Two children died recently. There is no escaping the conclusion that they were failed by the system. Yet we've been told our system has not failed. The discussion around these tragedies has focused on blame. Blaming the social workers that may have been the last responsible adults to see the children. I can relate to the need to find blame in the aftermath of what will be a piercingly vivid moment in collective memory.

I've walked more than a mile in their shoes. For several years I was a child protection social worker. In 2008, my team investigated an allegation of child abuse of a newborn. He showed no marks from the abuse and I was therefore unable to act within the parameters of my role and my authority. Two weeks later, the child was dead. Killed by his father who had a history of domestic violence.

In this situation, uninformed critics claimed the social workers failed to run a background check on the father. They left out the fact that although domestic violence is the single strongest predictor of child fatalities from abuse, it would have made no difference. My team had no authority to remove that child just because the father had been violent with his past partners.

Although it provides a fleeting relief to point anger, the social workers did not cause this. Even if they were flawless in their execution of their protocols, this was caused by a deeply flawed system. I wrote about it in 2011 while I worked closely with social workers on the front lines. These insiders aren't allowed to raise flags of concern about the system they are a part of, so I did.

Unfortunately, the same epic failures I witnessed three years ago are present today. A series of failed attempts at reform have left us with an ineffective child protection system hamstrung by bureaucracy. Blaming social workers that function in a broken system is akin to blaming fish for dying in polluted water.

If we must blame, blame the culture of politics that pervades the Agency of Human Services (AHS). It's time to change that culture. Changing organizational culture is rarely easy or fast. And it rarely changes without accompanying leadership changes. Though I would caution that calling for the resignation of Commissioner Yacavone and Secretary Racine will change nothing if they are replaced with other politicians as is likely.

Let's stop blaming individuals and start critically examining the construct that allows innocent children to die. With a few key reforms, we could potentially avoid another child fatality.

The Agency of Human Services is structured to create a completely compartmentalized view of the child and family. Despite repeated attempts to break down these silos through various reform efforts, the stubbornness of bureaucracy (read: individuals lacking courage) has prevented any real transformation. Break down the silos financially, legally, organizationally. Thus, creating a common view of the client.

Vermont caseloads are 130 percent of the national standard. More social workers will immediately ease this pressure and allow them to focus on helping bad parents become good ones. For those concerned with spending more on AHS, we don't need more money. The AHS budget has grown by an average of 5.5 percent annually since 2008; a cumulative 46 percent or $729 million during the same period.

Revise Chapter 49, Title 33 of the Vermont Statutes to empower and require social workers to complete a thorough assessment of the child's well-being. Including the requirement of a home visit and face-to-face with the child for every allegation of maltreatment. We are currently regulating for the 5 percent of people who abuse the reporting system, not the 95 percent that make legitimate reports.

Include a provision that compels the State to intervene when abuse is present. No, this is not the case currently.

Revise family reunification policies that currently return children to unsafe, poisonous homes because of arbitrary mandates.

The policy known as "Differential Response" was a failed experiment. The Department for Children and Families (DCF) will have us believe the decreasing numbers of children in their custody is a result of safer children and thus fewer removals from the home. This is a lie. We are ignoring calls for help made by concerned citizens, resulting in more kids being hurt. But boy those charts look good. In reality, Vermont ranks second to last in the percentage of abuse and neglect calls that are actually investigated. Only South Dakota investigates fewer calls.

Start measuring reoccurrence of abuse and neglect, not just when allegations were accepted for formal investigation and substantiated. These numbers will tell us which families need intensive intervention.

Open up the reporting process so that community organizations can partner with DCF to help families. In the current model, reports are made by professionals that serve families, and they never know if their concern is being addressed.

Child abuse and substance addiction are highly correlated. We can't solve one without addressing the other. We need to effectively integrate substance abuse treatment services with child welfare services.

Current policies set an essentially unachievable burden of proof on the social worker to prove neglect. Yet child neglect can be just as harmful on the developing child, especially over extended periods.

These suggestions are a starting point. I am not an expert on the internal policies of DCF. There are people within DCF that know which reforms will make kids safer. Let's listen to them and put in place reforms that will generate results and keep our kids safe.

A child fatality rocks a community. Two in a short time threatens the trust we place in our child welfare system to protect our most vulnerable. Vermont should be able to trust this system to ensure our children are being raised not just in a safe environment, but a nurturing, supportive, healthy home.

Cyrus Patten is a licensed social worker and Executive Director of Campaign for Vermont. He lives in Monkton.