FATALLY FLAWED: WARM SPRINGS' CHILD WELFARE SYSTEM PROVES LITTLE PROTECTION FOR ITS MOST

VULNERABLE AND LITTLE DETERRENT FOR THOSE WHO HARM THEM

The Oregonian, December 9, 2003

By BRENT WALTH and KIM CHRISTENSEN

In the early hours of March 2, 2002, Frances Jefferson called Warm Springs
police from a trailer park a mile off the reservation, pleading for an officer to take
her newborn son off her hands.
She called every few minutes for more than two hours, repeating the message
over and over.
Jefferson's desperation was well-known to tribal authorities, who say they had
been looking for her to determine whether her 1-month-old baby, Lance Miller,
was in danger. Her brother had told the Warm Springs' police chief that Jefferson
was often drunk and neglecting her child.
"I warned him that baby was going to die," Clarence Jefferson III said. "You could
have put money on it."
But on the night his sister kept dialing the tribal police, nobody came.
Two weeks later, Jefferson called Warm Springs 9-1-1.
Lance was dead.
The Oregonian's review of child deaths on the Warm Springs Reservation shows
that Lance was one of five children who died in the past 12 years after tribal
officials learned they were in danger but failed to protect them.
Three died from physical abuse. One succumbed to heat exposure after his
guardian left him locked in a car for nine hours. Lance drowned while alone with
his mother.
Two of those deaths have occurred since the tribes revamped their child welfare
system in late 2001 to ensure that reports of neglect and abuse received
immediate attention.
Tribal authorities acknowledge in interviews that the reforms failed to fix the
problems at Warm Springs, governed by three tribes as a sovereign nation with
its own police, courts and social service agencies.
Twenty-five years ago, Congress gave federally recognized tribes jurisdiction in

custody cases involving their children. But the law also made tribes accountable
for protecting them.
The tribal judge who hears child custody cases said the agencies involved often
fail to deliver the evidence she needs to make sound decisions.
Experts on a panel that is supposed to oversee each child welfare case said they
are often kept in the dark but should be rigorously reviewing each child's death
for lessons learned -- a standard practice on other reservations and throughout
Oregon.
"We should be looking at the death of every child here, but we don't," said Dr.
Thomas Creelman, an Indian Health Service physician who has worked on the
Warm Springs Reservation for 28 years. "Most deaths fall into a no man's land
where no one looks into them."
Becky Main, director of Warm Springs Children's Protective Services, said the
tribes on the Central Oregon reservation have made enormous progress by
creating a web of family and child programs where none existed.
"The emphasis is to care for children as much as we can on the reservation," Main
said. "We have been very fortunate to be able to do that, and we're very proud of
that."
Main said her agency is doing its best in the face of an overwhelming number of
families shattered by poverty and substance abuse.
Children are placed in the supervision of the reservation's tribes -- the Warm
Springs, Wasco and Paiute -- at four times the rate of those in the state child
welfare system.
In deciding whether to remove a child from a dangerous home, tribal officials
said, they must balance competing interests.
The 1978 federal law requires tribes to give preference to extended families or
tribal-approved homes when placing children in foster care.
Jim Quaid, who as Warm Springs Family Services director oversees Children's
Protective Services, said the tribal child welfare system is a reflection of
community values.
"The state system is far more cut and dried," Quaid said. "The state gives parents
no second or third chances. People here get a lot of second and third chances."

When the system fails -- and Warm Springs children die -- justice has been
neither certain nor severe.
The guardian of Andres Saragos, a 4-year-old whose death in a locked, hot car
prompted Warm Springs to re-examine its child welfare practices, was sentenced
to 6 1/2 years in federal prison. A man convicted in the 1994 death of a battered
22-month-old girl received the same sentence.
The death of Lance Miller remains under investigation. No one served time for
the 1991 killing of a 3-year-old.
"What kids are left with is either thinking they can get away with a lot, or that
there is no one there to protect them," said Anita Jackson, former Warm Springs
public safety manager.
"Either message is not good. It gives kids the impression that they live in a
lawless society, that nothing happens to people who commit crimes."
Child beaten, no one punished
On Aug. 8, 1991, Warm Springs 9-1-1 received a call that a young girl had stopped
breathing. Paramedics rushed to a house in the reservation's Sunnyside
neighborhood, where they found the body of 3-year-old Wynter Falling Star
Stormbringer.
Twelve years later, her death is unsolved and haunts those who tried to keep her
safe.
Crystal Winishut, the toddler's foster mother and aunt, told police she had left
Wynter in the care of her three sons that morning and found her lifeless when she
returned, according to records in the child's medical file. Wynter's mother,
Cecelia Winishut, released the file to The Oregonian.
According to the records, the boys said Wynter had hit her head on the floor
during a tantrum. They had not called 9-1-1.
The Oregon state medical examiner's office ruled the death a homicide as a result
of a blow to the head, according to Wynter's file and autopsy report. Dr. Edward
F. Wilson, who performed the autopsy, told the newspaper Wynter appeared to
also have suffered other physical abuse.
That finding did not surprise Jon Grant, then the director of the tribes' Children's
Protective Services.
Wynter had been removed from her mother's custody in January 1991 because of

