Some were beaten to death. One was tortured. Another was shot.

As many as 83 Maryland children died from abuse or neglect in 2023, according to the most recent data reported by states to the federal government. That’s more than one death per week on average, making the state’s published rate of child maltreatment fatalities among the worst in the nation.

But the alarming number of deceased children reported that year wasn’t a blip or an outlier.

It’s evidence of an apparent crisis that has been building in Maryland for nearly a decade. Two governors, four legislative leaders and even the state agency responsible for tracking and preventing these deaths all seemingly failed to notice.

One child abuse expert called the tally “terrifying.” Another called it “staggeringly high.”

When asked what the state is doing to address the problem, Department of Human Services spokesperson Lilly Price questioned the accuracy of the agency’s own data, arguing that the true number of child maltreatment fatalities in recent years is lower than Maryland reported.

Price said problems with the agency’s antiquated data system make the numbers unreliable and that they’re still investigating.

The result — Maryland isn’t sure how many children have died from abuse or neglect. The confusion underscores how little attention these deaths received from Gov. Wes Moore’s administration before The Banner started asking questions about the staggering figures that had been reported publicly.

“The Maryland Department of Human Services envisions a reality where all children in the state are safe from incidents of abuse and neglect,” said Secretary Rafael López, who declined to directly address problems with the state’s data.

Compared to other states, Maryland shares little about children who die from abuse or neglect, information that experts say is vital to preventing future deaths.

State law allows for the routine release of child maltreatment fatality records, upon request, but such documents have been shared only once since Moore took office, according to public records obtained by The Banner. The Moore administration vowed to start sharing more soon.

Not much is known about the 83 Maryland children whose caregivers reportedly killed them in federal fiscal year 2023, although some pieces of their lives and details about their deaths have been documented in news stories and court records.

When Amir James and his twin brother were taken to the hospital, detectives discovered the 4-year-old boys from Baltimore County covered in cuts and bruises. One had a black eye that was swollen shut. He lived. Amir didn’t. He died from skull fractures that caused his brain to bleed.

Zavier Giron had several broken ribs in various stages of healing, a dislocated femur and a perforated intestine when he died. The internal tear caused fluid to leak into his abdomen, which became infected. A prosecutor likened his abuse to torture. The Montgomery County boy was 16 months old.

Charlee Gamble was shot in the head at her home in Baltimore with a gun her father purchased illegally. She was 2. Christopher Gamble told police he left the weapon unsecured on a television stand in his bedroom. Three of Charlee’s siblings were also home when the gun went off.

Of the nearly seven dozen victims Maryland reported in 2023, 15 had been returned to parents or guardians who previously lost custody, many more such children than any other state that year. The distinction raises questions about whether the Department of Human Services is doing enough to protect known victims from further harm.

Price, the agency spokesperson, now says that figure is incorrect, too, but she did not provide an updated tally.

“We believe our ranking is closer to the national average,” Price said, adding that the agency works under the oversight and approval of the juvenile court system when making decisions about family reunification.

Five-year-old Zona Byrd had also been returned to her parents’ custody before she starved to death last year. She should have been in kindergarten, yet when police discovered her body, she was wearing toddler-size clothing that hung off her skeletal frame. Now her parents are facing first-degree murder and child abuse charges.

Not even a consent decree mandating high-quality care for some of Maryland’s most vulnerable abuse and neglect victims has been enough to force the state to consistently provide it. Price pushed back on that characterization, saying the safety and well-being of Maryland’s children is the Moore administration’s top priority.

Experts say fatality data is a good way to judge the health of a child welfare system because the metric is, or should be, indisputable.

“The deaths are the canary in the coal mine,” said Paul Griffin, the legal director of Child Justice Inc., a nonprofit that litigates custody cases involving domestic violence and child abuse in the state. “The coal mine is full of bruised and battered children. Something needs to be done.”

Analyzing the data

The first indication of a deadly child safety problem in Maryland came in June 2016 when the annual State Council on Child Abuse and Neglect report landed on Gov. Larry Hogan’s desk.

The council advises the state’s top elected officials on abuse prevention, and that year’s report included an alarming statistic.

Ten out of 26 children who died of abuse or neglect in state fiscal year 2014 were being monitored by the state child welfare system at the time of their deaths or had their cases closed in the previous 12 months.

None of the deceased children’s names was included in the report, but Hogan may have recognized one as Anayah Williams, a 21-month-old girl whose father punched her in the stomach and killed her in 2014 weeks after she was returned to her parents’ custody in Frederick County. Anayah had been placed in foster care as a newborn after her father fractured her skull.

Hogan signed legislation in her honor known as Anayah’s Law. The measure gives Maryland more flexibility to keep some abuse victims in foster care longer.

But, by federal fiscal year 2019, child maltreatment deaths had grown to 55.

That year, 4-year-old Malachi Lawson’s mother burned him in a scalding bath, failed to seek medical treatment and later dumped his body in the trash. He, too, had been previously removed from his parents’ custody.

Ten months ago, yet another annual report from the council warned of an alarming increase in maltreatment fatalities. Copies went to Moore, state Senate President Bill Ferguson, state House Speaker Adrienne A. Jones and nine Moore administration officials, including López, the human services secretary.

Eighty-four children died from abuse or neglect in federal fiscal year 2021, according to the report.

When The Banner first asked a senior Department of Human Services official about the growing number of child maltreatment fatalities in Maryland, he said he had not looked at the figures.

Price, the department spokesperson, said the Moore administration had started reviewing the data to identify trends and explore preventive strategies. She accused the Hogan administration of failing to do this work for nearly a decade and leaving Moore a “broken” system.

But the agency later acknowledged that the review began only in response to questions posed by The Banner in December.

