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 tribalapproved 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 then-Assistant
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."