First of three parts

Fraternal twins Tariji and Tavont'ae Gordon were born together but died two years, eight months, 24 days apart. One was buried in a potter's field; the other was disposed of in a shallow grave covered by earth, plywood and a sheet of tin.

Tavont'ae suffocated at 2 months of age while sleeping on a couch with his mother, Rachel Fryer, who later tested positive for cocaine. Child welfare authorities took Tariji from Fryer and put her in foster care. Then they gave her back, convinced Fryer had tamed her drug habit and neglectful ways. Three months later, Tariji was killed by a blow to the head.

Fryer stuffed Tariji's body into a leopard-print suitcase, caught a ride and buried her 50 miles from her Sanford home. The girl's pink-and-white shoe, an unintended grave marker atop freshly turned dirt, was the only hint of her life and death.

The twins joined a sad procession of children who died, often violently, after the Florida Department of Children & Families had been warned that they or their siblings could be in danger.

They tumbled into canals and drowned, baked in furnace-like cars, were soaked in corrosive chemicals, incinerated, beaten mercilessly, and bounced off walls and concrete pavement. One was jammed into a cooler posthumously; others were wrapped like mummies to silence their cries, flattened by a truck, overdosed and starved. An infant boy was flung from a moving car on an interstate. A 2-year-old girl was killed by her mom's pet python.

The children were not just casualties of bad parenting, but of a deliberate shift in Florida child welfare policy. DCF leaders made a decision, nearly 10 years ago, to reduce by as much as half the number of children taken into state care, adopting a philosophy known as family preservation. They also, simultaneously, slashed services, monitoring and protections for the increased number of children left with their violent, neglectful, mentally ill or drug-addicted parents.

The result: Many more children died.

"They want to keep families together," said James Harn, a 30-year law enforcement officer who spent his last nine years supervising child abuse investigators at the Broward Sheriff's Office. "But at what cost?"

Prompted by a series of high-profile deaths, a Miami Herald investigative team dug through six years of DCF deaths "verified" by the state as abuse or neglect, starting with Jan. 1, 2008. The Herald focused on those deaths in which the family had at least one encounter with child welfare over the previous five years.

Among the Herald's findings:

• The number of deaths with prior contacts totaled at least 477, far more than child welfare administrators reported to the governor and Legislature. Lawmakers could have committed more money to address the problem had they known its full scope. Instead, they cut funding.

• The overwhelming majority of the children were 5 or younger, and slightly more than 70 percent were 2 or younger — in many instances, too young to walk, talk, cry out for help, run away or defend themselves.

• Drugs or alcohol were linked to 323 of the deaths, and yet the state cut dollars for drug treatment. Children snatched their parents' pain pills off nightstands, gobbled them and died. They were smothered by moms who passed out while breast-feeding under the influence. One Hillsborough County couple concealed a loaded semiautomatic handgun under their sleeping baby's pillow during a drug raid. Ulysses Franklin, 6 months old at the time of the raid, survived, was removed by the state and returned only to be crushed by a car months later while left unattended in a parking lot.

• Rather than go to court to force parents to get treatment or counseling, the state often relied on "safety plans" — written promises by parents to sin no more. Many of the pledges carried no meaningful oversight. Children died — more than 80 of them — after their parents signed one or, in some cases, multiple safety plans.

• Parents were given repeated chances to shape up, and failed and failed and failed again, and still kept their children.

Twenty-six times, DCF received calls about Kaleb Cronk's family. The 27th was to report his death when the 1-year-old from Palatka was run over by a tricked-out red pickup truck as he crawled across a private road. Kaleb's mother, Amy Sowell, had been arrested 18 times and had been the subject of repeated DCF reports of chronic drug abuse and inadequate supervision.

"I don't think we are broken; I think we are challenged," interim DCF Secretary Esther Jacobo said in a two-hour interview. "Maybe we got it backwards, in that we tried to reduce out-of-home care before having those safety services that are needed. But I firmly believe if you have those safety services, you should be striving to fix a family. That is our mandate."

Jacobo said the agency is improving its child welfare computer system, revamping its process for studying and reporting on child deaths, and experimenting with other child protection methods, such as having investigators work in pairs on high-risk cases.

Two weeks after Jacobo spelled out her reforms, the latest DCF scandal erupted: It involved Tariji Gordon, Death No. 477.

