Minnesota was supposed to learn from Cottrell Short’s death.

He was 19 months old when he died in February 2012 from beatings and untreated wounds in a squalid house in St. Bonifacius. His troubled family was well known to Hennepin County social workers, yet Cottrell suffered through what the medical examiner called the worst case of child abuse the office had ever seen.

State law requires local and state social workers to review the circumstances of Cottrell’s death, as they must any time a maltreated child in Minnesota dies or suffers a near fatal injury. The purpose of these “child mortality reviews” is to find out what went wrong and recommend any changes that could prevent future harm.

It took nearly three years for Hennepin County to conduct that review after Cottrell’s death. It was completed a few weeks ago, only after repeated inquiries from the Star Tribune. The conclusion: No recommendations for any changes to the child welfare system.

A Star Tribune examination of state and county records shows little evidence that the mortality reviews are stopping child protection failures. The reviews often take years to complete — and sometimes do not occur at all. What’s more, findings from such reviews are frequently sealed off from public scrutiny, despite a federal law requiring more disclosure.

Fifty-six children in Minnesota have died of maltreatment since 2005, despite counties knowing the child was at risk or the caretaker was dangerous, records show. Dr. Mark Hudson, a member of the state mortality review panel and a child abuse specialist with the Midwest Children’s Resource Center, said the volume and number of those deadly abuse cases raise significant questions about whether the panels are effective.

“The same problems are continuing,” Hudson said. “We’re making recommendations, but I don’t see anything changing.”

In response to the death of 4-year-old Eric Dean after 15 reports of suspected abuse, a case reported by the Star Tribune in August, Gov. Mark Dayton convened a task force to recommend changes to the child protection system. Dayton has described Eric’s death as a “colossal failure.” But Pope County’s mortality review recommended two policy changes and found no shortcomings with county social workers.

Counties conduct the first mortality reviews and send their findings to a state panel.

Department of Human Services Deputy Commissioner Chuck Johnson defended the child mortality panels as effective in identifying patterns of child deaths, such as from unsafe sleeping practices.

Still, Johnson said there are “multiple ways” that the process can improve, possibly by providing more oversight of counties and sharing the recommendations more widely with social workers and the public.

For now, some state panel members say the process is not fulfilling its mission.

“We should be using the mortality review as a place to present to the community what they ought to be doing to prevent injury and death to vulnerable children,” said Esther Wattenberg, a University of Minnesota child welfare professor. “I don’t think we do enough with prevention.”

The same conclusions

When a county’s child protection agency fails to prevent a death, the reason is often “obvious,” said William Pinsonnault, a former social services director for Carlton and Anoka counties.

“Ninety percent of the time, a county should have intervened more strongly, or they should have monitored the family longer,” he said. “That means lowering caseloads for child protection workers, and lowering the threshold for legal intervention.”

A Star Tribune analysis of 32 county mortality review findings since 2005 shows that child protection agencies only twice reached that conclusion.

State law requires that county mortality reviews in child abuse cases be completed within 60 days, unless a criminal charge or a lawsuit is pending. Review teams are often composed of child protection supervisors and workers who handled the case, as well as physicians and law enforcement officials. The state has told counties that they should assess the effectiveness of child protection, determine if the death or near fatal injury could have been prevented, and develop changes to reduce the number of those types of cases.

The counties frequently issue the same recommendations. Records show that 11 times counties said they needed to work better with other agencies and law enforcement. Eight times counties lamented they did not find out enough about the caretakers before a child died. Seven times the counties absolved themselves of blame.

Clay County, in northwestern Minnesota, reviewed the death of 5-month-old Christiana Sandstrom, who was left in a hot van by her father in June 2013. Christiana’s family had been reported five times to child protection for neglect before her death. Three of the reports were screened out, meaning the county did not offer child protective services. The county responded to the other two reports by offering services, in which “the family did not actively participate.”

“The team did not believe this death could have been prevented by the system,” the county concluded in its review of Christiana’s case. “There are many families experiencing similar supervision concerns that do not result in the death of a child.”

Meetings held in secret

After receiving a county’s mortality review, the state panel does its own analysis. Twenty-five of the panel’s 29 members are employed by government agencies, including 12 with the DHS.

Jo Zillhardt, who has been on the state mortality panel since 1999, said it was “unfortunate” that Human Services manages the reviews.