signs of medical neglect, according to her records. Tribal officials placed her with
Crystal Winishut.
But Grant said caseworkers learned that Wynter was also being neglected in her
foster mother's home. He said child welfare officials removed Wynter and
revoked Winishut's foster-care license. Tribal judge Lola Sohappy ordered
Wynter returned to her aunt, Grant said.
"I remember standing up in the courtroom and saying, 'No, no, no, you can't do
this,' " Grant said. "But the little girl went back and was dead not long after that."
Sohappy said in an interview that she did not recall the case or Grant's objections.
Tribal court records on child custody cases are not public.
Wynter's death prompted a criminal investigation by the tribal police and the
FBI, which investigates major crimes on reservations.
Winishut's son, Willie Danzuka, told The Oregonian that police identified him as
the chief suspect in Wynter's death. Danzuka, 13 at the time, declined to discuss
the case in detail.
"It brings back some bad memories," said Danzuka, now 25. "The system was
trying to put the blame on me for that."
Federal prosecutors did not file charges.
"We had causation and death but couldn't pinpoint who to put it on," said thenAssistant U.S. Attorney Michael Mosman, now a federal judge. "You can't charge
a murder case when you can't say which of several people in the house at the time
committed it."
Mosman's decision left the case in the hands of tribal prosecutors, who handle
the equivalent of misdemeanor crimes such as theft and assault. The maximum
sentence tribal judges can impose is one year.
Tribal prosecutors took action.
Willie Danzuka said he was charged as a juvenile in tribal court, but he declined
to describe the case against him. He and his mother, Crystal Winishut, said the
case was dropped.
A tribal jury convicted Winishut of child neglect in Wynter's death, according to
Winishut and her defense attorney, Dereke Tasympt, who is now the tribal
prosecutor.

Winishut said she did not go to jail and, eventually, the tribal appeals court,
which has broad power to review all aspects of a case, overturned her conviction.
Grant, the former Children's Protective Services director, said tribal leaders
blamed his agency for Wynter's death and for failing to help Crystal be a better
foster mother.
"That was the irony," Grant said. "We tried to do something, and we became the
alibi in this girl's death."
Police slip, child returned
In early October 1994, 20-month-old Antoinette Heath-Tewee and her 3-year-old
sister were found wandering their neighborhood while their mother, Roberta
Heath, went drinking.
Heath had lost custody of her children before because of neglect, according to
federal court records.
The neglect case was assigned to a tribal police investigator, with a report due 30
days later, according to the records. When police failed to submit a report at a
Nov. 15 custody hearing, the girls were returned to their mother.
Antoinette and her mother moved in with the family of George Picard Jr., 37,
who, according to federal court records, had a history of psychological problems
and convictions in tribal and federal courts on assault and weapons charges.
During the next six weeks, Picard slapped Antoinette in the face, punched her in
the head and beat her with a military belt and a cane, federal court records say.
Nobody, including her mother, intervened. Antoinette died three days after
Christmas.
Picard was charged with manslaughter but pleaded guilty to a lesser assault
charge. He was sentenced to 6 1/2 years in prison and has since been released.
Roberta Heath was convicted in tribal court of child abuse and neglect and was
sentenced to one year in jail, according to federal court records.
Antoinette's death, like Wynter's, attracted little attention beyond the
reservation.
The case of Andres Saragos was different.
Andres died after his legal guardian, Tamera Coffee, left him locked in a car for

nine hours on a 90-degree day in July 2000.

