Between 2001 and 2004, 11 local children died while in the legal custody of state or Clark County agencies.

A 2005 state analysis of Clark County child fatalities mentioned the deaths but didn't provide the whys.

On Thursday, those were finally made public to the state's Blue Ribbon Panel for Child Death Review. Led by retired Nevada Supreme Court Justice Deborah Agosti, the panel is charged with helping fix the failures within Clark County that led to a serious underreporting of juvenile deaths related to abuse or neglect.

Their recommendations are expected to be completed by Dec. 1.

"A lot of these children had significant medical problems," Barbara Legier of the Nevada Division of Child and Family Services said during a report on the 11 deaths.

Six deaths involved congenital defects, health issues related to premature birth, AIDS, or exposure to drugs in utero. Two accidental deaths by asphyxiation occurred because improper bedding was used by relatives or foster-care givers. One death was determined to be Sudden Infant Death Syndrome. One child died of natural causes.

The 2001 death of a child who possibly suffocated while in bed with the natural mother is more problematic. In that case, the state Division of Child and Family Services had legal custody of the child while the mother retained physical custody.

It's one of the 79 child fatalities red-flagged in a state review that uncovered a failure to investigate all juvenile deaths that may have been rooted in maltreatment.

"Prior CPS (Child Protective Services) history," stated the printed summary of the 2001 case that accompanied Legier's report. "Case was open at the time of death. Agency was providing services. The agency coded the fatality as an investigation only, because there were no siblings in the home. Metro and the coroner's office investigated the death and the case was closed."

The state's report on those 11 deaths reiterated the findings of national expert Terri Covington, who in April reported that poor record-keeping, a lack of documentation and incomplete files hampered a thorough review of efforts within Clark County Family Services to investigate child deaths.

It's a problem that panel members experienced firsthand in June, when they reviewed case files for themselves.

"The only thing that was consistent in the files was that there was no consistency," said panel member and Assemblywoman Susan Gerhardt, D-Henderson.

Gerhardt criticized the poor tracking of children in the system, saying many files did not even contain treatment plans or records of follow-up visits to foster homes where a child was placed. There appeared to be little supervision of case workers responsible for updating the files.

"It didn't seem too surprising that we had kids slipping through the cracks," Gerhardt said.

At the same time, panel members also reported that they did not find evidence that records had been tampered with by case workers after child deaths occurred, a concern that had been raised in April.

The files had been added to, Gerhardt said, but it didn't appear that anyone had tried to falsify documents or alter the existing record.

Michael Willden, director of the state Department of Health and Human Services, said the case files showed sloppiness but not a malicious intent to change the record.

Cases were closed that identified a child as being safe when the child had actually died, Willden said, but that reflects a quirk in the family services computer program that only allowed a case to be closed with that finding.

That's being changed now, Willden said.

Officials for state and county family services agencies assured panel members that efforts to improve services are under way.

They also presented the panel with a 73-page rough draft of an improvement plan that incorporates recommendations from Covington's report, federally identified best practices and the public.

The document will serve as the panel's starting point in reworking family services in Clark County.

Recommendations include:

• Coordinate local and state procedures for investigation abuse-related deaths.

• Continue improving the child abuse reporting hot line. The average wait time for callers is now four minutes, down significantly from the half-hour and hour waits reported earlier this year.

• Increase case worker training, evaluate the qualifications of current staff and review hiring requirements.

• Identify measures requiring legislative action or additional funding in time for the next legislative session.

• Revise policy for Child Protective Services so that a full on-scene investigation is required in the accidental death of all children that involve inadequate parental supervision.

• Improve follow-up investigations in fatalities involving surviving siblings.

The panel will meet again in August to revise the action plan.