OLYMPIA -- A mother's seemingly plausible explanations for injuries and health problems plaguing her young son, Tyler DeLeon, kept many child welfare workers and other community professionals from uncovering the pattern of abuse and neglect that he suffered throughout his life, concluded a review of Tyler's death on Jan. 13, 2005.

Tyler died on his seventh birthday, due to "severe dehydration," according to the Spokane County medical examiner. He weighed only 28 pounds. His death has not been ruled a homicide and currently no one faces criminal charges in regard to his death.

A 10-member Executive Fatality Review panel was convened in October 2005 by the state Department of Social and Health Services (DSHS).

According to the review, many professionals closely involved in Tyler's life – social workers, doctors, therapists, counselors and school personnel -- had been collectively convinced by Tyler's mother, Carole DeLeon, that his injuries and behaviors were due to factors other than abuse or neglect.

Ms. DeLeon said that Tyler was born addicted to methamphetamine and that his doctors told her to restrict his fluid and food intake. There were no facts to support those claims.

"Professionals continually commented on her credibility, articulation and knowledge without considering her ability to deceive or misrepresent," noted the review. "This case illuminates a common bias among helping professionals: if a parent presents well, it is less likely the self-report information will be questioned. Confirmatory bias (the desire to identify data that supports an initially developed hypothesis) was pervasive throughout the case."

"She was the primary source of information for professionals involved in Tyler's life… Most of the professionals believed Ms. DeLeon was honest and credible. This confidence in Ms. DeLeon had a significant impact on the assessment of all events that occurred in her home," according to the review.

"There are powerful lessons for us to learn from this tragedy, indeed for all community professionals who are charged with protecting children," said Ken Kraft, a DSHS Spokane regional administrator. "Many professionals had seen Tyler's injuries and were told by his mother to restrict his food and water intake. The mother's deception made it difficult to put all the pieces together."

Following Tyler's death, DSHS discovered that Ms. DeLeon had failed to reveal previous involvement with CPS and law enforcement when she applied for her foster care license in 1996.

Kraft said that when DSHS reviewed the case files following Tyler's death, "Ms. DeLeon apparently deceived all of us beginning in 1996 when she failed to include her previous involvement with CPS on her foster case license application. Had DSHS had that information then, she never would have been licensed to provide foster care."

An obscure reference to Ms. DeLeon's CPS involvement with her own sons and another foster child in 1988 was found in the department's antiquated child welfare information system. But the paper records had been destroyed under the state's retention policy, according to Kraft.

After Tyler died, child welfare records revealed a "significant pattern of suspicious injuries throughout his life," according to the review. "The injuries were documented in medical, school and department records... but no agency or provider was aware of the cumulative number and nature of his injuries until after his death. Medical records contained reports of injuries that were not reported to Child Protective Services or law enforcement, presumably because abuse was not suspected."

"We didn't see the pattern," said Kraft.

"What Ms.DeLeon reported to the school differed from information she presented to medical providers, which was different from statements she gave to DSHS," according the review.

Kraft said that changes are under way in the Children's Administration that will help address some of the issues identified in the review.

To make social work more consistent across the state, a new model for child welfare practice is under development. This includes a redesign of CPS and Child Welfare Services (CWS). CPS will focus on investigating child abuse and neglect, while CWS will work to get essential services to children and families.

Allowing CPS to focus on investigating and assessing the risk of abuse or neglect should help to identify risks sooner and intervene more quickly with families.

The department also plans to replace the outdated children's information system that currently takes 26 steps to document a 30-day visit with a child. A new Statewide Automated Child Welfare Information System (SACWIS) will fix that and will help produce more accurate data and reports for decision-making.

"The changes proposed in the Children's Administration are designed to increase competency, support social workers, and decrease staff turnover," Kraft said. "As we provide more support and training to our workers, more children will have positive outcomes."

Connie Morlin, regional manager for foster home licensing, said staff still struggles with Tyler's death.

"Any death of a child in a community is tragic.  The impact of the death of a child within the community of professionals dedicated to the protection of children is impossible to measure," said Morlin. "While the Children's Administration staff mourns Tyler's death, they also rededicate themselves to the mission of protecting children."