"A child has died, and a child didn't need to die," said panelist David Lawrence, a former Miami Herald publisher. "We could have done a hell of a lot better than we did."
The three-person panel recommended that the state Department of Children and Families immediately review the qualifications of case managers, child protective investigators and psychologists contracting with the state, warning in the 14-page report "there is no substitute for critical thinking." The panel also suggested that the state establish a more concise and immediate information-sharing system and review its state abuse hotline procedures.
The investigation revealed that child welfare officials repeatedly missed signs that the girl, Nubia Docter, and her twin brother Victor were being abused by their adoptive parents.
A child protective investigator visited the home on Feb. 10, one day before Nubia's death, after the state received a call to its abuse hotline that the twins were being bound and locked in a bathroom. She never saw the twins, but marked on a safety questionnaire they weren't likely "in immediate danger or serious harm," even though she didn't know where they were. She spent four days looking for the twins but never called police.
Many of the panel's recommendations match the findings of other commissions in Florida foster-child deaths in recent years. Case workers didn't talk to teachers and medical professionals. Critical information was missing from case files. Abuse allegations were treated with little sense of urgency. In short - no one was ultimately responsible for Nubia and Victor.