Trevor Secord nearly died at 14. He drank so much liquor that his blood alcohol rose to a level that would have killed many adults. Emergency responders rushed him from Warrenton to a Portland hospital. Friends were so convinced he was going to die that they told his family about the adult who provided him alcohol.

Oregon child protection workers decided not to investigate.

The next time the Department of Human Services received a call about Trevor, the boy who dreamed of building shelters for homeless people was dead.

He was struck and killed by a pickup truck on U.S. 101 while drinking with friends.

Any time a child dies from likely abuse or neglect within a year of child welfare workers being asked to check on the child, the public should be informed. Oregon law requires the state to do a prompt review and disclose what went wrong.

But state officials have failed to issue those reports in a timely manner -- or at all -- in the case of every child who has died since March 2017.

A year and nine months went by before the state publicly acknowledged Trevor died after child protective workers received numerous reports that, in retrospect, showed a "theme of neglect" that the agency failed to act on. A reviewer who read through case files concluded that a call-taker should have passed along the report about Trevor's near-death from alcohol poisoning to a case worker to investigate.

But state officials omitted that determination, as well as specific details about their past investigations into Trevor's safety, from the report shown to the public.

Brenda McKune wonders if her grandson would still be alive, a junior in high school pursuing his goal of professional football or baseball, had child welfare workers investigated his near-death from alcohol poisoning.

"It could have saved his life," she said. "It may not have, but it could have."

Child fatality reviews serve two purposes: They uncover systemic problems that need to be corrected and hold the Department of Human Services accountable for missteps that end in tragedy.

The agency is highly secretive about the steps it takes to protect vulnerable children, in part to protect privacy. The fatality reports are one of the few, and perhaps most crucial, windows into an agency that has consistently failed to meet nearly every federal benchmark for child safety.

Officials are required to carry out the reviews quickly so the problems they find can be fixed to save other children like Trevor.

The delayed, brief review of his death reflects a widespread pattern that has emerged over the past year and a half. Department of Human Services officials have failed to meet legal deadlines to report child deaths and, when they finally have published them, excluded significant facts about most of the children's lives.

The state didn't release a single fatality report for the first five months of this year. Since then, the department has made public just six summary reports. In five, the state concluded that the agency made no significant errors that contributed to the death. In all but one, more than a year had passed since the child had died.

Leaders of the Department of Human Services contend that changes to reporting requirements in 2017 give the agency an indefinite amount of time to make public the report of a child's death, as long as they are conducting an internal review. But Sen. Sara Gelser, D-Corvallis, who lobbied for the changes, said interpreting the law that way violates its spirit of transparency and its plain language.

"Without publishing those, there is no way for the public to know the department is following the statute," she said.

The agency posted two of the six summary reports, including the one on Trevor's death, during the final two days of Oregon's contentious race for governor, and one more since then. Gov. Kate Brown drew criticism from her Republican challenger, Knute Buehler, for failing to improve Oregon's child welfare system.

The governor's office said it did not ask the child welfare agency to delay reports highlighting the department's involvement in children's deaths.

Case after case of children dying or being left in foster homes where they were starved or abused made child welfare a central issue in the election. Turnover among case workers is high. The department completed just 11 percent of its child welfare investigations on time this summer, far short of the federal standard of 90 percent.

New leader, less transparency

Brown's pick to lead the agency, Fariborz Pakseresht, has pledged since taking over in September 2017 to bring about change. But transparency in reporting the agency's role in child deaths has lessened on his watch.

Delaying release of fatality reports can stymie wrongful death lawsuits brought on behalf of children killed after case workers knew they might be in peril. State law makes it extremely difficult to sue if families don't file a claim within a year after the child's death. But if they don't know about mistakes by the state until after that year is up, any claim could be derailed.

A former top civil attorney for the state wrote in a Nov. 16 court filing that large settlements both prompt lawmakers to press the agency for positive change and help pay for needed care for surviving siblings.

"I believe that children slip through the cracks of our social justice system, to the benefit of the financial interests of the state," Timothy Wood wrote on behalf of the estate of a McMinnville infant who died in 2016. It was once his job to help defend the Department of Human Services against such lawsuits, he wrote. Now retired, he works on behalf of surviving siblings.

By law, the Department of Human Services must complete an initial fatality review within 70 days after state officials learn neglect or abuse likely contributed to the death of a child. If the team assigned to look into a death can't finish its report on time, it must publicly disclose that it is reviewing the death and explain the delay. Review teams also must post updates or finalized reports every 30 days after that or explain why they need more time, state law says.

The public summary reports refer to children who die only by their initials and leave out their hometowns and other identifying details. The Oregonian/OregonLive independently determined which child's death each of the reports discusses, including the one on Trevor's death.