“They don’t let us make recommendations unless they go through their commissioners,” said Zillhardt. “I think what happens is our recommendations don’t meet the light of day. If anything we recommend would cost money, they don’t approve it.”

Johnson, of the DHS, responded: “That would be unacceptable if that’s actually the process that’s going on.”

The state mortality panel’s protocol is to share its findings only with the county in which the incident happened, Johnson said. Nor are those reviews shared with the public, unless someone involved in the child’s death or injury has been charged with a crime. State law shrouds panels’ meetings and the records they review in secrecy, saying any person who attends “shall not disclose what transpired at the meeting.”

Federal law mandates that Minnesota must tell the public about the cause and circumstances of a death or life-threatening injury in nearly all abuse and neglect cases, the age and gender of the child and any child protective services provided.

The U.S. Administration for Children and Families notified the state in April that it was not complying with federal law; Johnson said DHS will propose a law next year to do so.

Failing to share information weakens the child protection system, said Rich Gehrman, director of Safe Passage for Children, a child advocacy group, and a member of Dayton’s task force.

“By not making these reports public, that’s not helping anybody,” Gehrman said. “Who is the state trying to protect? The dead children?”

‘So much abuse’

Nearly three years after Cottrell Short’s death, Hennepin County conducted a mortality review in his case the last week in October.

It was delayed, said Janine Moore, Hennepin County’s Children and Family Services area director, because the county had to wait until the criminal charges were resolved.

Those charges were resolved in October 2013.

Rex Holzemer, assistant Hennepin County administrator, attributed the delay to “scheduling issues related to the medical personnel that need to be involved in the review.”

Child protection had intervened for years with Cottrell’s family and caregivers, according to more than 600 pages of records reviewed by the Star Tribune.

Three of Cottrell’s caretakers at the home when he died had previously been found responsible for child neglect.

In 2002, Cottrell’s mother, Shacara Foster, lost custody of her then-2-month-old daughter when she abandoned the girl. The county’s action triggered a state law that allows counties to terminate rights to any other child of the parent. No county took that action with Cottrell or his siblings.

In 2003, Foster was found responsible for neglect after a second daughter died at age 2 from Sudden Infant Death Syndrome.

In 2005, Ramsey County petitioned a juvenile court to protect Foster’s then 1-year-old son from her after she threatened to abuse the boy.

Foster’s boyfriend, Kentae Todd, also had a history with child protection. According to records, he was found responsible for maltreatment after breaking his 7-month-old daughter’s ribs in 2010.

In September 2011, Foster and Cottrell moved to St. Bonifacius to live with Todd and his mother, Kasyiah. Kasyiah Todd had been found responsible for child maltreatment twice, and on three other occasions child protection responded when she was reported for neglect and abuse of her children.

In October 2011, Kentae Todd was arrested for domestic assault after threatening to kill one of his brothers in the home while numerous children were present.

On Feb. 7, 2012, Hennepin County received an abuse report that Foster was smoking marijuana while three months pregnant. The county said the report didn’t meet the criteria to offer child protection, and screened out the call. Three days later, on Feb. 10, child protection referred Foster to a voluntary program for pregnant women who use drugs.

That night, Kasyiah Todd called 911 to say Cottrell was not breathing. Paramedics got there first and started giving Cottrell CPR. When police arrived, they were stunned to find that Foster was “mellow” about what was happening. Her son’s body was already cold and rigid.

They learned Cottrell lived with 16 other people in the duplex, including 12 children. Cottrell was kept confined to a hot basement filled with garbage, rotting food, dead animals and animal feces. His skull was split. Numerous bones throughout his body were broken, some from days or weeks earlier. He had cuts and bruises from his head to his feet. His hand was burned to the bone and had gone untreated, causing a blood infection that ultimately killed him.

“I wonder how one little boy survived so much abuse,” Hennepin County Sheriff Rich Stanek said when criminal charges were filed in the case.

Foster was sentenced to serve about seven years in prison after pleading guilty to second-degree manslaughter. Kentae Todd, who was accused of inflicting many of the injuries to Cottrell, was sentenced to about 12 years in prison after pleading guilty to second-degree murder.

“This was a tragic case of a child who died as a result of physical abuse and neglect,” Hennepin County’s mortality review concluded. “There did not appear to be system failure where something different could have been done to prevent this death.”