Investigating the death of a baby in foster care: Could it have been prevented?

Baby Joseph had an infectious smile, and he sweetly danced his little moves to Baby Shark when his mom streamed the song on YouTube. Like most moms, Leah Garcia videoed it all. Unlike most moms, it’s now all she has left of her baby son, an archive of just five months of life, the age when he was taken from her by LA’s child protective services. 

Just over one year later, Joseph Chacon died in foster care, one of more than a dozen children to die in the last five years while in the custody of LA’s Department of Children and Family Services (DCFS). 

The mission of DCFS is to keep children safe. While individual social workers may take that mission to heart, not every child is better off after time in foster care. And in this case, after the worst had happened, our reporting found the system left Garcia with unanswered questions about whether the death was preventable.

Who is most likely to end up in the system? Most families who encounter DCFS are Latino or Black, and Black children are overrepresented in the child welfare system.

Joseph’s story illustrates a worst-case scenario.

Joseph Chacon was born in June 2018. His bubbly older sister was thrilled to have a brother, yet his mom, Leah Garcia, was in a rocky relationship with Joseph’s father. The violence that he perpetrated crept up on her, according to Garcia.

“I feel like he eased into the way he treated me,” Garcia said. “When people slowly ease into treating you a certain type of way, they kind of manipulate you a lot, and I feel like that's what happened.” 

Garcia’s former partner could not be reached for comment on this story.

Police notified DCFS about the abuse Joseph’s father perpetrated against his mother, and social workers asked Garcia if she could move to a new place where Joseph’s father would not be able to find them. But Garcia still had months left on her lease and couldn’t afford to break it and find a new spot. 

The police gave her an emergency restraining order. Then it was on her to get a permanent order of protection to prove she wanted to keep her children safe. 

“I didn't know how I was able to obtain a restraining order [or] what you need to get a restraining order,” Garcia said. “Nobody ever talked to me about how I was able to do those things.”

Getting a restraining order is complicated, according to Sharon Balmer Cartagena, an attorney with Public Counsel. She’s helped many parents who have survived domestic violence — only to have their children removed by child protective services. “I've seen lots of cases where folks really get tangled up in the process.”

That’s exactly what happened to Leah Garcia. She got the restraining order and texted her social worker a picture of it, she said. Then she had to figure out how to serve her abusive partner. 

DCFS could not share information about this particular case because of privacy laws. Yet social workers concluded Garcia was not doing enough to cut off access of the abusive parent to the home. “They gave me the reason that I wasn't protecting them properly, that I was like allowing the abuse in the home,” Garcia said.

Her 3-year-old daughter ended up with her own father, but 5-month-old Joseph was placed with a foster family.

Mary Nichols, a former DCFS administrator, believes social workers are at a disadvantage because no matter what they do, they are criticized. “If we take a child from a parent who may have been a victim of domestic violence, maybe because we know some other pieces, maybe because the battery is so dangerous that the children are at risk, even if the mother is appropriate but can't protect because of his dangerousness, if we take the child and the child dies, we are damned. If we leave the child and try to protect her and the batterer breaks through and kills the child, we're damned,” Nichols said. “We can't predict people's behavior. And yet society, media think, ‘Why did you do that? And can't you see how bad it was for that child?’”

Racism and poverty play a role

Leah Garcia is not wealthy. She didn’t have the resources to leave her apartment and find a new one that her boyfriend wouldn’t know about.

A lack of resources alone can lead to involvement of the child welfare system. So can class bias.

“You have folks called on … for behaviors that wouldn't be called on if they were white and upper middle class,” said Cartagena. “I've seen cases where folks are called on for co-sleeping [with a baby] or for falling asleep while breastfeeding. I've seen cases where folks are called on for resource issues. There's a call by a teacher to the child abuse hotline because the child doesn't have glasses.”

Many of the children who are removed in LA County are poor, and impoverished children here are overwhelmingly Black and Latino.

African American children make up 7.4% of LA County’s child population, but are almost one-quarter of all the children removed. White children are almost 17% of the county’s child population, but make up 12% of all the children removed.  

“What we see in Los Angeles and really nationally in the child welfare system are Black and Brown mothers are being brought into the system for behaviors that occur across racial and income groups,” Cartagena said. “Implicit bias really infuses every aspect of the child welfare system.”

DCFS Director Bobby Cagle is aware of the disparities. He sees a solution before his social workers even get involved. “If we're not getting the kind of services to families, to the children in order to avoid those kinds of outcomes, that's the ultimate racism, and that's something that we've got to address. We have to really get more preventative services out there to keep kids from coming into our care at all,” he said.  

A bad situation made worse

A few months after Joseph was placed with a foster family, he broke his arm. After a brief hospital stay, DCFS placed Joseph in a new foster home in Palmdale. The new foster mother had multiple children in her care. 

One Saturday morning in January 2020, Leah Garcia was informed by a detective that her son Joseph had died in foster care. He said Joseph died in a car seat but didn’t have much more information.

“I don't remember too much,” Garcia said. “I remember I was on the floor and I was crying. … He tells me, ‘Your son passed away, he died.’”

Case closed as an accident

Months later, Joseph’s death was ruled an accident and the case was closed. 

The former chief child death investigator for LA County, Denise Bertone, is troubled by this case. “I am aware that this case was closed as an accident. I'm not comfortable with that,” she said. 

