Child Protective Services had a backlog of nearly 10,000 unfinished cases by the time it kicked off its SWAT program to respond to the overload.

That's a basketball arena packed with children in potentially dangerous and troubled homes.

This was in August 2011, and CPS was drowning in what workers call "stale cases." Thousands of reports had been investigated, only to sit open on computer screens for months. Thousands more had been assigned to workers who then left the agency, meaning the cases hadn't been investigated or were incomplete.

It was a dangerous mess, and the solution CPS developed was SWAT teams in each region. Across the state, units of veteran workers would review these cases. If the cases were investigated properly and ready to be closed, the SWAT workers would close them. If the cases needed to be investigated again, they would get sent back with explicit investigation guidelines. This meant the cases would be added to the existing workloads of CPS workers.

By January, Child Protective Services was celebrating SWAT's success with a press conference announcing how the case backlog had been cut by 73 percent.

But in Pima County things didn't go as smoothly.

Here, the SWAT team rushed to close cases and missed an opportunity to intervene with Za' Naya Flores, who starved to death at 21 months old. Much of the attention on Za' Naya's case has focused on CPS worker Donald Hauser, who copied and pasted his notes about the little girl over the course of months.

Records show the CPS SWAT team in Pima County picked up Za' Naya's case on Dec. 12, 2011. That's exactly one month before she died.

CPS has blacked out the records relating to SWAT's involvement with Za' Naya's case (see image). But at least two of the workers tied to SWAT in Pima County - including a manager who volunteered to lead the team - have since left the agency. Administrators with the state's Department of Economic Security, the umbrella agency for CPS, will only generally acknowledge something went wrong.

"This is a work in progress and, as anything you put in place, you are going to always find some kind of little gaps and holes," said Veronica A. Bossack, an administrator with the agency. "And so along the way we did uncover some inconsistencies."

Before returning to Za' Naya's case, it's important to outline the creation of SWAT, which stands for Social Worker Assessment Team.

It took months to develop SWAT and the protocols to guide it. State records show officials did this with thought and care, creating review tools and guides for workers.

Cases were divided into tiers, depending on how complete or incomplete the investigation and report were. Records show each tier came with numerous and exacting guidelines for what was required before a case could be closed.

Deborah Harper, an administrator with DES, told me SWAT workers were expected to, among other things, review past and current reports; gather police reports; look at the severity of allegations; and identify domestic violence, substance abuse and mental illness in the household. If they sent back an investigation, they outlined what needed to be done to complete it.

"Nothing within the SWAT team process that we developed compromised child safety," she said. "For each of those cases, we took a look at those seven or eight components, and we made a decision."

The SWAT program formed just as CPS began receiving more and more case reports. Between April and September 2011, 19,666 reports of abuse or neglect were made. Compared with recent previous years, that was about 2,500 more reports than normal. For example, in 2010 the agency received 17,068 reports between April and September.

Given this strain, SWAT came as a relief to staffers.

"I would like to add that one worker in particular has been verbally expressing her fear of something 'going wrong' on a case because she cannot effectively manage her caseload due to backlog," says an email to Harper from Aug. 18, 2011.

"I spoke to a few workers yesterday about getting their cases together," another email to Harper reads. "One of them in particular had adopted an abandoned caseload. All of the work was done but nothing is entered into the computer. The cases are old!"

It's unclear when SWAT reviews started in Pima County, but by the fall there was talk of creating a formal SWAT team here.

On Oct. 28, June Willson, then an assistant program manager with CPS, emailed Lillian Downing, the then head of CPS in Pima County, suggesting a Pima SWAT team and the staffers she would like on it

She brought up the issue again on Nov. 3:

"I am proposing that you make me the lead on the SWAT process," Willson wrote to Downing. "I will then work with several others to create multiple teams to review cases and hopefully close cases in a more timely manner."

Willson is no longer with the agency, and efforts to reach her were unsuccessful. When I reached her a few months ago, she hung up on me.

On Nov. 14, Downing sent out an email updating SWAT's progress, and proposing Willson as the leader of the SWAT team.

"We have done a great job thus far and have closed over 52.85% of the total number of cases," Downing wrote. "I think with the extra SWAT team we can close out many more cases between now and the end of the year."

Given the thoroughness expected from SWAT workers, Pima County was really moving through cases.

Harper, the DES administrator, said over the past year, SWAT has reviewed about 92 percent of the original 9,903 cases across the state. She said it has about 750 cases left.

Sources close to SWAT in Pima County said workers were, for whatever reason, told to close cases that did not have any new reports of abuse or neglect. CPS officials would not comment on this.

"I wasn't there to be a part of that process, but I can share to you that the directive was clear that cases would be reviewed as a team, and that if two people were concerned or just didn't feel right about a case then they would bump it to the SWAT team coordinator position," Harper told me.

"Throughout the time that we started the process, I did identify inconsistencies," Bossack said. "I did ask senior staff to do a refresher of the process and spread that information out across the state."

But not in time for Za' Naya.

SWAT picked up Za' Naya's case on Dec. 12. We know she died of starvation a month later, and Hauser had copied and pasted his notes for months before. We also know Hauser reported in October that Za' Naya had a black eye. And we know cops and medics called to Za' Naya's home when she died described a gruesome scene.

But we don't know what SWAT did in Za' Naya's case. We don't know how many cases Pima County SWAT handled without following protocol - "inconsistencies" as Bossack said. We don't even know what those "inconsistencies" are. We don't know if CPS has done any kind of review of those SWAT cases.

Given history, do you trust this agency with these secrets?

"This is a work in progress and, as anything you put in place, you are going to always find some kind of little gaps and holes. And so along the way we did uncover some inconsistencies."

Veronica A. Bossack

Administrator with Department of Economic Security

Contact Brodesky at 573-4242 or On Twitter: @joshbrodesky

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