Tragedies Unreported: Illinois DCFS Flouts Law on Child Death Reviews

Eight-year-old Navin Jones weighed just 30 pounds when paramedics found him clinging to life in a bathtub in 2022, his tiny body bruised and emaciated. Days later, Navin died, one more child lost under the watch of the Illinois Department of Children and Family Services (DCFS). Both his parents were convicted of murder, and an investigation revealed a DCFS caseworker had seen Navin’s dire condition a month prior yet failed to get him medical help. Navin’s horrific death should have triggered an official report examining how the system failed him and what must change. Such a report is required by Illinois law. It never came. And Navin’s case was not an outlier, but part of a staggering pattern.

More than 1,200 children have died, and over 3,000 have suffered serious injuries, in cases meeting the criteria for incident-specific DCFS reviews since July 2018. Each of these tragedies, whether a fatal beating, a neglect-related drowning, or a suicide in foster care, was supposed to prompt a public report by DCFS explaining what went wrong and outlining steps to prevent it from happening again. Yet not a single such report has been published in all those years. The state agency charged with protecting Illinois’s most vulnerable children instead kept these incidents shrouded in bureaucratic silence, in clear violation of the Abused and Neglected Child Reporting Act, the very law designed to force transparency after a child’s death or near-death in DCFS care. This systemic failure of accountability has real consequences: without public scrutiny and self-examination, opportunities to fix fatal flaws have been missed, and children continued to pay the price.

A Transparency Law Born from Tragedy

Illinois’s mandate for child death reporting was literally written in blood. In the 1990s, a series of horrific child welfare failures, “one horrific DCFS case after another,” as then-State Representative Tom Dart recalls, underscored the need for greater accountability. One case in particular seared itself into public memory: 3-year-old Joseph Wallace was returned from foster care to his mentally ill mother despite repeated warnings, only to be hanged with an electrical cord in 1993. Outrage over Joseph’s murder and others led Dart to sponsor a landmark reform. Passed in 1997, the law created a presumption that when a child dies of abuse or neglect or suffers a life-threatening injury under DCFS watch, the best interest of the public demands disclosure of what happened. The statute declared the agency “shall” release an incident report with details of the case and recommendations for systemic changes, with only limited redactions allowed. In 2008, after an investigative series revealed 53 children had died in DCFS care over just a few years, lawmakers strengthened the act to ensure those incident reports be made public as a matter of course. The goal, Dart says, was to shine a light on DCFS’s failures so that “information from child fatalities can be used to correct systemic problems and prevent future occurrences.” In short, the law was meant to replace secrecy with transparency, restoring public trust in the child protection system through honest self-examination.

Dart wrote the requirements to be unequivocal. DCFS was given a strict six-month deadline after each child death or serious injury to complete its internal case review and make the report available. Copies of each report were to be sent to the legislative leaders, the local lawmakers representing the child, and an annual cumulative report compiling data, findings, and recommendations was mandated for the Governor and General Assembly. “You have to do it, and you need to move expeditiously,” Dart says of his intent, “because what if you find out that a vendor working with that child is the problem? Are you gonna let 10 more kids be subjected just because we didn’t get around to it yet? No, we need to move rather quickly on this stuff.” The whole point was to learn from each loss before another child is put in danger. “We have to start with the analysis of the deaths. These children have to be viewed as our children. We need to take it that seriously,” Dart insists. The public, he adds, “deserves to know what happened here, what went wrong with this,” not in order to assign blame for its own sake, but to make sure the same mistakes are not repeated. In the words of Cook County Public Guardian Charles Golbert, who represents thousands of foster children in court, “These reports, which are required by law, are critical to protect children and to prevent deaths and serious injuries to children in DCFS care or who are reported as abused or neglected.” The law promised a measure of clarity and accountability after tragedy. It was a promise to Illinois’s children that their lives would matter, that their deaths would teach us how to save others.

