Connecticut's Child Advocate Sarah Eagan waits to provide her testimony at a hearing for the Connecticut General Assembly's Children's Committee on October 11, 2023. Shahrzad Rasekh / CT Mirror

A review of the events leading up to a 2-year-old’s death by blunt force injury to the head found the state’s child protection agency and judicial staff didn’t follow proper procedures in handling the case and that the court didn’t have complete information when it made decisions about care for the toddler, who was later found buried in a Stamford park.

The fatality review from the Office of the Child Advocate found that the state’s Department of Children and Families didn’t follow proper procedures to make sure that the toddler, Liam Rivera, was safe. They also found that there were missteps in the Judicial Branch’s monitoring of Liam’s father after he was let out of prison, among other system failures.

These missteps and mistakes collectively led to “a catastrophic failure to ensure Liam’s safety,” the report said. It said there was an “urgent need” to address problems with DCF’s handling of cases.

DCF says it’s made several adjustments and that work is ongoing toward its goal of keeping children safe and healthy.

OCA issued several recommendations to change policy and make sure vulnerable kids, particularly very young children, stay safe and that the juvenile court has all the information it needs to make decisions. Some of the recommendations were about agency procedures while others would require legislative change. The office issued its report and a summary document on Tuesday.

Liam’s body was found buried in Cummings Park last December. Officials ruled his death a homicide. He had several interactions with the state through his two years of life, was diagnosed with ‘failure to thrive’ — an indication he was not growing at a healthy pace — and suffered serious injuries from suspected abuse.

His father, Edgar Ismalej-Gomez, faces previous charges of risk of injury to a child, assault and violating probation. His mother, Iris Rivera-Santos, faces charges of intentional cruelty to persons, hindering prosecution, tampering with physical evidence and risk of injury to a child.

Neither parent has been directly charged for Liam’s homicide.

The OCA report offered several policy and practice recommendations for the Department of Children and Families, the Judicial Department and the Office of the Chief Public Defender. 

The report discussed similar concerns from previous fatality reviews: DCF needs to find a way to make sure that there’s enough staff supervision and documentation of cases in which there’s alleged abuse or neglect. The OCA recommended that DCF add outside oversight to examine how its work is going. It also said the state needs to make changes to ensure children are safe and families have access to the services they need to take care of their kids.

DCF has made strides in recent years and last year exited a court settlement known as Juan F. The decades-old case mandated federal court oversight of the state’s child welfare system and required officials to report certain measures related to the system.

But advocates have said that the state exited the court monitor system without an adequate replacement to track and report information on how well the system is helping families and children.

“There is very little margin for error in this business,” said Sarah Eagan, the state’s child advocate. “I think what we’re saying is that we have serious questions about operations at DCF, and stakeholders — which includes the legislature — need to look at what is contributing to these inconsistencies in practice and this concerning operational data.”

Eagan’s office flagged similar concerns with quality improvement and transparency in its report on the death of Kaylee S., a baby who died last year after ingesting fentanyl and an animal tranquilizer.

DCF conducted a review of its practices which led the state agency to “continue to enhance its ongoing work,” in several areas including working with undocumented families, identifying and assessing failure to thrive cases, partnering with foster parents, reinforcing safety practices and in-person family contact post-pandemic, refining rules around trial home visits for kids, partnering with stakeholders and developing post-Juan F. workgroups, according to statement from Commissioner Vannessa Dorantes.

“It is important to note that the majority of our interactions with the family occurred during a global pandemic — which impacted our normal operations and procedures — resulting in challenges supporting families and requiring us to frequently update case practice guidelines,” the statement says.

Early state involvement

DCF first got involved with Liam’s family in 2017, before Liam was born. Reports of child maltreatment and abuse weren’t substantiated. In January 2021, when Liam was six months old, he was found to have unexplained injuries including a broken arm, a healing leg fracture and bruising on his chest, according to the OCA report.

