A community deserves to know when one of its children dies of unnatural causes. That’s especially true if the family had already come to the attention of child protection officials. In that case, the natural question is why, despite the warnings, the state failed to prevent the death.

So now I will tell you the strange and disturbing story of the death of a 5-month-old baby on the Waianae Coast and what it says about Hawaii’s disclosure of information in such cases.

Short answer: nothing good.

Even if you are a diligent follower of the news, you would never have heard of this case. That’s because not a single word has been written about it by any media outlet since the baby’s death two years ago, not a single mention on the TV news.

Here’s how I found out about it.

I learned that the federal government requires states to disclose certain information to the public in cases of death or near death from maltreatment. 

According to a 2012 report, “The federal government has determined that the good that can be gained from disclosing information about child abuse or neglect deaths or near deaths will exceed any potential harm or embarrassment that some individuals might experience as a result.”

“The public has a right to know if the laws for the protection of children are being followed and its tax dollars well-spent. Child abuse deaths and near deaths reflect the system’s worst failures.”

Once I learned about the federal law, I asked the Hawaii Department of Human Services for a list of such cases over the last several years. The department, eventually, provided it.

One of the cases stood out. It said that in 2021 a social worker from Child Welfare Services had visited an infant’s “caregiver” – apparently as the result of a complaint – and that the “caregiver shared that the child had passed.” This caregiver initially stated that the child had drowned, CWS said, but the death remained unexplained.

CWS two and a half months earlier had gotten a “report of concern” about the baby, then 3 months old. CWS concluded that the caregiver had “mental health and substance use issues.” For reasons that are not explained, CWS did not officially confirm abuse or neglect, which it must do to initiate Family Court proceedings.

It left the case open, however. When the baby died, it finally confirmed “threat of abuse and neglect” by the caregiver.

And that was that. No names, no location, no detail about what CWS did and did not do or why – not even an explanation of the caregiver’s relationship to the baby. Oh, and CWS incorrectly listed the baby’s age as 3 years, not 5 months.

With only the date of the death in hand, I contacted the Honolulu Medical Examiner. And lo and behold, they were able to provide a report that included the baby’s name and details about what happened.

I asked the Honolulu Police Department for its report from that night. Earlier this year, HPD declined because the investigation was still open. But when I asked again recently, the case had closed and HPD gave me the heavily redacted 144-page report.

With these two documents, I was able to piece together the following bizarre narrative.

Shortly before 4 a.m. on Oct. 13, 2021, the baby’s mother called 911 from an apartment in Makaha Valley reporting that the baby had drowned. The firefighter who got there first found the baby lying face up on the bathroom floor, wearing a blue onesie, a diaper and white socks on his hands.

The firefighter carried the baby to the living room to perform CPR on a table. The mother kept yelling “get the water out.” But CPR had no effect. The baby was clearly dead.

Police noted that the tub and the sink were dry and the toilet lid closed. There was, however, a wet washcloth and the back and sides of the mother’s pants appeared to be wet.

One officer’s report describes the mother as “somewhat upset, but not distraught.” Another said she sat in the patrol car just staring into space. She said she “didn’t care if she got arrested, just wanted EMS to get the water out of her son’s body.”

Her explanation of what happened? “I fainted and then went walking. I could have been dreaming and then I came back and my baby was on the floor.”

At another point that night, she “related that she experienced a lapse in her memory and the next thing that she remembers she was walking on the roadway.” Her location is redacted in the police report, but the medical examiner makes clear it’s the Waianae Mall. That’s more than 4 miles from her home – a walk of well over an hour. 

Her explanation continued, “She caught a ride from a stranger and returned home” where she found her baby lying on the bathroom floor. She was “adamant that she could not recall anything.”

HPD checked her record and found that she had previously been referred by the police for emergency psychiatric treatment because she had been suicidal. The medical examiner reported a history of anxiety and depression and possibly schizophrenia, as well as a suicide attempt during pregnancy. 

Four days later, police interviewed the mother’s mother – the baby’s grandmother. She reported that she used to see her grandson more frequently, but because of her daughter’s irrational behavior, had not spent time with him or her daughter as often. She had not seen the baby for two and a half weeks.

The important point is that these accounts raise legitimate and crucial questions about how CWS handled this case.

The day after the baby died, the grandmother – unaware of what had happened – called 911 for a welfare check on her daughter and grandson. She never heard back. 

Then, earlier on the day the police interviewed her, she had gotten a text from her daughter saying that the baby had been adopted. She even named the adoption agency.

The grandmother called CWS several times that evening, before the police arrived, desperate to find out what was going on. But the social worker never got back to her as promised.

So, four days after her grandson’s death, she was still in the dark. It’s not even clear from the police report that the officer told her, although I assume that happened.