Systemic Failure to Inform and Reform

That promise has been broken. For nearly seven years now, DCFS leadership has effectively flouted the law, failing to produce the very reports that legislators fought so hard to require. When pressed by journalists in late 2024 and early 2025, the agency could not point to a single recent incident-specific report. In fact, a Freedom of Information Act request for the most recent DCFS child death report, whatever the last one was, came up empty. DCFS officially responded that no reports exist. It appears the practice of conducting and releasing these case-specific examinations quietly died out years ago, with neither public notice nor formal announcement. The last time Illinois’s Auditor General checked up on this requirement was in 1999, and back then, the agency was already falling short. In a compliance audit soon after the law’s enactment, auditors in 1998 found DCFS had “not filed a report with the Governor and the General Assembly” on child fatalities as required, and was not even investigating child deaths within the law’s scope. At the time, DCFS officials sheepishly blamed “inadequate resources and personnel” for the failure. Under scrutiny, the agency pledged to do better, and by the following year auditors noted some improvement. But after that point, oversight faded, and at some unknown time, DCFS slipped back into non-compliance. No state audit in the past 25 years has specifically tested DCFS on this legal mandate. Away from the spotlight, the department simply stopped producing the reports that could expose its weaknesses. It stopped telling the public and lawmakers what was going wrong, and children kept dying.

DCFS’s leadership has offered shifting justifications for this opacity. Agency officials insist they do conduct internal reviews of each death or injury; indeed, multiple layers of review exist, from the DCFS Office of the Inspector General to regional Child Death Review Teams and special internal panels. But almost none of that resulting information ever sees the light of day. By law, most child welfare records are confidential, shielding the details of investigations and services from public view. The incident-specific reports mandated in the statute were supposed to cut through that secrecy and extract key lessons for public consumption. Yet DCFS effectively chose to keep those lessons to itself. In a recent statement, DCFS spokesperson Heather Tarczan claimed the agency “meets and exceeds its duty under the law to report on tragic cases” through the OIG’s annual reports and the work of the independent Child Death Review Teams. In other words, DCFS argues that these existing reviews satisfy the requirement, an “understanding” under which it had been operating, instead of preparing the public-facing incident reports the law demands. Tarczan declined to explain how the agency arrived at this interpretation. The rationale does not withstand scrutiny. The Inspector General’s annual report, while informative, covers only a subset of child deaths, typically those involving allegations of misconduct by DCFS employees or particularly egregious system failures, and omits hundreds of other cases of abuse and neglect injuries each year. The regional Child Death Review Team reports are not public at all in Illinois, and in any case they have fallen behind. The most recent CDRT annual report as of early 2025 examined deaths from five years ago. In reality, nothing DCFS was doing came close to the comprehensive, timely disclosure envisioned by the law. The agency’s claim that it “exceeds its duty” rings hollow when, in truth, it has skirted a core duty of transparency and left the public in the dark.

The consequences of this dereliction are profound. Without incident-specific reports, there has been no public accounting for what went wrong in case after case, and thus no assurance that DCFS has learned anything from these failures. The law did not merely require isolated case reports; it also directed DCFS to compile cumulative data and findings from those cases to spot patterns and recommend system-wide reforms. Because the underlying case reports were never done, those higher-level reviews have been essentially meaningless. DCFS has continued to send the Illinois legislature perfunctory quarterly statistical updates listing child fatalities and injuries, but these contain no analysis, no findings, no recommendations. In short, none of the insight the law mandates. The statute explicitly requires those quarterly and annual reports to include the agency’s “findings and recommendations”, drawn from each incident investigation. Instead, lawmakers got sterile tables of dates and locations, with all the substance missing. As Golbert warned, “if DCFS is not consistently completing these reports about individual children, the required cumulative reports will be incomplete and erroneous.” He was right. State Senator Erica Harriss, who represents the district where one victim died, confirmed that she received none of the promised findings or recommendations about that case, only a notice that the death occurred, the cause (neglect) and a note that investigations were “pending.” There was never any follow-up. In effect, Illinois law has been subverted, and the feedback loop that was supposed to drive reforms has been snapped. Lessons learned on paper count for little if they never reach the people with the power to change policy. By failing to report its own failures, DCFS not only broke the law, it forfeited crucial chances to fix systemic problems before more children are harmed.