In February 2021, the juvenile court determined that Liam and his sibling were abused and neglected and put them in DCF custody. Liam had a low weight and was diagnosed as failure to thrive, a term used to describe children who haven’t grown appropriately for their age. 

Over the next few months, Liam gained weight in foster care and lost the failure to thrive status, according to the report. In August 2021, police arrested his father, on risk of injury and assault charges because he said he might have hurt Liam’s arm when he was trying to keep him from falling off the bed, according to the report. An order of protection was issued against Ismalej-Gomez with Liam as the protected party.

Liam’s parents were living in separate households, and DCF developed a reunification plan with his mother. In October 2021, DCF got a call alleging that Rivera-Santos was using drugs, but DCF records don’t show any follow-up to the call. The agency also didn’t share the concerns about drug use with the attorney representing the children, the guardian ad litem, or the court, according to the report.

DCF filed a motion asking to restore custody of Liam’s sibling to his mother and to approve the goal to restore custody of Liam in December 2021. The court approved those motions, but the agency took the next step without court approval. They informally reunified Liam “under DCF-commitment,” according to the report.

The OCA report says state law doesn’t allow for informal reunifications of this type and recommends that the legislature take a look at the issue and set protocols.

“There is no law authorizing the state to return a child at its own discretion to the care of a person the court has found abused or neglected their child,” Eagan said.

In January 2022, Liam’s mom called the police and said the toddler had been kidnapped by a paternal relative. Police found the child with his father with no shoes, no coat and wrapped in a towel. Ismalej-Gomez was arrested and incarcerated after the incident.

Liam’s mother later recanted the kidnapping allegation and was charged with making a false statement to police. DCF found that the father had neglected the child.

DCF workers remained concerned about Liam’s mother’s ability to keep him safe.

“​​While texts indicate that DCF was having internal meetings regarding whether to keep Liam informally with his mother or return him to foster care, the DCF record contains little to no information about DCF’s internal review of the matter or its decision-making process in leaving Liam home with Ms. Rivera,” the report says.

DCF delayed filing a legal motion with the court to restore his mom’s custody, according to the report.

Guardian ad litem

DCF also didn’t inform the guardian ad litem, the court or Liam’s attorney that the father had violated the order of protection. His lawyer and guardian ad litem also didn’t ask for any DCF records “during much of the case,” and visited him at home only once before he died.

A guardian ad litem is the court-appointed individual tasked with looking out for the best interests of the child. They’re often appointed in cases in which the child is too young to speak for themselves.

The child advocate’s report recommended that the Office of the Chief Public Defender strengthen the legal representation of children through quality assurance measures and ensure attorneys can bill for activities such as reviewing records and communicating with service providers.

OCA recommended that the legislature create a working group to review legal services for children in Connecticut and offer enough staff to the Office of the Child Advocate to enhance its capacity to review the agency, among other oversight recommendations.

Chief Public Defender TaShun Bowden-Lewis declined to comment on the report.

In April, Liam’s doctor found that his weight was dropping again since returning home. DCF held a meeting to review his case. Liam’s father was also released from prison with probation requirements that he cooperate with DCF, but the department records don’t show attempts to contact him after May 2022, according to the report.

Adult Probation Services was monitoring Ismalej-Gomez, but didn’t verify his address. An internal review found that his case needed a domestic violence screening, which would have meant he was given a “high supervision” level with more contacts.

OCA recommended that the Judicial Branch Court Support Services Division take steps to strengthen agency policy that impacts children such as enhanced home visits and address verifications.

The office also recommended that the Superior Court for Juvenile Matters ensure that the court has reliable information about kids’ safety and wellbeing. The report says that foster parents should be consistently notified of juvenile court hearings and their right to be heard in court.

This came up as an issue during the last legislative session when a group of foster parents pushed for a foster parents’ bill of rights, citing concerns such as inconsistency in whether their concerns are heard in court.

