LEWISTON — State child welfare officials visited the home of Jasper Smith seven times at the behest of family members, neighbors and health care providers, but did not take any action, the boy’s aunt and a child advocate said this week.

That was before the early morning of May 17, when the 4-year-old found a loaded, unattended firearm registered to his stepfather, Robert McCoy, at his home at 93 Pierce St. Just hours later, he was pronounced dead at Central Maine Medical Center, his cause of death a gunshot wound.

Maine State Police continue to investigate the boy’s death, Shannon Moss, spokesperson for the Department of Public Safety, said Tuesday. His siblings have been removed the Pierce Street home, Jasper’s aunt, Laura Smith, said.

Smith and Bill Diamond, a longtime advocate for child welfare reform, say the Maine Department of Health and Human Services, which has faced intense criticism in recent years over its ability to identify and aid children who are being abused or neglected, could have done more to help him.

“There’s been 17 calls to DHHS from various places and people like health care providers, mental health workers, neighbors, family members,” said Smith. “There were seven investigations and zero findings for abuse or neglect, and that blew my mind.”

The Maine Department of Health and Human Services did not immediately respond to questions Tuesday.

Smith said the home was disgusting and that Jasper and his siblings were perpetually dirty.

But that’s not how Smith wants the world to remember Jasper.

“He was a sweet little boy,” she said. “He loved to love. He loved people. He was wanting always to just play and he had this curious mind about him. He needed to know everything about everything. It’s just challenging to know the world is going to miss that light.”

When Smith was called to her sister’s home with the news that Jasper had died of a gunshot wound, she said, every scenario imaginable flashed through her mind about what might have happened.

However, she was sure of one thing, which she said she made known to officials at the scene: “My nephew would still be alive if DHHS did their job.”

Smith said a caseworker reviewing Jasper’s file essentially agreed and passed her a piece of paper with a number for Bill Diamond.

“Just give Bill a call,” the caseworker said.

Diamond, a former state senator and secretary of state, advocates for child welfare reform through a nonprofit organization he founded in 2001 called Walk a Mile in Their Shoes. The organization’s mission is to prevent the abuse and homicide of children who have had involvement with the Maine Department of Health and Human Services. It also performs research and files reports and performs community engagement and advocacy.

“We’re told the department came into that home seven different times — seven times! — based on referrals from a pediatrician, a home nurse, neighbors, family members,” Diamond said. “Each time, they found no findings. That’s unacceptable.

“You’re talking about a child who, according to family, was living in filth — mice running across the bed, droppings on the counters. The child wasn’t being cared for. This tragedy could have been prevented.”

To Diamond, Jasper’s death is the latest example of what he calls a broken system — one that repeatedly fails to protect children despite warning signs, evidence of which Walk a Mile’s 2023 report “Unsupported” illustrated.

When the organization interviewed frontline child welfare workers like case managers and counselors, they asked the obvious questions like “Why are kids dying?” and “Why are they being abused at such high rates?”

Maine had the highest rate of child abuse and neglect in the nation at that point — and by more than double the average, Diamond said. Walk a Mile found “a real failure in management” in which caseworkers are overloaded and do not have the support they need to do their jobs effectively.

“Foster parents don’t feel supported and the same problems have been going on for as long as I’ve worked on this issue,” Diamond said. “It doesn’t seem to be getting better.”

The organization’s 2023 report highlighted “a culture of secrecy and denial” within DHHS, including agency officials’ tendencies to lean on confidentiality laws to avoid public accountability. When media, advocates or legislators ask questions, they hide behind confidentiality laws, Diamond said: “They stretch that definition way beyond its intent.”

Behind closed doors, caseworkers fear retaliation for speaking out, Diamond said.

“There is a culture of fear,” he said. “One caseworker told us that working in Lewiston was like working in a war zone. The conditions are so difficult and unsafe, many quit, leaving their caseloads to others.”

Walk a Mile found, at one point, that there were 79 open caseworker positions in Lewiston alone, Diamond said, adding that the department’s digital case management system, which went live in 2022, only makes the job harder.

Meanwhile, in the last six years there were 148 child deaths from abuse or neglect, or in households with prior involvement in the state welfare system, including 34 in 2021 alone. Diamond added that a federal inspector general found that Maine failed to follow safety protocols 94% of the time in a sample of child welfare cases.

‘WE’VE SEEN IT AGAIN AND AGAIN’

“We’ve seen it again and again,” Diamond said. “In all these cases, DHHS knew what the situation was — and did nothing.”

And it’s not just researchers, advocates and families that are aware of the issues, Diamond said. This winter, 145 DHHS employees signed a vote of no confidence in the director of the Office of Child and Family Services, the facet of DHHS that deals with child welfare cases like Jasper’s. A legislative bill to make OCFS a standalone agency with its own commissioner passed in state Senate, but was blocked in the House.

Smith said improvements with child and family service in Maine will only happen when more people call for changes, especially when caseworkers can recognize situations like Jasper’s as dangerous and still not be able to do anything.

“There wasn’t even any education provided with all of these calls (of concerns) about nutrition, about the cleanliness of the home,” Smith said. “There were a huge amount of things that were just never really addressed. They’d go in, they’d investigate and they’d leave. … Again, zero reports out of those seven visits.”

Smith advocated for DHHS to put more power back into caseworkers and less into the administrative teams that make decisions such as whether to take a child out of the home or to close a case out without follow up.

“Caseworkers are in the homes. They’re there, they’re seeing it,” Smith said. “Then they go out to their car and they sit in front of the house for three, four or five hours talking on the phone to their superiors, who are sitting in their offices. And they’re deciding, without even seeing anything, the fate of these children. Maybe make parents want to change, make people want to work with you.

“You’re DHHS. You’re the biggest organization in the entire state of Maine. Figure it out.”