Our investigation into the death found that the foster mother called 911 after finding Joseph tangled in his car seat straps and choking. But his body was already cold by the time he reached the emergency room, suggesting a delay in calling for help. There are also questions about whether marks found on the body were consistent with Joseph getting caught in his seatbelt. 

The delay in seeking treatment may be squarely the fault of the foster mother, but was the system neglectful as well? One startling fact from the autopsy may begin to answer that: It turns out Joseph was not the first baby the foster mother called 911 about. Just two months before Joseph died, another foster baby, Draco Ford, was found not breathing in the very same foster home. 

Like Leah Garcia, this baby’s mother feels like she was told very little about how her son passed away. “I didn't really get an answer, and then later I was told that he died of SIDS [Sudden Infant Death Syndrome],” said Delaysia Taylor of Lancaster. 

“My mom asked one of the [social] workers, and one of the [social] workers ha told her that he was asleep in his bed and that [the foster mother] came back like a few hours later, and he was deceased or unconscious … but he was rushed to the hospital.”

The autopsy was made final in April 2021 — 16 months after Taylor’s son died. Yet despite having no official cause of death for the first baby who died in the Palmdale foster home, DCFS did not immediately remove other children from the home. 

DCFS would not answer questions about any specific case, they are bound by privacy laws. But they did say the following department procedure is followed: “If there is no suspicion of abuse or neglect by the caregiver or someone in the placement, DCFS takes no further action.”

In Draco’s case, it appears investigators believed the cause of death to be SIDs, and took no further action. Denise Bertone questions whether a SIDs death determination can happen that quickly, especially by non-trained experts. 

She sees two distinct possibilities that need to be investigated. One is an unintentional death due to an unsafe sleep environment. So if the crib had soft toys or pillows, and a baby rolls over and his face buries in the pillow, and then he cannot lift his head or turn back over, he suffocates. The other is intentional suffocation. Investigating how a child died is complex, Bertone says.  

The safest route would have been to take the other foster children out of that home the day Draco Ford died until these questions could be answered by the medical examiner. 

Exactly how many children die in foster care is incredibly hard to know. There are different criteria used to report deaths, which leads to different numbers. For example, in 2019, I was told there were 23 “out-of-home fatalities.” DCFS says out-of-home care is when a child lives with a relative, in a foster home or in a group home. But the department separately reported only 13 out of home deaths between 2015-2020. Why the discrepancy? In an email, DCFS said “the 23 fatalities and 13 fatalities contain data extracted at different times and using different criteria.”

Ending the system

Child welfare costs the U.S. about $9.8 billion annually. It’s money that Molly Tierney says is for “taking other people’s children.” Tierney ran the Baltimore child welfare agency for almost a decade, and when she left she had reached the conclusion that the system, as it was set, was failing children and families. 

“The only time the federal government pays me is when I take someone’s kid,” she said on a Tedx stage in 2014. “And as soon as that kid is in foster care, they instantly become a commodity and the industry starts to wrap around: doctors, lawyers, judges, social workers, advocates, whole organizations. The industry is committed to this intervention, this taking other people’s children, because that's what it needs to survive, and it's on autopilot.”

Tierney agrees with DCFS Director Cagle that the solution should start much earlier.

“We could find the earliest moment to intervene with a family long before they need a catastrophic intervention like putting their kid in foster care,” Tierney said in her talk. What she proposed in 2014 was to take the billions of dollars invested in the Foster Care industry, as she calls it, and use it way earlier to build a better social safety net to support families so they don’t falter. 

It’s an idea found in circles of mothers-turned-activists who have had their children removed. Joyce McMillan is a movement leader in New York City. 

“The system mistreated me because they came in looking for reasons to separate my family and not reasons to support us,” she said. 

When her children were removed due to a positive drug test for a recreational drug, her stable middle class life crashed. It gave her a lot of empathy for mothers who have had their children taken away by authorities. “We are trapped in shame the same way prisoners are trapped in a cage,” she said. “It is a cage — walking, living and breathing with extreme shame is a cage. It prevents you from functioning properly.”

McMilan found compelling evidence that Black and Latino children were extremely over-represented in foster care, leading her to the conclusion that “it’s a racist system.”

She doesn’t think the government should take anyone’s children. “What would it look like if we instead supported the family who we said was not rising to a level that we wish they would rise to [in] caring for their child?” she asks. “If they lack a coat, instead of giving money to a foster parent, you bought a damn coat or you bought a bag of groceries. Even if you had to do that consistently for a moment, it makes no sense to me that we would spend our resources to separate. Separation is not support.” 


In Los Angeles, Delaysia Taylor, Draco Ford’s mother, wants answers and justice. She still has one child in the foster care system, but after her son passed, social workers placed her remaining child with her own mother, the child’s grandmother. This was a request that had been made — and denied — at the first court hearing when her children were removed. 

“Like literally, [there is] probably nothing more horrible than that feeling of your small and tiny baby being taken … and I think about [his death] every day, but never really shared it,” Taylor said. 

Leah Garcia has finally had her daughter returned to her care. She cherishes every moment. But she says not a day passes when the loss of Joseph doesn’t well inside of her. 

“The last time I seen [sic] Joseph was when I had taken my daughter, and it was the last time both of us had seen him while he was alive,” Garcia said. “I'm glad that she got a chance to see him before he passed because they weren't just taken from me, they were taken from each other.”

To hear more details uncovered in this investigation into Joseph’s death, listen here to the Latino USA two-part audio documentary.

Deepa Fernandes is an early childhood reporting fellow at Pacific Oaks College, which is funded in part by First 5 LA.