An alarming report arrived at an Oregon child protective services office in February 2016. A mother was hallucinating. She was getting a gun.

Two months passed before a social worker checked in on her kids, a new review showed.

Oregon's child welfare system leaves children in danger because workers routinely miss or ignore threats to kids' safety, according to an internal state report made public Monday.

The Oregon Department of Human Services reviewed a random sample of 101 case decisions, after the death of a foster child last year raised questions about agency decision-making. The teen died after a medical condition went untreated.

The analysis found social workers incorrectly determined children were safe in 47 of the cases -- nearly half. Social workers didn't look for defined safety threats in 27 percent of the cases, and identified the wrong risks in another 20 percent.

The report summarizes 49 cases and raises questions about the outcomes of nearly all of them, including the case of the mother in a mental health crisis who planned to obtain a firearm.

State employees "took it at face value that children said they felt safe with their mother," the report said of that case.

Senate Human Services Chair Sara Gelser, D-Corvallis, brought the damning study to light during a legislative hearing Monday. Gelser, who has advocated for reforms to Oregon's child welfare system, requested the report and received it last week. She said she was stunned.

She described one example in the report, in which children were left in a home where they were bitten by rats.

"Those children are not safe," she said. "It makes me very worried about the quality of our assessments in general and the lack of safety for our kids."

Gelser said the report, when combined with other failing metrics, make it clear that the agency is in "a state of chaos and disrepair."

The report's high-profile release also raises questions about internal communications at the state's highest levels. Department of Human Services Director Clyde Saiki said he was not given a copy until Friday, after Gelser received it. He said he hasn't had a chance to fully review it and recommend changes that the agency should implement as a result of the findings.

Saiki did tell lawmakers the agency's current outcomes were unacceptable, and it needs to take a different approach.

The review, written by an unidentified state employee, looked at cases in 11 counties that spanned urban and rural parts of Oregon, including Clackamas and Washington counties near Portland.

Many of the cases were handled under the state's "alternative response" method, meant to keep children at home while getting their parents the help they need. Unlike in traditional cases, social workers don't have to determine whether a report of abuse or neglect is "founded" or not.

Gelser introduced a bill amendment Monday that would mandate that child protective workers record whether they determine each allegation of child abuse or neglect is likely true, false or not able to be determined.

The report itself doesn't say who wrote it or when it was published. Andrea Cantu-Schomus, a spokeswoman for the agency, said the document was written by "DHS staff" and finished in February.

In all but 15 of the 101 cases reviewed, kids were determined to be safe. Five of those appear to have ended because the family couldn't be found. The remaining 10 were the only cases in which children were determined to be unsafe. The analyst who reviewed the report, whose identity and qualifications are unclear, agreed with 100 percent of those decisions.

The families whose cases were reviewed in the report were the subjects of 44 subsequent allegations of abuse and neglect.

The unnamed author identified common threads that ran through many of the faulty reports that deemed children safe. Social workers didn't collect enough information in many cases and failed to investigate beyond specifics of whatever allegation was made. In one example, a social worker talked to the alleged child victim, but not the six other children in the home.

Many investigations encountered extensive delays and overlooked opinions of "collateral contacts" such as relatives and teachers.

Often workers misunderstood or misapplied the state laws and policies that define threats to a child's safety, the report indicated. Caseworkers can consider more than a dozen defined threats to a child's safety, such as violence in the home or inadequate parenting.

One person determined a child was "not vulnerable because he is able to express himself clearly." The boy was 7.

Some of the children who the state deemed safe included:

A brother and sister abandoned by their mother and left in the care of an unrelated man, who she met while trafficking in sex overseas. The man often relied on active drug users to watch the kids, and his employee may have sexually assaulted one of the children. Police called Child Protection Services to alert them that the man did business with drug users and sex workers, who lived in the home. But the children weren't removed for another year, following a traffic stop. Officers found a woman holding one of the kids, as well as methamphetamine.

Three siblings locked in the basement for days at a time, allowed out only to go to the bathroom. The parents were "protective," the caseworker said, and were willing to get the kids counseling.

A boy left with his mother's boyfriend while she was in a substance abuse treatment program. The man was recently charged with intoxicated driving for the fourth time. The boy was in the car.

A boy whose father had a documented history of domestic violence against his siblings and his mother. The social worker believed the child was making up accusations of mistreatment so he could play sports despite his bad grades.

A "vulnerable 1 year old" girl who was not contacted for a month after the state received reports of her mother's regular meth use. The mother said she never used around her daughter. "The worker wrote, essentially, that the mom is using meth, but doesn't use around her daughter, so it's ok," the case notes said.

The report is a reminder of the grave risks children face and the tragic consequences that can result when child protections fail, Gelser said.

The state is actively reviewing the deaths of three children, including Caden Berry, a 12-year-old from the Salem area who was killed in January. His mother, who was the subject of reports to child welfare officials, was charged with murder.

Child advocates said their biggest takeaway from the report was its lack of surprise.

Cases like those described in the report are an everyday norm seen at the Liberty House, a child abuse assessment center in Salem, said Alison Kelly, the organization's chief executive. She said some of the risks children in Oregon face are "beyond belief."

David Paul, a Portland attorney who represents victims of child abuse, said the report is the latest example in an ongoing pattern of failure. The agency regularly fails to meet federal performance benchmarks, such as how quickly it responds to reports of abuse.

The same concerns always come up and do not get fixed, he said. "It's nauseatingly familiar."

During the Monday afternoon hearing, Gelser also pointed to the failing statistics. She showed the photos of five children who died after the state had contact with their families due to abuse or neglect reports.

"There are too many kids at risk," she said, "and it's urgent that we make a shift."

-- Molly Young

myoung@oregonian.com

503-412-7056

@mollykyoung