Five of the six reviews issued this year falsely indicate they were made public earlier than they were and at least two withhold the agency's full case history with the families in question. The very small number of public reports also raises questions about how many abuse deaths have gone unacknowledged. The department, for example, has said nothing in the year since Payshience Adams was shot to death in her Douglas County foster home, nor has it acknowledged that it investigated allegations a Lane County teen was being abused just months before he died in April 2017.

Department of Human Services officials declined to answer all but two questions, about the 70-day deadline and the inaccurate dates, for this story saying they would treat the bulk of the detailed questions provided to them Nov. 14 as a public records request. The Oregonian/OregonLive did not ask for any records when it sought explanations of department actions and inaction.

"The tragedy of a child's death is taken very seriously by the Department of Human Services," spokeswoman Laura McGinnis said.

In the year since Payshience Adams was shot to death in her Douglas County foster home alongside her foster mother and sister, state child welfare officials have told the public nothing about their agency's role in her life or death. Credit: Michael Sullivan/The Roseburg News-Review

Shining a light

Fatality reviews are meant to help prevent deaths of vulnerable Oregon children.

The process, formally known as critical incident response teams, started after the 2005 death of Karly Sheehan, a 3-year-old from Corvallis who child welfare workers left in a home where she was later killed. Lawmakers recognized the reviews as essential to saving more children like her.

Department of Human Services staff members carries out the reviews. The teams can also include doctors, police, judges or lawmakers appointed by the agency's director.

As recently as April 2017, reports that the teams produced detailed every interaction the agency had with a child or other member of their household. The reports concluded what, if anything, went wrong at each point and outlined preventive steps for the future.

In 2017, legislators gave the agency more time to complete the reviews. Officials now have 10 days, rather than 24 hours, to begin a review after they learn about a child's death that likely was caused by abuse or neglect.

Lawmakers also expanded the department's scope of responsibility to publicly report child deaths. Until then, officials did not have to review the deaths of children if a brother or sister, but not the child who died, had been the subject of a recent allegation of abuse.

That previous limit is likely why state officials maintain they weren't required to examine the strangling death of 12-year-old Caden Berry in January 2017. His older brother tried to report the abuse he said they both endured to child welfare workers in 2016, but nothing was done. Their mother now faces charges of aggravated murder, murder by abuse and criminal mistreatment.

State officials did issue a truncated preliminary review of Caden's death in July 2017, but they called their decision to do so "discretionary." They stripped it of any information about department missteps, writing, "Due to the ongoing criminal investigation, this report does not include any department history regarding this family."

A leading child welfare advocate, Gelser backed the changes to the fatality review process last year that expanded the scope of reviews. When the state's child protection system breaks down, officials owe it to child victims to see what can be learned, Gelser said. The process, she said, is not about blaming any state worker or workers, but about improving outcomes for children.

"The intention is supposed to be that it's open and transparent, consistent with the law."

That's not what happened.

When Trevor Secord encountered someone who was homeless, he made it a point to spend time with them and talk with them, his grandma Brenda McKune said. She had no doubt he would have someday constructed the homeless shelters he dreamed of building. He died Jan. 26, 2017. Credit: Beth Nakamura/staff

Incomplete picture

The Department of Human Services did not disclose its review of Trevor's death until Nov. 5. His family had mourned him for 648 days. The report it published runs just two pages. An internal case review obtained by The Oregonian/OregonLive is 13.

The department concluded in its public report that none of its actions or inactions directly led to his death. The report says the agency received seven reports involving his safety between 2012 and 2017.

The longer internal report, however, says case workers did not adequately assess Trevor's well-being during prior investigations. The document lists, case by case, the four times that Trevor came to the attention of child welfare workers between 2012 and 2017. (The other three reports were made following his death.) Case workers did not substantiate allegations of neglect or abuse by the parents in any of those instances.

In the internal report, the reviewer concluded that the child welfare worker who took the report that he'd been hospitalized in August 2016 should have talked to other people both inside and outside of Trevor's family before deciding not to investigate. His blood alcohol level was .408, five times the legal limit for an adult.

Until contacted by a reporter last week, McKune did not know case workers were alerted to her grandson's hospitalization. Trevor and his family lived near her in Warrenton, and she was especially close to him and his siblings. Had someone told her they were looking into how he had obtained the alcohol, she would have said, "Please and thank you."

"If they knew, they should have said, 'We've got to get to the bottom of this, because this isn't OK,'" she said.

She began her own calls to police and a child welfare hotline. She wanted someone to act on her reports about the man she believed was providing her grandson alcohol. Child welfare workers who took her calls sometimes told her they would pass her report along to a case worker to investigate, she said, but she never heard anything more.