Fifteen months earlier, Warm Springs police investigated suspicions of child
abuse after seeing bruises under Andres' eyes, according to the boy's medical
records, which also say Andres reported that Coffee hit him. Tribal officials say
they looked into this report and other concerns about Coffee but could not
substantiate them.
The boy's death was widely covered by news media in Oregon. It prompted
outrage on the reservation and brought to light significant flaws in the tribes'
overburdened child welfare system.
Warm Springs leaders took the extraordinary step of hiring outside experts to
help correct the problems.
The resulting report, by the Portland-based National Indian Child Welfare
Association, called for a revamping of Warm Springs' approach to child custody
issues.
The report has never been made public, but Terry Cross, the group's executive
director, said it called on the tribes to strengthen their Child Protective Team, a
committee of law enforcement officials, physicians and social workers who are
supposed to advise on child welfare cases.
Warm Springs' policies say the team is supposed to coordinate child welfare
efforts. On other reservations, such committees act as a watchdog over the
various tribal authorities and courts that deal with kids.
The report found the team was "ineffective and on the verge of collapse,"
according to a summary of its findings. Cross said he recommended that the
improvements be made quickly.
Main, the director of tribal Children's Protective Services, said that tribal leaders
have yet to act on that portion of the report.
The tribes did try to carry out another recommendation: that agencies improve
the handling of abuse reports to make sure all were promptly and fully
investigated, so that what happened to Andres would not happen to another
child.
But it did -- to Lance Miller.
Baby drowns, no charges
Lance Miller was born Jan. 28, 2002, a healthy 7-pound, 10-ounce boy. He never
had a permanent home.

His mother, Frances Jefferson, shuttled him between his father's place in Warm
Springs and her parents' home in a trailer park on U.S. 26, a mile south of the
reservation boundary.
Jefferson had a history of depression and had lost custody of her two other
children, court records show. In February, the Warm Springs police began
receiving reports that Jefferson was taking the baby with her when she went out
drinking. Her brother, Clarence Jefferson III, warned the tribal police chief that
his nephew would die from neglect if something wasn't done.
Early on March 2, Jefferson repeatedly called the Warm Springs police, asking
them to send someone to take the baby, according to Jefferson County sheriff's
reports. No one from Warm Springs responded.
Later that day, according to sheriff's reports, a deputy and a state child welfare
caseworker went to the trailer park. They were checking on a report that Frances
Jefferson was taking care of the two older children previously taken from her
custody.
The officials removed the children, ages 10 and 7, from the home, according to
the deputy's report, but left Lance with his mother.
"The child appeared to be all right," the deputy wrote.
But records show the deputy and the state worker disagreed on Jefferson's
condition. The state worker reported Jefferson did not appear to be impaired.
The deputy wrote in his report that she was "intoxicated and had slurred speech."
The deputy also wrote that Jefferson denied calling Warm Springs police the
night before: "She was advised not to call them anymore unless there was an
emergency."
State officials said the events of March 2 were not enough to justify a broader
investigation. The officials said tribal authorities never reported any concerns to
them about the baby.
On March 10, Warm Springs police and sheriff's deputies went to the trailer park
to investigate a domestic disturbance, one of five visits that day to Jefferson's
trailer, according to a deputy's report. The park's owner told officers that
Jefferson was "stumbling around and almost dropped the baby" and had been
getting in and out of strangers' cars.
Jefferson's mother told a Warm Springs officer who was assisting deputies that
Lance was "in danger if left with Frances in her drunken condition."

Jefferson went into the trailer and refused to respond. When a deputy looked for
her later, she and Lance were gone.
Tribal authorities say they had wanted to find Frances Jefferson so they could
check on Lance's welfare. It's not clear how hard they tried.
Main, the chief child protective official, said a Warm Springs police officer was
assigned to help find the family.
Don Courtney, the tribal police chief, said he did not know why his officers had
not alerted tribal child welfare officials when they encountered Jefferson at the
trailer park or when she called repeatedly asking for police to come get her baby.
Then, on March 16, Jefferson tried to give her baby away.
She showed up with her squalling son at the home of Laurence Heath and his
wife, Cheryl, who said Jefferson had no food or warm clothing for Lance.
"She wanted us to take over, raising him and all," said Laurence Heath, a cousin
of the baby's father. "She was tired of him and trying to raise him. She said she
couldn't stand it anymore."
The Heaths said they could not keep Lance for good but would care for him
overnight. Jefferson said no and left, taking her son with her.
"If we could have had him for that night maybe he would be alive," Cheryl Heath
said. "That's what hurts."
The next morning, March 17, Jefferson called Warm Springs 9-1-1 to say her baby
was not breathing. When no one responded, Jefferson called back about 20
minutes later, panicked.
"You killed my baby!" she screamed.
She then called Emerson Miller, the baby's father, who found her alone in a house
on the reservation.
Miller told The Oregonian that Jefferson was wrapped only in a wet towel. The
bathtub was filled with water; wet and bloody baby blankets were nearby.
Lance was on the bathroom floor, motionless.
Miller rushed the boy to a nearby fire station, and paramedics attempted to revive
him as they raced the 15 miles to a Madras hospital. Doctors there pronounced

him dead. An autopsy later determined Lance had drowned.

