SAN DIEGO – Eight days before Christmas 2005, Angela Bernard came home after a night of drinking and found her son propped up in bed, eerily still.

NELVIN CEPEDA / Union-Tribune Shelley McClure, great-aunt of Brandon McClure, held his favorite stuffed toys as she recalled the days she spent caring for him at her home. "He could eat two cans" of ravioli, his favorite food, she said.

Brandon McClure, 14, was cold to the touch and shockingly frail at 28 pounds. Bernard and her boyfriend called 911, but there was little point in following the operator's CPR instructions. Brandon was dead.

Nobody thought the Valencia Park home was a crime scene that morning. Bernard told police her son was severely disabled, explaining his shrunken frame. The house was neat and organized; there was plenty of food.

Authorities eventually pieced together what happened. Their findings implicated not only his mother but the county's entire child welfare system.

Brandon's disabilities didn't kill him. He starved to death.

Brandon McClure

In November, Bernard was sentenced to a nine-year prison term for her son's death.

But records show that the county knew the dangers Brandon faced. There were 17 separate Child Welfare Services investigations during his short life; each was closed after caseworkers decided he wasn't in imminent danger.

Brandon's death forced the county to examine its own failings.

“This case is undeniably tragic and very distressing to all of us,” said Mary Harris, who runs Child Welfare Services, a division of the county Health and Human Services Agency.

“Every day we come to work and expect our social workers to evaluate risk and exercise good judgment in difficult circumstances. In this case, the social workers and the supervisor did not make good decisions.”

U-T Multimedia: For documents related to Brandon McClure's case and a recording of his mother's 911 call, go to uniontrib.com/ more/ brandon.

The county fired two employees connected to the case, including the supervisor, and reassigned a third. It also changed the way it responds to abuse claims.

A month after Brandon's death, the county began requiring that secondary supervisors be consulted before any case on a medically fragile child is closed. Additional changes were made last year. Social workers now receive more health training. A master database tracks every contact so supervisors can see updated files for all children.

“Brandon's death was tragic and preventable, if not by his own mother, then certainly by those in charge of monitoring his welfare,” wrote a psychologist who interviewed Bernard for her criminal case.

Early trouble

Brandon Edward McClure was born Dec. 2, 1991. The delivery room clock read 5:17 p.m. His mother was 18; his father, Timothy McClure, was locked up on drug charges.

The pregnancy hadn't been easy, but neither was much of Bernard's life. She was a 10th-grade dropout often beaten by a crack-addicted mother. Her father was stabbed to death when she was 12. Growing up, she was the subject of five child welfare referrals herself.

Immediately after Brandon's birth, he was diagnosed with hydrocephalus, a buildup of fluids in the brain cavities that can stunt mental development. He also had cerebral palsy.

Brandon would never walk or speak. He couldn't dress or bathe himself. He wore a diaper. He took liquids through a tube that required constant cleaning. He could only eat soft foods.

Even so, his childhood was flecked with moments of joy. He giggled and cooed when he was happy. He waved his arms to most any music. He liked bubble baths and watching sports on TV.

He loved birthday parties, especially the cake-and-ice-cream part, but his favorite food was ravioli. “He could eat two cans,” said his great-aunt, Shelley McClure. “Oh my, yes.”

In those early years, McClure remembered, her niece would drop by with Brandon and a younger daughter. Sometimes Bernard would stay for a visit. Other times, she'd ask her aunt to watch Brandon so she could run errands.

“He was always clean and dressed so cute,” said paternal grandmother Diane Elder. “But that changed.”

Bernard was eligible for federal aid for families of disabled people. She signed up for food stamps and Section 8 housing assistance. Yet money was tight, and chores never ceased.

“I could hear it in her voice. She was overwhelmed. She was tired. It scared me,” Timothy McClure said.

The stream of child welfare files began four months after Brandon's birth and built as he grew older. At 22 months, he weighed 12 pounds, one report says. At 5, he was suffering “severe neglect,” counselors said. A year later, a nurse noticed a burn on his left foot that his mother couldn't explain.