Children and Families Left in the Dark

Behind the statistics and reports are the lives of real children, lives ended or forever scarred in preventable ways, without the public reckoning that might have saved those who came after. Each case is a heartbreaking story of a safety net torn and holes not mended. We have Navin Jones, the little boy from Peoria whose starvation death revealed shocking lapses by a DCFS investigator. We have the case of a 9-year-old in central Illinois, a child with a history of setting fires and suffering abuse, who was left without sufficient help until one night he allegedly started a blaze that killed five people, including three toddlers, in 2019. DCFS had been involved with that boy’s family since the day he was born, yet the tragedy still unfolded; the subsequent criminal case raised questions about whether more intervention could have averted the catastrophe. The law required DCFS to delve into such questions and release a report on its findings. Instead, the agency initially told reporters that any death review was “not public,” before finally admitting, under prodding from the Illinois Attorney General, that it had not created the reports at all, so there was nothing to disclose. It was only after media inquiries and the Attorney General’s intervention in early 2025 that DCFS begrudgingly acknowledged the scope of its non-compliance. By then, years of tragic cases had piled up with no public explanation, and Illinois families were left with only their grief and gnawing questions.

For families who have lost children, DCFS’s silence can feel like a second betrayal. Mackenzi Felmlee’s story is a stark example. Mackenzi entered state care as a young teen after suffering horrific abuse by a guardian, only to endure further torment in an Illinois foster home. Over four years, other children in the home reported that Mackenzi was being beaten, humiliated, and starved, yet she remained there until the day she was found at the bottom of the basement stairs, bruised, dehydrated, and struggling to breathe. The 18-year-old died in May 2024 from a blood clot in her lungs, weighing just 90 pounds at death. Local prosecutors call it murder: Mackenzi’s foster mother and another caregiver have been indicted on a litany of charges, including first-degree murder and aggravated battery, for allegedly torturing her to death. And what of DCFS, the agency that placed Mackenzi in that home and was responsible for overseeing her welfare? In the wake of this unimaginable tragedy, DCFS has refused to release any report or timeline of its involvement, despite the law requiring findings and recommendations when a ward of the state dies. Citing an ongoing criminal investigation, officials say they will not produce or share any information “until after a trial takes place,” which could be years down the line. Mackenzi’s mother and sisters, as well as the public, are thus left in painful limbo. They know how Mackenzi died, but not how the system designed to protect her allowed her to suffer so terribly for so long. The law was intended to prevent exactly that kind of information blackout. Transparency is not a mere bureaucratic formality; it is a lifeline for accountability. When agencies publicly confront their mistakes, they create pressure to change course. When they hide behind secrecy, the same dangerous practices can continue unchecked. For Mackenzi’s surviving family, and for the families of so many other DCFS-involved children who died, the lack of answers compounds their anguish. There is no public report to affirm that what happened to their child was wrong and will not be forgotten. There is no sense, at least not yet, that their tragedy might spur reforms so that it was not entirely in vain.

The toll of DCFS’s opacity must also be measured in the children who are still with us, those who might have been saved or spared trauma had the agency been more transparent about its failings. Each undisclosed death was a missed alarm bell. Each unexamined injury was a lesson unlearned. For every Navin or Mackenzi whose story briefly surfaced in news headlines, there are many others known only as line items in an internal ledger. Those children’s stories never reached the public ear to prompt outrage or action. Instead, they remain hidden in redacted case files, their suffering witnessed only by caseworkers and, sometimes, by nobody at all. The absence of incident reports means the public rarely hears about patterns that emerge across tragedies, patterns like caseworkers overloaded with impossible caseloads, or children left in unsafe homes due to communication breakdowns, or services that were not provided in time. These are the systemic issues that a transparent reporting process would bring to light, issue by issue, recommendation by recommendation. In the darkness of DCFS’s silence, however, such issues can fester for years. Frontline workers may quietly know what is wrong, and internal reviews might even flag the same problems repeatedly, but without public and political pressure, meaningful change too often stalls. The victims, meanwhile, continue to be children, overwhelmingly from poor and marginalized families, whose lives and deaths pass without the full measure of justice or reform the law envisioned. As Dart put it bluntly, “We have to look at these children that way, and we need to take it that seriously,” as seriously as we would if they were our own. By failing to publicly reckon with the deaths of children in its care, DCFS has failed to honor that basic moral obligation.

