NEW YORK (CBSNewYork) -- Disturbing findings were released Thursday by the city's Department of Investigation, with the agency saying critical mistakes by the Administration for Children's Services cost 3-year-old Jaden Jordan his life.
As CBS2's Hazel Sanchez reported, investigators found "significant" errors in the ACS' handling of a case involving the alleged abuse of the Brooklyn boy.
The investigation into the the case found "the depth of errors over a two-day period was so significant, and the errors involved the overall implementation of policies so basic, that they go to the heart of ACS's core mission of protecting children and implicate high-level, systemic problems," the report said.
Jordan died after he was allegedly abused by his mother's boyfriend in November.
The ACS was first tipped off to possible alleged abuse in the boy's home on Saturday, Nov. 26 – three days before Jaden was allegedly beaten to death. The ACS said workers responded to the address that was given, but it was incorrect.
Workers found the correct address after two days of investigating, the day Jordan was hospitalized. He died days later after being taken off life support.
The DOI report said the ACS had access to databases that would have provided the correct address in short order after receiving the complaint.
"The investigation found that despite ACS having the mandate, resources and information to urgently find Jaden, ACS did not find Jaden before he was allegedly beaten into a coma on Monday, November 28, 2016," the report said. "Specifically, DOI determined that while ACS publicly stated that it only obtained the correct address for Jaden on Monday, November 28th, ACS workers in fact had access to databases that would have provided the correct address for Jaden as early as Saturday, November 26th, when they first received the allegations of abuse and neglect."
But no one working weekends is specifically trained to perform those critical address searches.
"The failure to access this information was the predictable result of ACS's systemic determination to not properly and fully staff its intakes centers during nights and weekends," said DOI Commissioner Mark Peters.
Jaden's case was initially handled by the ACS' Emergency Children's Services Unit, or ECS, which handles cases during nights, weekends and holidays. The DOI said its investigation "exposed systemic issues" within ECS, finding there was "inadequate staffing, case practice, supervision, and training within the unit."
"We found that you know, many of those workers that we spoke to couldn't even recall the last time they had training," Peters said. "That is simply no way to run a system that children's lives depend on."
The report said the hours nights, weekends and holidays "receive an extremely high volume of investigations, 70 percent of which are high priority. DOI found that poorly trained staff and inadequate staffing in a unit that receives a high proportion of critical cases is a systemic problem."
ACS spokesperson Aja Worthy-Davis issued a statement, saying: "The loss of Jaden Jordan's life is deeply disturbing. From the time we received an anonymous report with various inaccuracies, to the 48 hours in which when we clarified data and visited the location, vital time was lost. We have reviewed and are implementing many of DOI's recommendations, and are disciplining staff who failed to exercise critical thinking in investigating this case."
Among the DOI recommendations are improving staffing and training for its ECS units, auditing and reviewing staff on performance and following policies, and improving coordination with police in criminal cases.
The union representing caseworkers said many of the recommendations are already in place, but they welcome anything that will improve their work environment.
"I see a little positiveness in terms of some of the issues we've talked about -- increased staff, adequate training, looking at policies and procedures that help workers," said SSEU Local 371 President Anthony Wells. "First time this has happened in all these reports other than just doing this -- long way to go."
CBS2 wanted to ask ACS more about the Department of Investigation's claims that caseworkers are poorly trained. ACS declined CBS2's request for an on-camera interview.
The agency did say in a written statement that it is implementing many of the DOI's recommendations.
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