“The Judicial Branch worked closely with the Office of the Child Advocate with respect to the Branch’s involvement in this investigation,” said Judicial Branch spokeswoman Rhonda Stearley-Hebert in a written statement. “The Branch has addressed the policy violations identified in this report to ensure similar violations will not occur in future cases. Although the Branch’s policies and procedures were found to be sound in the areas reviewed, we will continue to review and discuss whether additional modifications should be implemented.”

Court interactions

By June 2022, Ismalej-Gomez had stopped contacting his probation officer, according to the report. DCF also filed a motion to restore Liam’s mother’s custody in June. The agency’s motion included information about the January protective order, but not other key pieces of information such as Rivera’s false complaint charges or DCF’s investigation.

The agency also “erroneously” said that Liam was in the 50th percentile for his weight, when he was actually losing weight and left out information about his injuries, according to the report. The court decided to return Liam to his mother’s custody.

From July 2022 until Liam’s death in December 2022, DCF staff visited twice a month, and all the visits were announced. Staff also didn’t consistently use an interpreter, although English wasn’t the parents’ first language. They also didn’t contact his medical provider, an alleged breach of DCF policy and federal law, according to the report.

In September 2022, DCF staff said Liam was thin and unable to verbalize. They made a referral to get his development assessed. In late October, Liam got another failure to thrive diagnosis.

“The doctor called the DCF caseworker the same day to report the concerns about Liam’s weight and noted that he had normal weight trajectory while in foster care,” says a summary of the report. “The DCF record did not reference this call until a month after Liam died. There was no DCF follow-up with the doctor, and Liam was a ‘no-show’ for his follow-up appointment the following month — no additional notification to DCF made.”

In December, DCF noted that Liam still looked thin and like he had again lost weight.

In January, Liam’s mom said that he had gotten hurt and died and could be found in a park in Stamford, and she denied responsibility.

His weight at death was 17 pounds, 7 pounds less than he weighed when he left the foster home, according to the report.

“We are raising a red flag here,” Eagan said. “And there are questions here that need to be asked and follow-up that needs to occur.”

Additional recommendations

In a statement offered to the child advocate, DCF pointed to workgroups that look at intake, caseloads, case plans, and visitation standards as evidence that they are instituting quality assurance measures.

It also said they were working to better engage undocumented families, developing a nurse standard to incorporate a child’s weight and history of failure to thrive in assessments, improving partnership with foster parents by working with the national Youth Law Center to push a relationship-based system, and working with the Connecticut Association of Foster and Adoptive Families, among other initiatives.

Dorantes’ statement also said that the department can’t go into certain details of Liam’s case because of the ongoing investigation.

“We were notified of Liam’s death by the Stamford Police Department on 1/2/23 and, that same day, commenced a joint investigation with SPD. Our last contact with the family was approximately one week prior to his death,” her statement read. “During that home visit, the children were assessed to be safe after being interviewed and were visible to family members and community partners.

“Liam’s siblings are no longer in the home and are being well cared for while receiving specialized supportive interventions from community providers,” the statement said.

The OCA report also recommended that DCF take steps to develop clear protocols and checklists to help in handling cases of very young children like Liam.

“OCA supports maintaining children safely in their homes whenever possible as undue use of foster care can be traumatic and destabilizing for a child,” the report’s summary says. “Very young children like Liam are at greatest risk of poor outcomes.”

It also recommended more reliable communication with lawyers and guardians ad litem about case plan meetings and abuse or neglect reports.

“Given persistent findings of concern regarding practice in open cases like Liam’s, and the end of federal court oversight of DCF, meaningful state oversight of DCF operations is warranted,” the report says.

Ginny is CT Mirror's children's issues and housing reporter and a Report for America corps member. She covers a variety of topics ranging from child welfare to affordable housing and zoning. Ginny grew up in Arkansas and graduated from the University of Arkansas' Lemke School of Journalism in 2017. She began her career at the Arkansas Democrat-Gazette where she covered housing, homelessness, and juvenile justice on the investigations team. Along the way Ginny was awarded a 2019 Data Fellowship through the Annenberg Center for Health Journalism at the University of Southern California. She moved to Connecticut in 2021.