When teenager Darlene Armstrong arrived at the emergency room curled on a stretcher, she weighed a skeletal 23 pounds.



In serious condition, the 16-year-old had cerebral palsy and couldn't walk or talk, but the stunned medical staff also focused on her shriveled 3-foot-10-inch frame, her sunken cheeks and protruding ribs.



The doctors at Comer Children's Hospital at the University of Chicago agreed the girl had been starved for some time.



"Darlene has suffered from severe, long-standing, life-threatening malnutrition/starvation combined with unacceptable medical neglect," a hospital record said of the March incident.



It's now clear that the severely disabled teen could have gotten crucial help four months earlier if an investigator and her supervisors at the Illinois Department of Children and Family Services had done their jobs properly, the Tribune has learned.



The agency had gotten a Nov. 17 hotline call that Darlene wasn't being fed — an urgent matter under DCFS rules — but the investigator repeatedly walked away from the family's South Side home without seeing Darlene and without enlisting other resources, records show.



It wasn't until her fourth visit in March that she heard whimpering, confronted the mother and called 911.



The case underscores continued problems at DCFS as it deals with high child-abuse and neglect caseloads. In recent months, the newspaper also has examined troubling child deaths and the agency's failure to inspect many day-care facilities as required — issues that have raised new questions about whether a system designed to save children is failing them.



Documents obtained by the Tribune indicate Darlene Armstrong's case was mishandled from the beginning:



•Although the investigator went to the home within the required 24-hour hotline-response period, she failed to follow other procedures to help workers locate the child. Nor did she return each day as required until that happened.



•Before Darlene was rescued, there is no evidence the worker looked up the family's history with DCFS as required. If she had done so, the investigator would have realized the agency took protective custody of Darlene years earlier due to the same allegations of medical neglect and malnourishment.



•A supervisor failed to alert two later shifts, as required, to continue looking for Darlene on the first day the investigator didn't make contact. The supervisor and her manager also improperly granted extensions beyond the initial 60-day period set to resolve such cases, despite minimal effort to find the girl.



DCFS acknowledges serious mistakes were made.



"An investigation this badly neglected is a failure of supervision and management," said Kendall Marlowe, agency spokesman. "We are taking appropriate actions to right that ship and ensure this organization places the proper priority on child safety."



DCFS investigators have struggled to keep up with high caseloads during repeated budget cuts. More than 60 percent of the agency's 457 active investigators have been assigned more work than allowed under a federal consent decree, according to DCFS data.



As a result, the percentage of investigations still pending after the 60-day deadline has risen sharply.



The caseload for the investigator handling Darlene's case also was higher than permitted, but the response to the hotline call exposes a systematic breakdown of procedures, officials said.



The investigator and her supervisors face possible disciplinary action, officials said. The Tribune is not naming them because no formal action has been taken against them.



Meanwhile, Darlene is now improving at La Rabida Children's Hospital and eventually will go to a nursing facility for long-term care, officials say.



The teen smiles and can hum and recognize names and faces.



'Well cared for'



After her rescue, police inspected the modest white-frame home where she lived with her mother, Rosetta Harris.



Investigators found the house clean with adequate food, records show.



Harris, who did not have a prior criminal history, would plead guilty in the case to endangering the life of a child, a misdemeanor. She has been placed on a form of probation for 18 months and ordered to undergo parenting classes.



The unemployed single mother earlier in the spring invited a Tribune reporter into her home near the Altgeld Gardens public housing project. She denied starving Darlene, now 17.



"I was a good mother," Harris, 50, insisted in a quiet voice. "My daughter was well cared for."



DCFS has taken Darlene and her 15-year-old sister into protective custody. Harris also has three adult children. A sixth child, Derrick, was killed when he was 15 in a drive-by shooting in February 1996.



DCFS hotline calls that same year alleged that Darlene, then a 1-year-old, wasn't being fed regularly, so the agency first took protective custody. She and her siblings were placed with Harris' sister.



Darlene had been diagnosed at birth with fetal alcohol syndrome, records state.



"Mother does appear to provide all care necessary for siblings, but has a problem following through on the care of her special needs child," a DCFS worker wrote in a 1996 case note. Harris won back custody about three years later.



Harris acknowledged removing Darlene from special-education classes in 2000 "after DCFS left" because the mother said she wanted her daughter home with her, according to hospital records. She could not recall when Darlene last saw a doctor or had been outside.