Outrage and Calls for Accountability

When the breadth of DCFS’s non-compliance came to light, it ignited a firestorm of criticism from child advocates, lawmakers, and watchdogs who had long suspected something was amiss. “The failure to issue these reports,” wrote one reporter, “spurred blistering criticism” and prompted immediate calls for an independent investigation. Charles Golbert, the Cook County Public Guardian, formally asked the state’s Auditor General and the DCFS Inspector General to probe the agency’s refusal to follow the law. In his letter, Golbert underscored that these legally mandated reports are “critical to protect children, and to prevent deaths and serious injuries,” a scathing rebuke of DCFS’s dereliction. Cook County Sheriff Tom Dart, the very author of the reporting law, did not mince words about its neglect. Learning that DCFS had not been producing the reports at all left him “stunned, stunned,” Dart said. “Just so reckless. So irresponsible.” It was, to Dart’s mind, an unconscionable breach of the agency’s duty to deceased children and the public. “I can’t conceive of any scenario where this isn’t at the front of people’s lists,” he said. “We have a child in our care that died. What happened?” That such a fundamental question went unanswered hundreds of times struck Dart as beyond belief, a sign of deeply misplaced priorities within DCFS.

State legislators have also been galvanized by the revelations. In March 2025, as the news spread, a group of Illinois lawmakers held a press conference during Child Abuse Prevention Month to demand action. “Since July 2018, DCFS has failed to produce incident-specific reports for over 1,200 child deaths and more than 3,000 serious injuries,” announced Rep. Patrick Sheehan, spelling out the grim numbers under the bright lights of TV cameras. Sheehan, a Republican from Homer Glen, stressed that front-line DCFS staff are “dedicated” but stretched to breaking. “This is not their failure; it’s a failure of leadership and outdated practices,” he said pointedly. That failure of leadership, in the legislators’ view, has left caseworkers without the improvements and guidance that frank post-mortem reports could provide. Sheehan and his colleagues have proposed reforms aimed at modernizing DCFS practices, from better abuse investigation tools to stricter oversight, and they implored Governor J.B. Pritzker’s administration to finally enforce the transparency law on the books. “Protecting our children is a moral imperative,” Sheehan urged, calling for “swift and meaningful reforms to prevent future tragedies and restore faith in DCFS’ ability” to safeguard kids. That plea for restored faith resonates beyond partisan lines. Democrats and Republicans alike have watched in frustration as DCFS has been rocked by child death scandals year after year. The agency’s director has been held in contempt of court multiple times in recent years for failing to place children appropriately. Audits have found a litany of problems from high staff turnover to inadequate training. To those chronic issues, add now a crisis of transparency. The outrage is not solely that DCFS broke a law, but that it betrayed the public trust at the most anguished moment, when a child dies, and squandered a chance to learn from that loss.

DCFS and the Governor’s office, for their part, have responded defensively. Rather than immediately pledging to fix the reporting lapse, officials initially doubled down that nothing was wrong at all. In a statement following the Illinois Answers Project investigation, DCFS asserted that its “rigorous reviews” by the OIG and Child Death Review Teams “ensure accountability and systemic improvements while respecting confidentiality.” Governor Pritzker went even further, publicly dismissing the criticism as misguided. “There are no underreported deaths. Okay?” the Governor told reporters in April 2025. He argued that DCFS’s annual Inspector General report is “done by the independent IG, and you can read about all of those situations,” claiming he himself reads the entire report and acts on it each year. Pritzker suggested that the Illinois Answers investigative journalist “didn’t understand the way the system of reporting works. It was a false road that he went down,” implying that the reporter realized his mistake halfway through but “didn’t want to pull back” on the story. In essence, the Governor contended that DCFS’s internal processes were sufficient and that no children’s deaths were being swept under the rug. Child welfare experts and advocates strongly challenge that rosy characterization. For one, the Inspector General’s annual reports, while valuable, cover only a fraction of the cases that legally demand review. According to DCFS’s own figures, more than 1,200 child deaths met the criteria for incident reports in recent years. By contrast, the DCFS OIG opened just 114 death investigations from 2018 through 2023. The vast majority of fatalities, especially those not involving obvious agency misconduct, never make it into the IG’s public report at all. So when Governor Pritzker insists “you can read about all of those situations” in the IG’s tome, the math simply does not add up. The OIG annual reports have documented dozens of egregious cases, but certainly not the full 1,200 plus tragedies that occurred. And even the IG’s narratives, by mandate, omit names and identifying details, which blunts their impact. Meanwhile, DCFS’s claim that the independent review teams ensure accountability rings hollow when those teams’ findings are largely kept confidential and have been delayed for years. Far from “exceeding its duty,” as DCFS proclaimed, the agency has, in truth, evaded its most basic duty of public accountability.