HPD also interviewed a CWS social worker. He said he had been working on the case for several months. In August, a couple of months before the baby died, the mother “was able to move into her apartment.” He visited her six times and “consistently found that she appeared to maintain good living standards within the unit.” He did not observe signs of abuse or neglect.

Something’s wrong with the picture. On the one hand, we have a grandmother saying her daughter was acting irrationally, had been diagnosed with a (redacted) psychiatric condition and was increasingly isolated from her family. On the other, we have a social worker reporting that everything looked OK. 

Social workers cannot be expected to know everything. The important point is that these accounts raise legitimate and crucial questions about how CWS handled this case. The public deserves an explanation.

HPD interviewed the mother again a couple of days after the death. She still could not recall any details but “was adamant that she did not cause any harm” to the baby.

Meanwhile, a detective found that “she was in an agitated state and unable to participate in a polygraph due to the traumatic nature of the incident.”

The medical examiner was clearly puzzled by the case. He found that the baby’s lungs were hyperinflated “consistent with drowning or aspiration of watery fluid.” But the amount of fluid in the stomach and part of the small intestine “seems excessive for drowning of infants.” It seemed possible that the baby inhaled the water after drinking a large amount, a scenario that “might suggest forced drinking.”

The findings were “bizarre” and not typical of an accidental drowning. “Another individual’s volitional action may be suspected” – in plain language, it looked like someone did it. 

The manner of death was listed as “undetermined.”

This case raises so many questions, among them what really happened, how the grandmother could go at least four days without being informed, why no one was ever prosecuted and why CWS apparently did not notice the mother’s mental deterioration or consider it significant. 

(I was able to determine the name of the baby and the grandmother, whom I tried unsuccessfully to reach. I narrowed down the identity of the mother to a small handful of possibilities, but because of the uncertainty and the mother’s mental health issues, did not try to contact them.)

But I want to use it to raise a different question: Why are Hawaii’s child welfare officials so intent on keeping information secret that the public has a right to know?

I have written before about the absurd explanations DHS has offered for not releasing information about its actions leading up to the horrendous death of Isabella Kalua, also known as Ariel Sellers, a 6-year-old Waimanalo girl whose adoptive parents are accused of killing her. In Ariel’s case, the state won’t even disclose the minimal information it gave me for the Makaha Valley case.

In other states, child welfare agencies post far more detailed information about child maltreatment deaths and near deaths, and they do it on public websites. That is key. It’s one thing to have the time to try to reconstruct a case like I did and only succeed by getting some lucky breaks. It’s another to be a citizen interested in the performance of the child welfare system able to simply click on cases on a website.

I did not do an exhaustive search for all 50 states, but my brief survey found that California, Florida, Rhode Island, Nevada, Wisconsin, Arizona, Delaware, New Jersey and Colorado all publicly post reports of child maltreatment, and often in far greater detail than I got when I demanded information not accessible on the internet.

Let’s consider Colorado. 

I opened one of the cases at random. It was seven pages long, compared to the three paragraphs I got on the Makaha Valley case. And this case did not even involve a fatality. It included demographic information about the child and parents, an extensive description of the child’s living situation and a two-page description of the abuse, including detailed medical information, an account of the caseworker’s involvement and the actions of police. 

It also contains a summary of the family’s earlier involvement in the child welfare system, a detailed timeline and, most important of all, an assessment of the strengths and weaknesses of the state’s handling of the incident and the earlier reports. 

In other states, child welfare agencies post far more detailed information about child maltreatment deaths and near deaths, and they do it on public websites.

I don’t know how many people click on such reports in the states that post them publicly. What I do know: Hawaii, in its annual reports to the federal government, reports in the last three years that exactly one person requested information about a child maltreatment death. Is that because no one cares — or far more likely, that no one knows they can do it or how?

Amy Harfeld, one of the authors of the 2012 report on state policies, said there are three reasons it’s important for states to disclose information on deaths and near deaths and, unlike in Hawaii, make it readily available to the public.

First is accountability for child welfare policies and decisions in individual cases. This is particularly important in states like Hawaii where child welfare cases are closed to the public – both records and court proceedings.

In that case, Harfeld said, “public disclosure of fatalities is one of the only remaining ways to demand accountability.”

Then there’s the right to know what’s going on in your community, much like what happens when police departments publish crime statistics for individual neighborhoods. 

Lastly is the importance of learning from what went wrong and adjusting policies accordingly. Harfeld said that lawmakers often react to one particularly heinous child abuse death, passing a law named after the child victim. That may be good or bad policy, she said, but it’s far less likely to be effective than a systematic look at all such cases.

“One fatality won’t expose the deepest cracks,” she said. 

I asked DHS to discuss its handling of the case.

You guessed it: I never heard back.