Child-fatality reviews released by the Utah Department of Human Services tell the tragic stories of children who have died after receiving state attention.

In 1997, 20 children under the age of 19 died within 12 months of having received services from the Division of Child and Family Services."The stories can break your heart," says Terry Johnson, a DHS program director who heads the DHS Fatality Review Committee. "But we try to learn something with each review to improve our services to our clients."

Two of those clients last year were Kalieb Winter, 2, and his brother, 7-year-old Skyler Peterson. Their brief lives, according to DCFS records, were governed by a series of chronic medical problems, instability created by numerous men - at least one with a drinking problem - moving in and out of their mother's life, and lack of parental supervision.

Kalieb and Skyler lived in Utah County with their single mother and two brothers. On May 29, 1997, all four boys were diagnosed with chronic ear infections. Skyler presented the worst case; his infection went untreated for five months, even after his teacher had discussed the problem with his mother. By the time the teacher complained to Child Protective Services, a foul fluid was draining from the boy's ear.

The children were prescribed antibiotics and CPS substantiated allegations of medical neglect against Amadee Peterson, the boys' 31-year-old mother.

Two weeks later, on June 11, Kalieb and Skyler were dead, victims of a car crash. Their mother and her latest boyfriend were taking the boys to visit their respective fathers. Ten miles north of Price, while going 80 mph, the car went off the road and rolled.

Kalieb was not in a car seat and died six hours later. Skyler was not wearing a seatbelt and died the next day. The driver of the car, Steven Peterson (no relation to Skyler), Amadee Peterson's boyfriend, was not seriously injured.

However, he is to stand trial April 30 in Price on two counts of misdemeanor negligent homicide in connection with the deaths.

Shortly after the accident, Amadee Peterson disappeared. While authorities searched for her, her two surviving sons were turned over to their biological fathers. DHS reports they are doing well.

Other causes of the child deaths reviewed by the state range from sudden infant death syndrome to diabetic shock to a self-inflicted gunshot wound. The children range in age from a few days to 17 years.

And almost without exception, the dead had been physically and sexually abused or profoundly neglected, victims of parents or other custodial relatives who showed a gross lack of parenting skills.

The panel that investigates the deaths is made up of a DCFS employee appointed by the committee chairman; a state attorney general's representative; a member of DCFS management staff; a supervisor from a DCFS region outside the one where the death occurred; and a representative of the Guardian Ad Litem's Office.

The committee meets twice monthly, Johnson says. It pulls no punches as reviews unveil faults in the child-welfare system.

Where several of the adolescent victims are concerned, the panel criticizes the state for its lack of early intervention programs for youths who are at risk for severe criminal and anti-social behavior.

"The committee's recommendations can seem harsh, but they are aimed at making the services better all the time," says Jean Nielsen, director of strategic development for DCFS.

The fatality reviews have taken on greater significance and are arguably more timely and complete since the National Center for Youth Law sued the state of Utah in 1993. The San Francisco-based NCYL represented numerous child plaintiffs in the DCFS system.

A settlement agreement, which called for several changes in foster care and other child-welfare programs, was forged between the state and the plaintiffs. A federal judge will review the settlement in August to determine if the state has adequately complied.