Investigators found the scene much as Miller describes it, according to records in
the baby's medical file. Jefferson refused to answer their questions.
No charges have been filed.
Neither the Warm Springs police nor the tribal newspaper, the Spilyay Tymoo,
has reported details of Lance's death. Miller said he has been told little by tribal
police or the FBI about his son's death.
Investigators say the 9-1-1 dispatcher's failure to send help caused major
problems for the investigation. The lack of medical response meant they might
never know whether Lance was dead by the time Jefferson called for help.
"Whether it was an accident or deliberate, we will never know, one reason being
that issue," said Jim Cole, the tribal police department's chief detective at the
time.
Courtney said he fired the dispatcher.
He also said tribal authorities' efforts to check on the baby before he died were
complicated because Jefferson often kept Lance off the reservation in Jefferson
County, outside his agency's jurisdiction.
"I've said to some of my officers since then if we were faced with the same type of
situation, we would just kick the door in and argue jurisdiction later," Courtney
said.
Assistant U.S. Attorney Bill Williams, who handles Warm Springs cases, said the
federal investigation into Lance's death remains open. But he said not enough
evidence has been collected to bring charges.
Gene Smith, tribal prosecutor at the time of Lance's death, said the fact the infant
drowned under Jefferson's care was enough to bring child neglect charges.
He said Warm Springs police never presented him with a report. His successor,
Dereke Tasympt, said his office never received one, either, and that the tribal
statute of limitations has since expired.
A state judge issued a warrant for Jefferson's arrest in April after she failed to
appear at a probation hearing on an unrelated assault case, according to court
records and her attorney, Jennifer Kimble.
Clarence Jefferson said he thinks his sister is living in Shiprock, N.M., with their

parents, who have custody of her two surviving children. When The Oregonian
contacted her parents by telephone, they said they did not know where Jefferson
was. No one responded to questions the newspaper sent to their address by
certified mail.
Cole, the tribes' former chief investigator, said he is still troubled by the case.
"This is one I'll look back on 20 years from now, and it will still bother me," he
said.
"There has been no justice for that child."
One mother, three deaths
Last New Year's Eve, while on tribal-court probation, Lillian Blackwolf tested
positive for methamphetamine and marijuana.
That could have cost Blackwolf custody of her 17-month-old-son, Kenneth
Sconawah, who had been taken away from her for most of the previous year
because of her substance abuse.
Instead, 14 days after one tribal judge found her guilty of violating her probation,
another one held a hearing to determine her fitness as a mother and granted her
permanent custody of Kenneth.
Lola Sohappy, the tribal judge who returned Kenneth, said she knew of
Blackwolf's drug test results. But Sohappy said Children's Protective Services
officials had characterized the drug use as a brief "relapse" and told her that
subsequent urinalyses had come back clean.
She said officials were adamant that Blackwolf was "back on the track."
"We're only as good as the information we receive from the experts," Sohappy
said.
But Sohappy never asked them what drugs had turned up in Blackwolf's system.
"They didn't tell me what the substance was," she said. "I had no evidence that it
was meth."
Main, the Children's Protective Services director, disputes that account. She said
her agency asked for the right to continue monitoring the welfare of Kenneth and
Blackwolf's three other children, but Sohappy rejected that request.
Everyone agrees on this: No one called for removing Kenneth from his mother's

home.
Eight days after Blackwolf regained permanent custody of Kenneth, she killed
him.
After Kenneth's death, tribal prosecutor Tasympt said he sent a letter to other
tribal officials asking for a review of the case in hopes of discovering what had
gone wrong. He said he never got a reply.
"Our system let that child down," Tasympt said.
Federal prosecutors charged Blackwolf with second-degree murder. She at first
contended that Kenneth accidentally struck his head on a stove when she pushed
him in a moment of anger, records show.
A deputy state medical examiner later determined the injury could not have
happened that way and was caused by a blow equivalent in force to falling from a
two-story building.
Facing a possible life sentence, Blackwolf changed her plea to guilty in November
in exchange for federal prosecutors' recommendation that she serve 12 to 14 1/2
years in prison. She is to be sentenced Feb. 17.
Williams, the federal prosecutor, said Kenneth's killing has prompted an
investigation of the deaths of two of Blackwolf's other infant sons.
One, a 3-month-old, asphyxiated in 1992 while in a hammocklike swing with a
scarf tied around him.
The other, a 2-month-old, died in 2000 of what was thought to be sudden infant
death syndrome. No autopsy was performed.
Creelman, the longtime Indian Health Service physician, said that lack of inquiry
-- required of Oregon counties and common on other reservations -- prevents
Warm Springs from finding clues that might save other lives.
"We need to make sure the whole process is looking out for the well-being of the
child," he said. "Right now, the accountability isn't there."