After Trevor died, she said, a case worker told her there was no record of her calls.

Trevor stopped by her house two days before he died. She chided him for not being at school. He said he was on his way but wanted to tell her he had bought something to eat and drink for a man who had nothing. Trevor said he walked with him to a store to buy him something with the $11.96 he had.

"That was the kind of boy he was," McKune said.

She sometimes wears a sweatshirt with his face on it, and people stop her to share stories. One girl said he did not know her but stopped to help her when he saw her struggling with two men as he rode by on his skateboard.

"I said, 'Well that's our boy,'" his grandmother said.

It's not clear why all the information in Trevor's case file review was not published in the public report. Oregon law requires the department to publish the findings of the fatality review panels.

Although child abuse reports are confidential in most cases, they are not after the child dies. Oregon law mandates records regarding the death be made public if a child died or suffered a serious injury as a result of abuse.

For Trevor's birthday this year, his grandmother tied balloons to the red memorial she built for him in her front yard. She didn't know a report involving his death was ever released.

"He just had the world at his feet," she said. "How quick it can all stop."

Firefighters survey the damage of a Nov. 30, 2017 fire that killed two sisters in Prairie City. Their deaths went unacknowledged for 350 days until the Department of Human Services disclosed that case workers had interacted with the girls' family 10 times since 2012, the final time two months before they died. Credit: Blue Mountain Eagle

Misleading the public

Other states' child protection agencies act with much greater speed and transparency after a child's death. Colorado publishes nearly instant updates to its online database. Nevada must disclose case information within 48 hours after a child dies. Arizona publishes both initial and final reports following a child's death.

Oregon is required to keep the public informed about what's going on by posting regular updates. But it has not done so at times in the past and has failed to do so at all in the past year and a half.

The Oregonian/OregonLive obtained an internal agency review of the April 2017 death of a Lane County teenager. He died by suicide five months after child welfare workers checked reports that he was suicidal and had been physically abused by his father.

To this day, the department has said nothing about the boy's death.

Gelser, who tracks the fatality reviews, said she has asked the department several questions about reports that appear to be delayed or missing. She was told that clerical errors contributed to the delays.

Five of the six fatality reports the state has issued this year mislead the public about their timeliness, as they are dated earlier than they were released. The most recent report, regarding the death of two sisters in a fire in Eastern Oregon, is dated in bold letters October 18. It first appeared on the state's website Nov. 15, four full weeks later. It was posted one day after The Oregonian/OregonLive asked the department why it was failing to comply with the reporting law.

McGinnis, the department spokeswoman, said the agency dates the documents when they are submitted for approval, not when they are made public.

The department issued a report about a Roseburg baby's spring 2017 death on Aug. 7 of this year. It's dated June 26.

The agency completed a nine-page internal review into the baby's death Sept. 29, 2017. That document, never made public but obtained by The Oregonian/OregonLive, details three interactions with infant's family that were not disclosed in the public report.

Under Oregon law, the fatality review team must request an extension if its members are not finished with their report within the required 70 days and each 30 days thereafter. Pakseresht, the agency's director, must weigh the request and decide if the delay is acceptable.

He can take into account whether publishing a report may compromise a criminal investigation.

The department has only published one report this year regarding a child whose death led to criminal charges. The man who supplied Trevor alcohol the day he died was sentenced in June to 10 days in jail. It was the same man his grandmother tried for months to report, McKune said.

The department has publicly acknowledged its child death reports are late in just one instance: a fatality report published Nov. 6. It cites staff changes and the 2017 changes in state law as reasons for the delay.

Internal emails submitted as court evidence eight days ago highlight the defensiveness behind some fatality reviews. In one message, Yamhill County supervisor Stacey Daeschner defended her employees' decision not to rule that the May 2016 co-sleeping death of Nevaeh Ellis was the result of neglect. She explained no one had told Nevaeh's mother, who had an extensive history of risky behavior around her children, that co-sleeping was dangerous.

When a superior asked Daeschner to explain her reasoning, she forwarded the message to a colleague and added, "this makes me want to throat punch her."

Daeschner said during a deposition in May that a fatality review was a negative experience for her and her employees. "There is a process where you go through a file review and the consultant really picks apart all of the errors you made in the case," she said under oath.

She is named, along with the Department of Human Services, in a wrongful death lawsuit seeking $3 million for Nevaeh's survivors.

