The state removed a 4-month-old infant from his parents’ custody after he was abused so severely he almost died. Doctors estimated his rib fractures were as much as two weeks old.

The Department of Human Services, which investigates child abuse cases, identified Zion McKeown’s parents in internal documents as the primary suspects in the 2008 case, according to records recently obtained by the Honolulu Star-Advertiser. The couple denied responsibility and were not charged, and the case was classified as one involving an unidentified perpetrator.

Despite the state’s suspicions and other red flags, including the parents’ history of family violence, the mother’s loss of her parental rights to a daughter and the father’s criminal record of assault and abuse, DHS eventually reunited Zion with his mother — the couple were separated by then — and imposed no conditions on the father’s visits with his son.

Before the Family Court approved reunification, the parents underwent counseling and other services, but even that was problematic. The two were largely noncompliant with the court orders and services associated with their son’s case, according to testimony the state attorney general’s office submitted to the Legislature this year.

Zion was returned to his mother without an assessment done by a team of outside experts — a step required under DHS rules in serious abuse cases, according to the documents.

“It’s a significant omission,” said Richard Gelles, former dean of the School of Social Policy at the University of Pennsylvania.

Three years later, Zion, then 4, was dead, the victim of abuse so severe that a doctor said the injuries were consistent with someone hitting a concrete wall at 65 mph.

Kyle McKeown, Zion’s father, and Grace Lee-Nakamoto, McKeown’s girlfriend, were charged with second-degree murder and are awaiting trial on Maui.

New revelations

The Star-Advertiser and other Hawaii media have reported on Zion’s case. But the documents recently obtained by the newspaper provide new, previously undisclosed details that cast a harsher spotlight on the state’s handling of the case.

The records raise questions about whether DHS was so focused on reunifying Zion that the red flags weren’t sufficiently heeded and that the agency was too quick to end oversight.

On a broader level, the documents provide an unusual glimpse into the machinations of a process that normally is shielded from the public by confidentiality rules designed to protect the interests of abused children.

“This kid is literally the poster child for a system that doesn’t work,” said attorney Carl Varady, who represented Zion’s estate and family members in a negligence lawsuit against DHS that was settled for $875,000 this year.

Even Zion’s guardian ad litem, a court-appointed attorney whose job was to protect the boy’s interests, questioned the department’s actions when it ended oversight of the mother, Angelique Rooney, by closing the child welfare case involving her daughter just days after Zion’s birth.

“Given the situation regarding mother’s history and evaluation, DHS had no business closing the case and putting Zion at risk,” Malcolm Hong wrote in a January 2009 report to the court. “Perhaps his injuries could have been avoided had DHS remained on the case.”

A multidisciplinary team of experts, who examined Zion’s case after his death, noted that a team review wasn’t done before reunification — required under DHS policy — and that the department provided only “minimal” post-reunification supervision of three months in a case involving a child seriously harmed by an unidentified perpetrator.

Such unidentified “perp” cases, as they are called, need extra scrutiny, experts say, given that the abuser remains unknown and the child, who typically is too young or otherwise unable to say who the abuser was, is at risk of more harm.

In the wake of Zion’s case, DHS in 2014 established a special unit that investigates all instances in which a child is seriously harmed by an unknown perpetrator.

DHS officials said they provided adequate oversight in Zion’s case and stressed that the recommendations to reunify him and end post-reunification supervision were supported by the child’s guardian ad litem and the parents’ attorney and ultimately were approved by the court.

They also defended their pursuit of reunification, rather than termination of parental rights, emphasizing that there were no aggravating circumstances to justify termination, they were providing services to the parents to address safety concerns, and the parents, as in other cases, were regularly monitored for behavioral changes.

“If they’re not making progress, at any point we can file for termination,” said Cynthia Goss, assistant administrator of the department’s Child Welfare Services branch, in an interview.

Kayle Perez, the administrator, said DHS’ role is to provide opportunities for families to heal and develop skills to help with reunification.

Asked about general criticisms of DHS’ oversight efforts, Goss referred to what happens in most child welfare cases. “I believe the outcomes speak to that,” she said. “Children go home and are safe at home.”

DHS faulted

Over the past several years, the rate of abused Hawaii children suffering re-abuse within six months has remained substantially below the national standard of 6.1 percent and generally has been declining since at least 2009, according to data provided by DHS. In the four quarters of fiscal year 2017, Hawaii’s rate never topped 0.5 percent, the data show.

Critics of DHS, however, point to Zion’s case to question how the department exercises its oversight. They say a case in which a child is seriously harmed and the parents are primary suspects demands extra scrutiny, especially if reunification is pursued.

Zion’s parents were primary suspects because they were unable to adequately explain Zion’s 2008 injuries, according to the case documents.

Heidi Staples, director of the UCLA Center on Child Welfare, was retained by Varady to evaluate the case. She said red flags were abundant yet were given insufficient weight by DHS, which Staples faulted for pursuing reunification given the egregious circumstances and for not following its own policies.

She said neither of Zion’s parents demonstrated substantial rehabilitation or the capacity to safely care for him.

Zion was reunited with his mother on Oahu in September 2009, and more than a year later she turned him over to his father, who had moved to Maui. A severely injured Zion was brought to Maui Memorial Medical Center in May 2012 and died a day later.

“This is the worst of the worst, the highest risk and most severe type of abuse, the youngest and most vulnerable of victims, the type of case that haunts communities and social workers and courts and advocates and anyone who cares about keeping children safe,” Staples wrote in her analysis. “It boggles the mind that this child who miraculously survived the first assault was then subjected to a return to the same unsafe and dangerous caregivers.”

Gelles, the former dean, said in a phone interview that Zion’s case underscores a problem with child welfare agencies throughout the country. They pay more attention to the rights of the parents than what is best for the child, he said.

“I think these agencies have a completely unrealistic notion of the capacity of people who maltreat children to change over a prescribed amount of time,” he said. “It’s illustrated time and time again, not just in the islands.”

Gelles said DHS’ failure to seek recommendations from an outside multidisciplinary team before returning Zion to his mother was a significant misstep because such reviews provide important feedback.

Asked why no review was done, DHS was unable to cite a reason.

“The multi-disciplinary team is a valuable resource in our reunification process where serious harm to the child had previously occurred,” spokeswoman Keopu Reelitz said in an email to the Star-Advertiser. “Having them review cases before reunification is our standard practice. We will continue to look into what occurred in this situation.”

By the time Rooney was reunified with her son, her behavior and attitude had improved, according to the reports made to the court.

“Mother has made a commendable turnaround in this case,” Hong, Zion’s guardian ad litem, wrote in a December 2009 report. “Initially, she was not as cooperative and compliant, but she has made a remarkable adjustment in her approach to others and focused on Zion and herself.”

Rooney could not be reached for comment.

A few months after Hong wrote that report and before Zion was moved to Maui, DHS received an anonymous call saying that the mother was abusing her son, the records show. DHS called the mother to offer services, according to the attorney general’s legislative testimony, but “no further follow-up was taken.”