The deaths of 19 Indiana children whose families had come into contact with child-protection workers could have been prevented, according to a report by the state's Child Fatality Review Team.
The independent review panel found that parents, caregivers, relatives, neighbors and medical providers -- not child-protection workers -- most often failed the children who died from July 1, 2003, to June 30, 2004.

The report, which did not divulge the names of the children, found no instances in which a child-protection worker's action was solely to blame.
"In every case, there were multiple people in the child's life who could have made a difference," said Dr. Antoinette Laskey, a forensic pediatrician heading the state team. "What's frustrating and infuriating was that most of these were not subtle but obvious opportunities."

The report on the 19 Hoosier children who died from abuse and neglect during the state's fiscal 2004 is the first of what team members hope will be many reports addressing child deaths and prevention opportunities.
The deaths of children "known to the system" were noted by the Department of Child Services in its 2004 report on abuse and neglect deaths. The state reported a total of 57 deaths that year, but a Star investigation found 10 additional deaths that had been overlooked. The 19 cases examined were chosen because the state had had contact with the victims' families before the deaths.
Here's what the team found:

Twelve of the victims were the focus of a prior contact with Child Protection Services. The other seven were siblings of children whose cases had come to the attention of CPS.
All but four of the 19 deaths were "definitely" preventable. The remaining four were deemed "possibly preventable," while none were considered "not at all preventable."
In every case, multiple people could have made a difference. In nearly every case, the primary caregiver -- a parent or other guardian -- could have done something. In nine cases, other members of the community also were aware of the potential danger.
In six cases, action on the part of a medical provider could have prevented a death.
In several cases, child-protection workers didn't or couldn't do enough because of a lack of adequate supporting information about who was responsible or that harm had been caused.
As an example, Laskey cited a case in which a doctor convinced CPS that a child's injury was not the result of abuse.