Before 5-month-old Trinity McIllwain died, a social worker responsible for her protection carried a caseload four times what the state recommends.
A report on Trinitys 2007 death found that Mecklenburg County Department of Social Services failed to keep in contact with her family and did not properly review records, citing social worker caseloads as a factor.
But instead of beefing up staffing after the review, the agency reduced the number of people protecting children from abuse and shifted resources elsewhere.
The decision left children in troubled families more vulnerable to abuse and neglect, contributed to high staff turnover and helped lead to a major shake-up in the agency.
Now county officials are embroiled in debate over who should be held accountable for depleting the agencys front-line workers at a time when they were needed most.
The controversy has also revealed virtually no oversight by the Board of County Commissioners, who are ultimately responsible for DSS.
In a memo written before she was fired last month after four years, former DSS Director Mary Wilson outlined her concerns to county officials. Wilson harshly criticized Paul Risk, director of Youth and Family Services, which handles child protective services.
The division needs to focus on holding staff at every level accountable however, I believe Paul Risk has a very hard time with this aspect of his role, and therefore, it was not emphasized within the division at that time, the memo says.
In their first extensive comments since Wilsons memo became public about two weeks ago, county officials defended themselves and suggested reforms championed by Wilson weakened safeguards for children.
County General Manager Michelle Lancaster said she disagrees with Wilsons memo.
The county is now trying to hire about a dozen new social workers to fill openings that were cut or frozen during Wilsons tenure.
Risk said he and others raised questions as resources were diverted from the division.
There was a constant conversation taking place, Risk said. We asked Do we really need to do this? What are the alternatives?
But Lancaster worked as Wilsons direct supervisor and had the authority to challenge the moves. Lancaster said she questioned Wilson, but gave her wide latitude because officials hired Wilson to examine the departments administrative structure and service delivery.
We dont micromanage, Lancaster said.
County Manager Harry Jones brushed off warnings from employees who sent anonymous letters to him and commissioners complaining that Wilson was hurting the agency.
Whos been watching the hen house? Commissioner Vilma Leake asked. I look to the (county) manager. The buck stops with the manager.
In an email, Jones said, I am accountable for the overall performance of the organization, including successes and failures, but did not specifically say whether he deserves blame for problems at DSS.
Asked whether he agreed with reforms Wilson implemented, Jones would not answer.
Wilson did not return phone calls seeking comment.
On Wednesday, a three-person employee panel will examine whether Lancaster followed policy when she recommended the county terminate Wilson.
In hearing Wilsons appeal, the panel will consider evidence from both sides and make a recommendation, but Jones makes the final decision. The county has not said why Wilson was fired.
Wilsons lone public statements came in September when she released prepared remarks citing numerous deficiencies in the agency.
Wilson said she worked to address the problems, but added the greatest challenge at DSS has been bringing forward the bad news of neglect, practices putting children at risk, wasteful spending, lack of controls to ensure that the taxpayer is protected and the backlash associated with continuing to uncover failure to adhere to policy.
The controversy intensified earlier this month when the Observer reported that Wilson sent a critical memo to Lancaster before she was fired. The memo, obtained through a public records request, said Mecklenburg County had struggled in recent years to meet federal standards for child protection.
Wilson attached a February 2011 state review that cited disturbing lapses, including one case where a social worker failed to follow up with medical providers about a child who had suffered second-degree burns.
The revelations exposed confusion about who is responsible for overseeing DSS.
Nearly every other North Carolina county has an independent board that holds authority over DSS.
In Mecklenburg, however, the County Board of Commissioners is charged with running DSS. County Manager Harry Jones has authority to make personnel decisions.
But some commissioners said they were unaware of the 2011 state review and did not learn about reorganization within the agency for months. Some blamed county administrators for failing to keep them informed.
Im not sure we know what our responsibility is, Leake said.
Commissioner Bill James said he is more likely to receive information about DSS failures from the media than from county administration.
We might get an email that says This happened, Commissioner Bill James said. More often, the first time we hear about something is when you guys report it.
James said the blame doesnt entirely lie with county staff. There are commissioners frankly, who dont want to know, he said. Theres a belief we shouldnt be involved.