Hayden James Henry died at the age of 2 in October 2014. His mother and his father separately alerted police and child welfare workers to bruises before he died, but he was left in the care of his stepfather. The man was later convicted of second-degree manslaughter. The state agreed in June 2018 to settle a wrongful death claim brought on behalf of Hayden for $725,000. Courtesy of: Harvey Henry

Costly cases

Timing is critical for wrongful death lawsuits. Families must provide official notice, called a tort claim, that they plan to sue the state for alleged negligence within one year after a child dies.

At a March 2017 legislative hearing, Gelser acknowledged that the specter of civil litigation factored into the requests to change the fatality review laws. The state does not want "reports to be used in a tort claim where you just go hand it over and say, 'Here's my case,'" she said. Stacey Ayers, who led the state's child abuse investigation unit at the time, agreed.

The state has paid nearly $1.5 million since 2016 to settle wrongful death claims brought by the families of two toddlers whose deaths were reviewed in the fatality reports. It is about to pay $1.1 million more, pending a judge's approval, that will go to the siblings and attorney of Caden, the Keizer boy who was strangled to death.

"There is a significant question whether the state has relied for years on these cases falling through the cracks and enjoying the benefit of not having to pay for their negligence as a result," said David Kramer, a Salem attorney representing the estate. He confirmed the tentative terms of settlement to The Oregonian/OregonLive.

The state's lawyers are fighting four ongoing wrongful death lawsuits, including one filed on behalf of Nevaeh's survivors and a second suit filed on behalf of the family of Gloria Joya, a teenager who died in foster care from an untreated health condition.

Their deaths, in 2016, are the most recent chronicled by fatality reviews that include detailed timelines of the state's case histories with their families. All of the subsequent reports provide much less information.

Wrongful death lawsuits can crawl through the court system for years. The state agreed to pay $750,000 to survivors of Coltin Salsbury, who was killed in March 2014 by his mother's boyfriend as case workers were investigating whether or not he was being abused. The case wasn't settled until August 2016.

At least two more mothers have given notice that they may sue the state for allegedly causing the deaths of their boys in separate foster homes. One of the boys, Nicholas Lowe, died in a fire with his four foster siblings and their biological mother in March 2017. His mother contends the state's decision to place him in a "dangerous home" caused his death.

The Department of Human Services has never publicly acknowledged that Nicholas died in the state's care.

-- Molly Young

myoung@oregonian.com

Child death reports delayed or dodged

At least nine children died from possible abuse or neglect on the Department of Human Services' watch in the past 2 ½ years. None of their deaths was disclosed by the 70-day deadline. The director has 10 business days after learning that a child likely died by abuse or neglect to convene a review, then an initial report needs to be completed within 60 days.

Washington County girl S.H.

Died from drowning: Aug. 24, 2016

Then-agency director Clyde Saiki decides a review is required: Jan. 27, 2017

State fatality report made public: June 8, 2018

Time elapsed: 654 days



Trevor Secord, 15, of Warrenton

Died when a pickup hit him on U.S. 101

Date of death: Jan. 26, 2017

Internal case review of his death completed: Nov 11, 2017

State fatality report made public: Nov. 5, 2018

Time elapsed: 650 days



Nicholas Lowe, 13, of Riddle

Died in a fire at the foster home where the state placed him

Date of death: March 1, 2017

State fatality report made public: Never



Lane County teen

Died by suicide after child welfare workers looked into allegations he was abused and suicidal

Date of death: April 22, 2017

The agency completed an internal review of his death

State fatality report made public: Never



Roseburg baby

Died from co-sleeping with her mother: April 24, 2017

Agency director Fariborz Pakseresht decides to do a formal review: Sept. 14, 2017

Internal case review of her death completed: Sept. 29, 2017

State fatality report made public: Aug. 7, 2018

Time elapsed: 472 days



Klamath Falls teen

Died by suicide after recent previous attempt

Date of death: Sept. 8, 2017

Pakseresht decides to do a formal review: Sept. 29, 2017

State fatality report made public: Nov. 6, 2018

Time elapsed: 425 days



Gresham teen

Died by suicide after reporting abuse

Date of death: Sept. 18, 2017

Pakseresht decides to do a formal review: Oct. 5, 2017

State fatality report made public: Oct. 6, 2018

Time elapsed: 384 days



Payshience Adams, 10

Shot to death in her rural Douglas County foster home

Date of death: Nov. 8, 2017

State fatality report made public: Never



Prairie City sisters Symbri Shelton, 3, and Lily Shelton, 1

Died in a house fire after child welfare workers were told of their mother's neglect

Date of death: Nov. 30, 2017

Pakseresht decides to do a formal review: Feb. 15, 2018

State fatality report made public: Nov. 15, 2018, a day after The Oregonian asked why fatality reports were delayed

Time elapsed: 351 days