according to a Times investigation.
There have been numerous calls for reform -- but little action. In the passing years, an unknown number of children have been harmed or killed.
At least a dozen reports have landed on county leaders' desks since the early 1990s saying agencies that work with troubled families must improve their ability to talk to each other. County supervisors have freely admitted that the system is broken, and even have voted several times to establish computer systems to open communication channels.
Solutions have been doomed by bureaucratic infighting, turf wars, privacy concerns and limited political attention spans. When horrific deaths or abuse drop out of the news, the board and department heads often focus elsewhere, leading to long stretches of inaction -- until another case gives them a terrible jolt.
"I couldn't believe it," former Supervisor Yvonne B. Burke said last year, upon learning of the 5-year-old's ordeal. "Our system has to be just tighter. . . . This is a time when we really have to be vigilant."
She joined her four colleagues in once again ordering county workers to draft a plan to improve information sharing. The plan has yet to materialize.
Meanwhile, county officials recently acknowledged that at least 32 children in L.A. County died from abuse or neglect in 2008. That set off another round of questions about what was needed to make kids safer.
"If we had a computer system that allowed us to the see the domestic violence, medical or mental health history in some of these families, some of these children might have been saved," said Trish Ploehn, director of the county Department of Children and Family Services.
To those who have followed the issue over the years, these words are sadly familiar.
Baby boy starves
The evidence was there for all to see in 1991.
A baby boy, Travon S., had starved to death. On sheets of paper stretching across two walls, then-Sheriff's Det. Ron Waltman diagramed in rich detail how Los Angeles County had repeatedly failed the child.
His audience included dozens of people -- officials from the coroner's office and Family Services, supervisors' appointees, health authorities and others. Police had known about violence between the parents and drunken brawls with neighbors. County doctors had treated the child, even dispatching health workers to find him after missed appointments. Family Services workers had investigated allegations of child abuse.
Ten agencies in all had connected with the family 52 times over the years, starting before Travon was born -- but, as Waltman made abundantly clear, none were talking to the others.
"People just snapped to attention," Deanne Tilton Durfee, the longtime director of the county's child abuse task force, recalled in 1995. "It was beautiful to see how dumb we really were."
County supervisors tapped Tilton Durfee to push for changes in Sacramento. The next year, legislation was passed intended to make it easier for mental health, medical, educational, criminal and family services agencies to share records. For Los Angeles County, such a computerized system would cost little to operate -- about $600,000 a year.
But the effort quickly lost steam.
For nine years -- from 1992 to 2001 -- the system was stalled as L.A. County agencies squabbled over who should pay what for the system and which staffers should be allowed to use it, said Tilton Durfee.
Four more years went by as the union representing social workers argued that the system would unreasonably increase workloads, Ploehn said. The union did not respond to a request for comment.