This was the first time in recent memory the agency had disputed the accuracy of the data, which gets published annually by the council and the federal Children’s Bureau, a division of the U.S. Department of Health and Human Services. The agency’s own staff provided the statistics.

Price acknowledged that the forms used to count child fatalities in Maryland were sometimes filled out incorrectly.

She said the agency had also misreported any death investigation by Child Protective Services as a maltreatment fatality. It intended to report only deaths in which child abuse or neglect was substantiated.

The state is manually reviewing raw data from the past five years to verify the precise number of child fatalities to which maltreatment was a contributing factor.

“We will now ensure that disposition levels are accurately represented,” said Alger Studstill Jr., executive director of the state’s Social Services Administration.

Importance of transparency

Maryland stands apart in its lack of transparency after a child’s death.

Arizona, Florida and Wisconsin, for example, share some information about each child who dies from abuse or neglect and the circumstances surrounding their deaths within days of their passing. Here, not even the children’s names get routinely released.

Maryland would be better able to prevent fatalities if it shared more, said Emily Putnam-Hornstein and Sarah Font, researchers who run a project that seeks to prevent fatalities through improved data collection, timely notification and greater transparency.

The project, called Lives Cut Short, gathers information about children whose caregivers killed them.

“There is no good, justifiable basis for being so restrictive,” said Putnam-Hornstein, a professor at the University of North Carolina at Chapel Hill’s School of Social Work.

For many years, information about child abuse victims in Maryland was completely confidential.

Then, in the late 1990s, state lawmakers expanded access after Pikesville third grader Rita Fisher died of torture and abuse at the hands of her family. Social workers had failed to protect her despite repeated warning signs.

Now, when a child dies, state law requires officials to release some information upon request, such as dates of reports of abuse, findings by investigators and services provided to the abuser.

But there’s a catch.

Prosecutors can block the records’ release if they think disclosure could jeopardize a criminal case against an abuser. They almost always do. State Del. Susan McComas and state Sen. Mary-Dulany James have been trying unsuccessfully to close that loophole for years.

Last year, López, the human services secretary, wrote a letter detailing his concerns with the legislation, which failed to get a vote in the House of Delegates.

In response to questions from The Banner, López directed his department to release records detailing as many as 45 deaths that occurred from 2020 to 2023, along with more recent deaths that are still being tallied. The documents will give the public an unprecedented view of what went wrong in those cases.

However, the agency’s publicly reported fatality data shows that three times as many children died in those years.

Wendy Lane, who stepped down as chair of the State Council on Child Abuse and Neglect last year, called on the state to count the deaths by hand and explain the discrepancy.

“Our reports include their numbers,” Lane said.

That review is underway.

“Our ultimate goal is to greatly improve our data collection practices and create a lasting culture of vigorously analyzing and validating data,” Price said. She added that the agency recently started a new data office and hired a chief data officer.

Font says the state has a long way to go.

“It’s nuts that they could have made this type of error for so long with no one noticing,” she said.

‘I have some grave concerns’

How could the state Department of Human Services not know how many Maryland children have died from abuse or neglect?

The agency’s problems are well documented in reams of L.J. v. Massinga court records. The federal class-action lawsuit was filed against the state on behalf of Baltimore foster kids 40 years ago. The case revealed just how badly Maryland mismanaged its federally funded foster care program in the city.

Children in foster care suffered deplorable conditions and treatment, according to court records, including egregious physical and sexual abuse, medical neglect, denial of care and education, and a lack of permanent homes.

In 1987 the court ruled in favor of the plaintiffs, and the following year the court approved a consent decree, detailing the reforms necessary to get the state Department of Human Services and the Baltimore City Department of Social Services back on track.

Two decades later, the plaintiffs brought the state and city back to court, alleging violations of nearly every requirement of the original court order. A new, modified consent decree with benchmarks was approved by the court in 2009 and has been in place ever since.

But Maryland has made little progress toward compliance.

According to recent court filings, the state has met just three of the 44 standards required to end the case, and for nearly half the benchmarks, the state wrote “TBD” over and over. There is no automatic punishment for noncompliance.

Price touted Baltimore’s progress reducing the number of children who enter foster care and improving outcomes for the ones who do. These things are not among the consent decree’s many exit standards.

Rhonda Lipkin, the federally appointed monitor responsible for overseeing the state’s progress toward compliance, identified two major barriers to more rapid improvement of Baltimore’s foster care system — staffing and data.

In her most recent report, Lipkin called worker caseloads “unacceptably high,” noting that two-thirds of staff oversee more children than the maximum allowed. She added that “determining and addressing the needs of children and families in the child welfare system continues to be hobbled by the lack of available data.”

As bleak as the outlook might sound, Lipkin said, there is hope for Maryland.

Alabama, Connecticut and Ohio all faced child welfare lawsuits and successfully improved their systems. A class-action lawsuit filed in Washington, D.C., on behalf of the city’s abused and neglected children also ended more than three decades after it was filed.

Attorney Mitch Mirviss has been working on the L.J. lawsuit his entire career. He joined the case right out of law school, and now he is one of the lead attorneys. Asked how he feels about the lack of progress, he said, “Can you print the sigh?”

“After four decades, it is high time that we get full compliance,” Mirviss said. “These kids, after all, didn’t cause this, and they deserve exactly what we would give to our own kids and nothing less.”

At a court hearing in July, the latest federal judge assigned to oversee the case expressed exasperation with the state’s anemic compliance. Judge Stephanie Gallagher was 12 years old when the long-stalled case was first filed.

“It’s fair to say that I have some grave concerns overall about where we are, what we are accomplishing and what we’re trying to do at this point,” she said.