Her name was Desi Irving. She was 3 years old when her battered, pajama-clad body was taken to the Minneapolis morgue one February winter day in 1997.RubenRosario

There, an autopsy found that the girl had suffered more than 100 scars and bruises that nearly covered her body. She had been burned with cigarettes and lighters. She had suffered 12 bone fractures, including both legs and her pelvis.

A broken upper arm bone had calcified, “essentially turning it to stone,” according to the autopsy report. In fact, the medical examiner could not determine which of three major injuries most likely caused her death: the internal bleeding from the lacerated liver, bleeding from the brain or asphyxiation.

Her mother, herself a child victim of abuse who grappled with substance abuse and mental health issues, is still serving a 40-year prison term. Irving’s death led to legislative hearings and the opening to the public of CHIPS (child in need of protective services) hearings.

But the death toll has continued unabated in the ensuing years. So a federal commission was convened by an act of Congress more than two years ago to find more proactive ways to reduce the number of abuse and neglect deaths, estimated at between 1,500 to 3,000 annually.

‘PREVENT HARM BEFORE IT OCCURS’

Last week, the commission came out with its final report after hearings across the country and interviews with researchers and front-line child protection workers, among others. It won’t attract headlines, but it should. It’s worth a read.

“When I was a child welfare director 10 to 15 years ago, we never discussed strategies to prevent these deaths,” wrote David Sanders, who headed the Commission to Eliminate Child Abuse and Neglect Fatalities. Sanders directed Hennepin County’s children and family services at the time of the Irving case and worked behind the scenes to publicly discuss the child’s case at a legislative hearing.

[Ruben’s earlier column]

“Our priority was simply to manage the crisis,” he said. “Our current network of services and supports does not adequately ensure safety for children because much of it is reactionary after a death has occurred. Over the long term, we need to dramatically redesign our approach to ensure children and families in crisis receive the supports and interventions they need to address the complex issues impacting families and prevent harm before it occurs.”

HALF OF VICTIMS UNDER 1 YEAR OLD

The commission found:

• Children who die from abuse and neglect are overwhelmingly young; about one-half are under a year old, and 75 percent are under 3 years of age.

• A call to a child protection hotline is the best predictor of a child’s potential risk of injury death before age 5.

• Several children who died were not known to child protective services (CPS) but were seen by other professionals (e.g., health care), highlighting the importance of coordinated and multisystem efforts.

• Access to real-time information about families is vital to child protection efforts, but legal and policy barriers prevent it.

• Although much is known about what puts children at risk, there are few promising solutions and only one evidence-based practice shown to reduce fatalities — the Nurse-Family Partnership.

One of the commission’s recommendations implores states to review its policies on screening reports of abuse and neglect to ensure that children most at risk for fatality — particularly those under age 3 — get the appropriate response.

Minnesota learned that the hard way with the 2013 death of Eric Dean in Pope County. Like Desi, Dean, 4, was a victim of long-term abuse and died on a winter’s day, the same month she did. It was later learned that the county’s child protection system received 15 reports of suspected abuse but investigated only one before the child’s death. Amanda Peltier, the boy’s mother, was sentenced to life and is serving time at the women’s prison in Shakopee.

SHARE REAL-TIME INFORMATION

Another recommendation became state law here: retrospective review of child abuse and neglect fatalities from the previous five years to identify family and systemic circumstances that led to fatalities.

Other recommendations include:

• Improved data collection and analysis for American Indian/Alaskan children as well as pilot studies of place-based intact family courts in communities with disproportionate numbers of African-American child-maltreatment fatalities.

• The administration should lead an initiative to support the sharing of real-time information among key partners such as Child protection service and law enforcement.

• State receipt of funding from the Child Abuse Prevention and Treatment Act (CAPTA) should be contingent on existing child death review teams also reviewing life-threatening injuries caused by child maltreatment.

• All other programs — such as Medicaid and home visiting programs — should be held accountable for ensuring their services are focused on reducing abuse and neglect fatalities.

Hopefully, none of these recommendations or this report is ignored or gathers dust somewhere. They might save a kid from suffering the same fate as Desi and Eric.

[Ruben’s earlier column] (http://www.twincities.com/2014/06/07/desis-spirit-is-present-as-adults-face-her-death/)

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