Tavont'ae and Tariji

In May 2011, Rachel Fryer dozed off on a couch with her newborns. Because of a heart condition, Tavont'ae needed an apnea monitor, but it was not in use — and was later found stashed in the garage. Sometime that night, Tavont'ae suffocated, probably after being wedged under his mother's foot.

After Tavont'ae's death, DCF asked a judge to permanently sever Fryer's rights to her four surviving children. She had already surrendered two others in 2006 after she was accused of selling drugs out of her house. After the death was ruled an accident, Tariji and her siblings were returned to their mother in November 2013 with DCF's blessing.

Two months later, a court-appointed guardian requested a hearing on the children's reunification, citing "pressing concerns."

The request was pending when Tariji was found on Feb. 11 in an unmarked grave in Crescent City.

Fryer denied she killed her daughter, telling police she found the girl unresponsive. However, one of her children told investigators Fryer would cruelly mistreat Tariji, hitting her with a broomstick. Three surviving siblings have been sheltered — again.

Fryer, jailed without bond, is expecting another child.

The undercount

For more than a year, Herald reporters examined thousands of pages of case histories — 1,738 pages on Tavont'ae and Tariji alone. They studied child-death reviews, police and court records, internal emails, autopsy reports, criminal histories and health department reports. The paper interviewed people across the state and sued three times over records.

Those records and interviews collectively show that child welfare administrators consistently underreported the number of verified deaths by abuse and neglect.

"Underreporting and underverification compromise the validity of the statistics (and) make it more difficult to ascertain true progress in combating these problems and, most importantly, defeat efforts to identify causes of preventable death," Bruce McIntosh, a pediatrician who heads the state's Child Protection Team in Jacksonville, said in a March 2011 memo to DCF's top death coordinator.

Florida's death totals per 100,000 kids are generally at or near the top in the nation, although such comparisons are difficult. The federal government keeps a yearly tally, but the numbers are self-reported. Some states don't report their "with priors" totals, including Florida in 2011.

In 2013, the Denver Post looked at six years of child deaths. The Post found 72 in Colorado; the Herald found 477 in Florida. Florida had three times as many children, but six times as many deaths.

History of missteps

Last summer, the Herald detailed the deaths of four children in six weeks, all with a prior family history. The stories elicited an outcry, and DCF's secretary, David Wilkins, resigned.

His replacement, Jacobo, responded to the critical news articles by hiring a national child welfare consultant, Casey Family Programs, to study DCF's operations, including 40 deaths during 2013.

Among Casey's recommendations: Develop an array of services — including free child care, in-home parenting instruction and respite care — to help struggling families, and do away with "promissory note" safety plans.

The report said that investigations preceding a child's death were often incomplete, and that DCF fixates on isolated events and ignores both the underlying cause of dysfunction and the broader picture.

"You can't fix something without understanding it," said Jacobo, who incorporated some of the consultant's proposals into her revamp. "I think we have tried really hard to do that."

Though it was not one of the deaths examined, Milo Rupert's story is indicative of the Casey group's findings. When the agency found a house in Avon Park infested with cockroaches, it saw a pest-control problem, not a mental health or drug abuse issue. After exterminators were summoned and the bugs were banished, DCF walked away.

Over five years, there were four investigations of the household. They alleged that the children were malnourished, slept in urine-soaked beds and lived in a home with "cockroaches everywhere." No one picked up on the degree of child endangerment in the home. Investigators learned later the three girls were being fed mostly Pop-Tarts, when fed at all, and were held as virtual prisoners in a bedroom, peering out at the world through a window coated on the inside with bugs.

One DCF supervisor suggested that some serious problems might lie behind the squalor, but that possibility was not explored — until the youngest child, Milo, died of malnutrition. By the time anyone looked in on the 10-month-old, the cockroaches had devoured much of his skin. Milo's father is serving 24 years for manslaughter; his mother is awaiting trial.

Under state and federal law, removing children from their parents is always a last resort and must be ordered by a judge. Investigators have other options, however, including parenting classes, mental-health counseling, drug treatment and free day care — which a judge can order parents to accept.

Amid a spate of town hall meetings, legislative hearings and continuing criticism, Gov. Rick Scott last month announced a nearly $40 million proposal to reduce investigative case loads, increase internal oversight and steer additional dollars to sheriff's offices that investigate child abuse reports.

That would be an apparent change in direction. The DCF budget has decreased in five of the past six years, sometimes marginally, other times by a lot. Including vetoes, DCF saw its budget cut $100 million in the current fiscal year.