The clash between DCFS’s self-justifications and advocates’ demands underscores a core issue: transparency in child welfare is often uncomfortable for agencies, but it is absolutely necessary. By ducking the law’s requirement for openness, DCFS shielded itself, and by extension, Governor Pritzker’s administration, from scrutiny and potential embarrassment. But that short-term avoidance of accountability carries a devastating long-term cost in public confidence and child safety. The growing chorus of voices calling out DCFS’s secrecy suggests that patience has run out. Editorial boards, child advocacy organizations, and lawmakers are openly questioning how an agency can be trusted to reform itself if it will not even acknowledge, publicly and specifically, what it did wrong. In the legislature, there are calls for the Auditor General to conduct a new performance audit specifically examining DCFS’s adherence to the child death reporting law. If such an audit occurs, it could force a formal accounting of why these reports stopped, who made that decision, and how to ensure compliance going forward. Some child welfare advocates have suggested that if DCFS leadership cannot implement something as fundamentally important as transparency, then perhaps an outside monitor or consent decree is needed to oversee the agency’s reforms. These are the kinds of drastic measures that surface when trust breaks down. As of mid-2025, DCFS has a new director, former juvenile justice chief Heidi Mueller, who has pledged a “renewed focus” on the agency’s core mission. To succeed, Mueller must also reckon with the agency’s culture of insularity. True accountability will require DCFS not just to quietly review its failures but to own them in the daylight, no matter how painful that process may be for those in charge.

A National Pattern of Secrecy

Illinois’s struggle with child welfare transparency is sadly emblematic of a broader national problem. Across the United States, state child protection agencies have often erred on the side of secrecy, citing confidentiality laws, liability concerns, or fear of political fallout, when confronted with fatalities and near-fatalities among children they serve. In fact, the federal government recognized long ago that too much secrecy can kill. In 1996, Congress amended the Child Abuse Prevention and Treatment Act (CAPTA) to compel states to allow public disclosure of information when a child dies or is gravely injured due to abuse or neglect. The idea was to ensure that these horrific cases are not hidden behind privacy laws, but rather examined openly to spur reforms. However, CAPTA left the details to each state and has been poorly enforced by federal authorities. As a result, disclosure practices vary wildly, and many states still prioritize confidentiality over candor even in the worst cases. A comprehensive 2024 report found that “only a few states make meaningful disclosures” after child maltreatment deaths, thanks to weak federal requirements and lax oversight. Out of 50 states and the District of Columbia, four appeared to have no policy at all for publicly releasing information on child abuse fatalities, and four more had policies for fatalities but none for near-fatalities. Even among the 47 jurisdictions with at least some disclosure rules on the books, only 35 states actually require releasing findings or information about child maltreatment deaths. The rest merely allow it at an agency’s discretion, or require only minimal facts. Many laws are so vague or riddled with exceptions that agencies can easily withhold critical details. For example, some states permit officials to omit any information they deem “not pertinent” to the cause of death, a loophole that can be used to exclude prior warning signs or agency missteps. Others have broad carve-outs delaying disclosure “if releasing the information would jeopardize a criminal investigation,” a clause meant to protect prosecutions but one that can be stretched to cover virtually any pending case and thus postpone transparency indefinitely.