Harris told hospital officials she typically fed Darlene eggs and grits for breakfast and steamed rice and chicken, chocolate protein drinks and pudding snacks throughout the day, according to the records.



When questioned by hospital staff in March, Harris said Darlene has lost about 10 pounds in the last three weeks but appeared healthy. Authorities were incredulous at the mother's story.



"There is no way that this child eats what mom is describing," wrote a social worker at Comer Children's Hospital. "It is unclear if mom is intentionally fabricating the history for fear of 'getting in trouble' or if mom truly believes she had been feeding her as described."



The records show police found that Harris got various benefits, including Social Security, to help with Darlene's care.



The woman's oldest daughter, Delichia Armstrong, 23, said her mother would never harm her children.



"My mom does the best she can, that's the truth," she said.



Four visits



The first hotline call had come Nov. 17, just before Thanksgiving.



The anonymous caller said Darlene was pale and losing weight, wasn't being fed and hadn't seen a doctor "in many years."



The investigator knocked on Rosetta Harris' door that next day, the DCFS case file states. She left her phone number with Harris' brother when told the mother and daughter weren't home.



On Dec. 21, Harris called DCFS and denied the allegations. The investigator, who told her she still needed to see Darlene, went back to the house Jan. 3. When no one answered the door, she left a note urging Harris to call.



The worker tried a third time Feb. 27. Again no one answered, records show.



When she went back to the home a fourth time, on March 14, Harris denied that Darlene was there. As the two talked, the investigator heard crying coming from inside.



Harris said it was the television, but after the investigator threatened to call police, Harris carried out her daughter, records say.



The investigator immediately called 911.



Investigators are required to make a "good faith attempt" to see a child within 24 hours. If an adult refuses access or if the child can't be located in cases involving serious risk or harm, the investigator is expected to keep returning daily until the child is found.



The investigator was not available for comment.



DCFS reports a high compliance rate in meeting its 24-hour mandate. But the data don't show how often contact is made.



Investigators must take whatever steps are necessary, including going to police, relatives, friends and schools, and searching post office, utility and government databases.



None of that was apparently done for Darlene, records indicate.



Given the family history, Cook County Public Guardian Robert Harris questioned why DCFS wasn't more persistent.



"The allegation of medical neglect and malnourishment is exactly what happened in the first case to the same child as a baby," he said. "That should have lit a fire under this woman to find this child. Four months is ridiculous. She should have gotten the police involved a lot earlier."



DCFS violates the terms of a 1991 federal consent decree if an investigator is assigned more than 12 new cases a month. For three months of the year, that number may go up to 15. Since investigators must close out their cases within two months, the theory is that they will not juggle more than about 24 combined cases at one time.



Darlene's investigator had a caseload above the limit, agency reports show. She had more than 30 cases pending when given the hotline call about Darlene. She was assigned about 60 additional cases in the months that case languished, the reports show.



The worker is a longtime employee with a clean discipline record, Marlowe said, adding that the agency is "proceeding with the appropriate disciplinary process for the relevant employees."



Besides failing to call on the later shifts for help, the supervisor and her manager also inappropriately kept giving her more time to resolve the case despite the minimal effort made to find Darlene, he said.



"There's no excuse for this," Marlowe said.



DCFS staffing was slashed one-third in 12 years, but the demand for investigative services remains steady. There were 63,046 investigations last year, compared with 59,238 in 2002, DCFS statistics show.



As a result, there's a backlog of cases where it's still not known whether a child is at risk. In April, 16 percent of the open cases still lacked a resolution beyond the 60-day deadline. That's down from 22 percent a few months earlier.



Marlowe said DCFS has sent teams of workers temporarily into troubled areas to reduce unresolved cases.



He said Director Richard Calica has told supervisors to be less liberal with approving extensions. Calica is in the midst of an agency reorganization to augment his depleted staff of investigators and reduce layers of management that he said weren't needed.



But after lawmakers last week passed a proposed state budget that includes a reduction in DCFS staffing by 375 positions, Calica said he'll likely be forced to eliminate important functions that aren't legally mandated, such as child-abuse prevention services.



Meanwhile, health care workers are focused on making sure Darlene continues to improve. Initially, there were concerns about her condition: Doctors had never seen anything like it before, records show.



Since her transfer to La Rabida, Darlene is getting better, records show. She is gaining weight. The smiles continue.



There is deep regret among the medical staff that the teen might not reach her full potential as a result of her lack of proper care.



But, according to one doctor, she is "doing fine for now."



cmgutowski@tribune.com