The governor and DCF say they have increased spending on child protection during Scott's term by about $10 million, including hiring an additional 150 investigators, even as the overall budget has shrunk. But the agency includes in its child protection numbers $4 million legislators allocated in one-time funds for redesigning child protection — money that is not used for client services.

Senate President Don Gaetz, R-Niceville, called the state's child welfare system "porous" and conceded that "tens of millions of dollars" are needed to make improvements.

"I think in child welfare we have gone on the cheap, and I think that's been a mistake," he said.

Family preservation

Florida's first effort to shrink the number of youngsters in care was as much about pragmatism as philosophy. In 2002, DCF Secretary Jerry Regier inherited a department overwhelmed with more than 30,000 backlogged investigations. Among the remedies: increase the number of children adopted from state care and reduce the number of children taken into care in the first place.

Five years later, when Bob Butterworth took over, the former state attorney general embraced the drawdown, seeing it as a way to conserve scarce resources, shield children from foster care and, whenever possible, preserve families.

"The trauma of removal, many times, is more traumatic than the abuse," Jacobo said.

But, as more children were left behind in troubled households, spending on services and supervision to protect those children did not keep pace.

From 2003 until the present, the number of children in out-of-home care declined from 27,674 to 18,185 — a 34.3 percent reduction. At the same time, the number of children under in-home supervision or receiving family-preservation services also fell, from 17,079 in 2003 to 12,132 as of January 2014.

As early as 2005, a consultant warned that it appeared investigators were "only working with families who are in the most severe, egregious circumstances." In a report to a Miami watchdog group, Norma Harris said services and interventions for vulnerable children were declining across the board, adding, "There does not appear to be an explanation for the decreases."

"Children under 5 years of age are at special risk of death," the health department's child abuse expert, McIntosh, wrote in 2008, because they were often being forced to remain with parents who could not cope with fussy, crying and hard-to-handle youngsters.

Death of Triumph

The short life and cruel death of Triumph Skinner, one of those 5-and-under children, offered an example of how parents were given the benefit of the doubt.

Keith Skinner told investigators he was a "changed man" following his release from prison, where he was sent after whipping his daughter and punching the girl's mother. Given his past, the agency could have required that Michelle Ford restrict Skinner's access to their daughter and Ford's newborn, Triumph, as a condition of her retaining custody.

It didn't. The agency wrote in a report that Skinner had "served his time for the crime he committed against his own daughter."

With Skinner back home in Orange County, Triumph's world descended into hell. Skinner beat Triumph habitually and would choke the boy into unconsciousness when he cried, reports said. Five months after DCF approved Skinner's return, he attacked the infant in a frenzy of violence. The catalog of injuries to the 7-month-old, which proved fatal, included a skull fracture, torn bowel, five broken ribs, bruises to his eye, shoulder and back. His sister said he "looked like he got run over by a bus."

That miscalculation and others have left loved ones to pick up the pieces.

Michael Barnett visits his three children every other week. They are in a West Palm Beach cemetery. His two sons and a daughter were killed in a September 2010 massacre. After a long and violent history, Patrick Dell shot his estranged wife, Natasha Whyte-Dell — Barnett's former partner — and five of her children, then killed himself.

Dead in the 2 a.m. rampage: Bryan, 14; Diane, 13; and Daniel, 10. Barnett's oldest son, Ryan, 15 at the time, survived a bullet in the neck. The children's half-brother, Javon Nelson, also was killed.

Police had responded to Whyte-Dell's home 34 times over four years and, in late 2009, reported that Dell had threatened her with a knife at a neighbor's house. As Whyte-Dell and a friend crouched behind a door, Dell screamed at her, "You will be going to the morgue!" He then carved an "X" in the driveway and slashed all four of her car's tires. Whyte-Dell obtained a restraining order five months later.

After that encounter, DCF concluded the risk to Whyte-Dell's children was not "serious" and suggested that she and her kids call 911 if her estranged husband turned violent again — advice the agency now concedes was inadequate. In a death review, DCF said the investigator should have at minimum interviewed neighbors and relatives and consulted police.

Barnett, 45, has filed a wrongful-death suit against DCF.

His memories live in old school photos, a necklace crocheted by Diane, a funeral program and three grave markers.

"I sit in my car and cry," said Barnett during another visit to the grave markers of his children. "I can't heal. This is a sore that can't heal."

Times/Herald staff writer Mary Ellen Klas contributed to this report.