DCFS evaluates every child death in Utah if the division provided services to the family within 12 months prior to the death. It investigates whether division policies were followed, points out weaknesses and makes recommendations for change.

A caseworker had been working with the Wagner family since Aug. 7, after school officials logged a report of suspected child abuse.

The fatality review committee found numerous policy and procedural "weaknesses" in Trevor's case.

Among the major flaws was the lack of a formal process for shelters to notify DCFS when a mother who has received child welfare services leaves with her children. Also noted was the failure to provide in-home services for a family with a history of domestic violence-related child abuse.

The committee recommended DCFS caseworkers and shelter staff be cross-trained and that families with repeated abuse incidents receive court-ordered intervention.

Soon after, DCFS announced plans to change the way it communicates with area shelters.

"We made some changes in the gaps in how we were communicating," Sisco said this week. "It changed the way we work with the shelters in that they ... would always contact us if someone who was receiving services from us left the shelter suddenly."

So, are endangered children still slipping through the cracks today?

The answer comes in court records and from interviews with shelter workers, police officers, victims and child advocates.

In one such case, that of Mary Davis (which is not her real name), there are different views on the impact to three boys who saw her common-law husband beat her up.

Davis did call police one winter night recently. But she told a Salt Lake City police detective she did not want to press charges and told the victim advocate's office she didn't need any assistance.

"In that way it is a very typical case," said Alana Kindness, a Salt Lake Police Department victim advocate.

It is part of the delicate dance advocates walk in domestic violence cases.

"We let them know that if they are a victim, there is a responsibility to protect the children," Kindness said. And also that they can be charged with a crime called "failing to protect a child" if the abuse continues and children are in the house.

But it's a huge issue, Kindness said. "Do you punish the victim again by taking away her kids?" she asked. "It's more damaging to take them out of the home even if it isn't totally stable."

The fact is that a victim who isn't ready to leave her abuser will not do so. Research shows a battered spouse may leave up to eight times and return repeatedly before leaving for good.