Perhaps most tellingly, very few states proactively inform the public that a child fatality has occurred in the first place. Only nine states routinely issue any kind of public notification when a child dies or nearly dies of abuse or neglect. In the vast majority of states, unless a particular death draws media attention, the public may never even hear about it, much less see an official report dissecting what happened. Illinois, to its credit, does list child deaths and serious injuries in those quarterly reports to legislators, which are technically public. But as we have seen, those lists omit names and contain no meaningful findings. They are a whisper when the law intended a full-throated report. In many other states, there is not even a whisper. The result of this national pattern is that systemic failures in child protection often remain hidden until a scandal erupts. Time and again, a particularly egregious case will force an agency’s practices into the spotlight, as happened in Los Angeles after the torture death of 8-year-old Gabriel Fernandez in 2013, or in New York City after the killing of 7-year-old Nixzmary Brown in 2006, or in Florida following the 2011-2013 child death cluster reported by the Miami Herald. These moments spur public outcry, officials vow improvements, and laws are sometimes toughened. Florida, for instance, strengthened disclosure requirements after media revealed multiple child deaths that had been kept quiet. Yet without consistent transparency, those hard-won changes can falter over time. Illinois’s law was one of the stronger transparency mandates in the country on paper, a model born of tragedy and reformist zeal. That DCFS managed to ignore it for years speaks to the persistence of what one advocacy group bluntly calls “state secrecy” around child deaths. It is a secrecy that is by no means unique to Illinois, but Illinois now offers one of the most vivid case studies of why it is so dangerous.

The national stakes are high. Approximately 1,750 children die from abuse or neglect in the United States each year, according to federal data, and those are only the cases we know about. Each death is investigated internally by child welfare authorities, yet only in some states is the resulting information ever shared with the public. Sunlight is the best disinfectant, Supreme Court Justice Louis Brandeis once said. In the realm of child welfare, sunlight can be the difference between a hidden cycle of recurring mistakes and a public awakening that forces better policies. States that have embraced transparency, like Texas and Arizona in recent years, now publish detailed fatality reviews that have prompted changes, for example improvements in how abuse hotline calls are screened, after patterns were revealed. Those states still face many challenges, but at least the dialogue about reform is anchored in concrete facts from real cases. In Illinois, that kind of dialogue has been hamstrung by DCFS’s information blackout. Lawmakers in Springfield have been legislating and budgeting for child welfare without a complete picture of what is going wrong on the ground. Advocates have had to rely on whistleblowers, court cases, or journalists to find out about the worst breakdowns in the system. And families, especially those with children still in DCFS care, have had to live on faith that the agency learns from its errors internally, because no one on the outside can see if it truly has. That faith, unsurprisingly, is in short supply now.

Conclusion: From Darkness to Accountability

Illinois finds itself at a crossroads. The revelation of DCFS’s failure to publish incident-specific death and injury reports is more than a bureaucratic misstep; it is a moral failing that cuts to the heart of the agency’s mission. DCFS exists to protect children from harm. When that protection fails, as it tragically did for over 1,200 children who died and thousands more who were hurt, the least the agency owes those children and the public is the truth. Instead, DCFS allowed a veil of silence to descend over their fates, as if their stories held no lessons worth sharing, no reforms worth making. The cost of that silence can be counted in lives lost and trust squandered. It is evidenced by each new headline of a child who died despite DCFS involvement, and by each anguished parent or grandparent who asks, “How did this happen, and will it happen again?” For too long, those questions met with no answer.

It is not too late to correct course. The law compelling DCFS to confront its own failures is still on the books, waiting to be enforced with renewed vigor. Advocacy groups and some legislators are now pushing not only for DCFS to catch up on the missing reports, but to institutionalize a culture of openness going forward. This will mean more than a one-time cleanup; it will require sustained commitment from leadership and perhaps external oversight to ensure compliance is real. If and when DCFS begins producing the incident-specific reports again, Illinois will need to pay attention to what they say. Patterns of mistakes that have been conjecture will be confirmed by evidence. Reforms that have long been delayed, improving training for investigators, reducing caseloads, enhancing substance abuse treatment for families, better supervising foster homes, might finally gain momentum, armed with the hard proof of what happens when those fixes are not in place. Transparency is not a threat to DCFS; it is a tool to help DCFS do its job better. As Dart noted, those children who died “have to be viewed as our children.” Their lives cannot be in vain. Public disclosure of how and why the system failed them is a first, necessary step toward honoring their memory and protecting those who come after.

In the end, this is a story of accountability, the kind owed to the voiceless. The Illinois Abused and Neglected Child Reporting Act was born from tragedy and written with the hope that shining light on failure would drive change. For several years, that light was dimmed by neglect and indifference. Today, the demand for answers is rekindling it. The public is saying that these children’s lives mattered, that we must learn from each one of them. The question Illinois faces now is whether its child welfare agency will continue to hide in the shadows or finally step into the light. The children, living and lost, deserve nothing less than full accountability and a promise that their stories will teach us how to do better.