Lancaster, the county general manager, said administrators alert commissioners about major reports and other information the board needs to shape DSS policy.
Commissioners voted unanimously in 2008 to name Wilson as DSS director.
Even though she lacked social work expertise, Jones said she was hired because she possesses a strong intellect, excellent communication skills, knowledge of our community and a strong desire to develop a culture of excellence within DSS.
Wilson, who spent much of her career in the corporate world as an attorney, almost immediately announced plans to merge some operations, create new divisions and launch a review of how agency divisions were operating.
DSS must protect children from abuse and neglect and ensure their health and educational needs are met.
Under Wilson, the agency shifted a partnership with Charlotte-Mecklenburg Schools from Youth and Family Services to another division, where Risk said workers took on additional responsibilities. DSS also transferred nurses from child protective services to another division.
Mecklenburg County also imposed budget cuts in recent years to cope with the economic recession. Last year, a six-month hiring freeze left 14 social worker positions unfilled. Department directors would typically recommend such budget choices. Risk said historically the agency avoided freezing such positions.
That meant heavier caseloads for remaining staff. State officials recommend child protection workers carry no more than 10 cases at one time. Mecklenburg social workers now have an average caseload of 13 to 14 cases, Risk said.
The increased work has pushed the employee turnover rate in Youth and Family Services to 28 percent, a figure Risk called high.
The problems hit at a bad time since reports of child abuse and neglect tend to spike during economic downturns. DSS now receives about 1,200 to 1,250 reports of suspect abuse or neglect each month, about 20 percent more than in 2007 when the agency counted 900 to 950 reports each month.
Risk acknowledged that all of the changes diminished his divisions ability to address child well-being.
Since late March, he has reported directly to Lancaster instead of Wilson, who was his supervisor.
Lancaster has agreed to hire about a dozen new employees to help restore staffing lost in recent years. Officials have already moved the CMS partnership and nursing program back to Youth and Family Services.
The new hires likely will push the turnover rate down to 15 to 20 percent because additional staff would lower caseloads and burnout, Risk said.
Not long after Wilson started at DSS, some employees sent anonymous notes to commissioners critical of her decisions and of her lack of experience in social services.
One letter said Wilson has been on the job one month but has wreaked more havoc in this short time than all the years I have worked at DSS.
At the time, County Manager Jones publicly defended Wilson. This new leadership is asking questions, quite frankly, that need to be asked, questions that challenge the status quo, Jones said.
Lancaster said she questioned changes Wilson proposed.
To demonstrate how she scrutinized ideas, Lancaster provided a Dec. 5, 2011, email she sent in response to a memo from Wilson. The email is about DSS Community Resource Division, which provides emergency financial assistance, subsidized child care and other needs.
The division was created under Wilsons leadership.
Lancaster challenges whether moving resources to the Community Resource Division from other areas of DSS has produced better results. How does the service delivery described lead to minimize the likelihood that no student will fall through the cracks ? Lancaster wrote.
Some commissioners now want to reconsider how the county oversees DSS.
Since the 1970s, commissioners have exercised authority typically reserved for a DSS board of directors.
In most N.C. counties, a separate board sets policy and hires the DSS director. Supporters say the arrangement allows for closer scrutiny of spending and policies.
Mecklenburg has a so-called consolidated human services board in which commissioners watch over DSS and mental health and public health agencies. The setup gives County Manager Jones power to make personnel decisions dictated by county policy instead of state rules.
But Mecklenburg commissioners rarely meet to specifically address DSS issues. Commissioners said they rely on Jones to keep them updated.
Commissioner Jennifer Roberts said she doesnt believe the board receives enough information. Commissioners should receive briefings on child fatalities more often, Roberts said.
She suggests the board create a DSS advisory panel that would make recommendations and issue reports.
The county dissolved a similar board about a decade ago because members were critical of commissioners decisions , Commissioner James said.
He said he wants the commissioners to discuss DSS more often to improve outcomes.
Right now, the only people who review the system are bureaucrats, James said. Its a closed system. There isnt any independent oversight of the system.
Researcher Maria David contributed to this report.