One time, officials at Keiller Middle School found cockroaches infesting his wheelchair. Again, caseworkers were summoned. Bernard failed to keep appointments, and the case eventually was closed.

In addition to the 17 files opened on Brandon, social workers checked on his two sisters 11 other times.

The county “would receive referrals from several sources and would investigate,” Bernard's probation report states. Then “care would improve for a while.”

County officials wouldn't discuss Brandon's case in detail. But Harris said some parents do just enough to convince caseworkers that they have become responsible providers.

When that happens, the file is closed. If the county receives a subsequent referral for the same family, another investigation is opened and the process starts anew.

Caseworkers review family histories and sometimes contact previous social workers, but workloads are too heavy to allow for detailed discussions between caseworkers checking the same family. A typical social worker is responsible for more than 30 children a month.

In Brandon's case, county workers would show up unannounced and hear voices inside or see a child peeking through a closed window, but get no answer. One day, a man opened the door but wouldn't let the worker in. Bernard skipped most appointments.

Robert Fellmeth, a University of San Diego law professor who runs the Children's Advocacy Institute, said caseworkers should have done more to protect Brandon.

“If you've got someone who starved to death, and he's got 17 referrals, these are a lot of red flags,” said Fellmeth, a former prosecutor. “If this is happening in my county, I want the grand jury involved.”

Gruesome findings

Shelley McClure said that as Brandon grew older, Bernard would make excuses for visiting with her daughters but no son. “It was always, 'He had some school thing,' or something else,” she said.

One of Brandon's sisters once confronted her mother about leaving him at home while they ran errands. But it was no use. “I'd get so sick of it,” the girl told a counselor after her brother's death. “Why can't he go with us, or put him in his wheelchair?”

Bernard routinely spent the night out, leaving her children to fend for themselves. Brandon had a hospital-style bed in his room, but he preferred to sleep in his sister's room so he could watch TV.

Elder, Brandon's grandmother, last saw him in July 2005, six months before he died. “His clothes were dirty; his fingernails and toenails were dirty,” she said. “His Pampers hadn't been changed. His wheelchair was filthy.”

Social workers tried to visit Brandon's home several times that summer, but no one answered the door or called the phone number left behind. Social workers can't legally enter a home unless they think a child is in immediate danger, and they rarely go to court to seek a search warrant.

In November, the file on Brandon was closed for lack of contact. It was a judgment call on the part of the social worker. Two and a half weeks later, Bernard and her boyfriend were confronted with the small, cold body in the bedroom.

Brandon would have been buried, his case closed and forgotten, if not for one detail: Bishop Mortuary needed a doctor to sign the death certificate. The boy's primary-care physician refused. He hadn't seen Brandon in nearly a year.

The county Medical Examiner's Office took custody of the body and performed an autopsy.

The results were gruesome. Brandon's body showed signs of wasting syndrome. It was covered with bedsores and displayed a terrible diaper rash. The cause of death was recorded as “starvation/neglect.”

City and county investigators spent more than a year piecing together a criminal case, reviewing thousands of pages of medical records and interviewing teachers, neighbors and relatives. Bernard cooperated fully, answering question after question posed by police.

Bernard was arrested on suspicion of murder in January 2007. She later pleaded guilty in Superior Court to involuntary manslaughter and felony child abuse.

She never spoke during her Nov. 26 sentencing hearing. But public defender Ricardo Garcia steered some of the blame to the county's child protection services.

“Maybe CPS should should be standing here next to Ms. Bernard, shouldering a lot more responsibility for what happened to Brandon than they are,” Garcia told the court.

Brandon was one of 24 children in the county to die from neglect or abuse between 2003 and 2007, records show. Two had active cases when they died. Ten others, Brandon included, had previous files closed by caseworkers.

Harris said such deaths represent the worst she and her colleagues face. “You plug away at this work for a long time, and this is exactly what we don't want to have happen.”

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David Hasemyer: (619) 542-4583; david.hasemyer@uniontrib.com