Most of the 137 died from illnesses or accidents, but at least 26 became victims of homicide, usually committed by relatives or caregivers.
More than a decade ago, state officials began to pass reforms that were supposed to prevent such cases. They hired more social workers, lowered recommended caseloads and adopted a less confrontational approach with most families, which is designed to build cooperation.
The head of the N.C. Division of Social Services, Sherry Bradsher, said the changes have vastly improved the child protection system.
Instances of abuse recurring within six months in families under supervision has declined from about 7 percent in 2004 to about 5 percent in 2009.
"We have implemented so many reforms that are working," Bradsher said. "Workers feel better. Feedback from parents is better than it's ever been."
But state reports and interviews show long-standing problems persist.
Expert reviews of the child deaths found mistakes had been made by social workers and were often linked to inexperience and heavy caseloads. In more than half of the 137 deaths, social workers weren't thorough in evaluating a family or didn't follow state guidelines, the Observer found. In one child death in Rowan County, a state report shows, the case was given to a social work intern.
And case workers often have difficulty getting child protective service records for families who have lived outside their county. In cases such as Zahra's, whose family moved between counties, social workers may have limited information to assess a child's safety.
Tom Vitaglione said Zahra's disappearance should sound alarms about child protection in the state. He co-chairs the N.C. Child Fatality Taskforce, which recommends child safety improvements to the General Assembly.
"I am not comfortable with where things are," Vitaglione said. "I don't think DSS is comfortable either."
Troubling signs
Zahra's wide smile and story of overcoming adversity have drawn attention to her disappearance, reported Oct. 9. Family and acquaintances describe her as a polite child, courageous while coping with bone cancer, and memorable for her Australian accent.
At age 5, she lost her left leg below the knee to bone cancer, a condition that also left her hearing-impaired.
She moved to the United States last year with her father, Adam Baker, after he started an online romance with his wife-to-be, Elisa Baker of North Carolina.
Trouble soon began.
At a vigil for Zahra last week, family friend Lindsay Parker told the crowd that family members had reported suspected abuse of Zahra to the Department of Social Services on three occasions.
"They tried," Parker said of the family members. "They really tried."
Libby Brown, a spokeswoman for the Caldwell County Schools, told the Observer that staff had visited the girl's home and sought help for Zahra from an "outside partner" because staff was concerned. But she wouldn't elaborate, citing confidentiality laws.
Zahra attended the district's Granite Falls Elementary and Hudson Elementary, where she completed fourth grade in the spring.
Bobby Green said he lived next door to the Bakers for about a year in the Caldwell County town of Hudson, about 70 miles northwest of Charlotte.
Green, 27, who has two 8-year-old daughters, said Zahra often came over to play. He and his fiancée, Kayla Rotenberry, 23, said Elisa Baker would leave Zahra locked alone in the house for hours.
In the spring, Zahra came over for an Easter egg hunt. The girls searched the yard looking for red, yellow, and white eggs.
Rotenberry and Green said they noticed bruises on Zahra. But when they asked the girl about it she wouldn't say anything. When they asked her parents what happened, Green said: "It was always, Zahra fell down. Zahra fell out of bed. It was always, Zahra had done something."
Elisa Baker's attorney, Scott Reilly, wouldn't discuss specific allegations but said generally some people have "embellished, exaggerated or made up" stories of abuse.
He confirmed that DSS had received and investigated reports of child abuse against his client, but said social workers found the accusations "unsubstantiated."
Hasty investigations
Whenever a child dies in North Carolina and abuse or neglect is suspected to have played a role, the state convenes a review team to figure out what went wrong.
The team of DSS officials, police and other professionals review case files and recommend improvements in a public report that aims to prevent future deaths.
The Observer analyzed reports of the 137 child deaths between 2003 and 2008, which included asphyxiation, illnesses, drowning, shootings, car accidents and physical abuse.
Social workers were most often cited for errors, but so were law enforcement and others. Here are some findings from the newspaper's study:
In 71 deaths, reviewers said social workers were not thorough in their investigation of abuse or neglect allegations, or in resolving them. Sometimes they looked too narrowly at a single problem instead of all issues surrounding the child's welfare. In the 2007 death of a Mecklenburg baby, who accidentally suffocated while sleeping with someone on a couch, social workers were criticized for failing to assess risk, properly review prior child protective records and maintain sufficient contact with the family.
In at least 51 deaths - more than one-third - social workers weren't told about additional incidents of suspected abuse in those families. State law requires any resident who suspects child abuse or neglect to report it to DSS. Among those who did not, one report found, were Winston-Salem police, who didn't notify DSS about numerous domestic violence calls to the home where a 5-year-old died of an Oxycodone overdose.
Forty reports said social workers or others had trouble getting previous child welfare records, usually from outside their counties or states. A Richmond County case involving a child who died of physical abuse suggested that county social workers got limited information from the state's central registry of child services cases, but not enough detail and background. And social workers didn't follow up with the family's previous county DSS to learn more.
Twenty-seven reports found DSS was too thinly staffed and that caseworkers carried loads far beyond what the state recommended - which meant they didn't have enough time to spend with each family. In a 2006 Stanly County death, the social worker was new and carrying 25 cases; the state standard was 12.
In Caldwell and Catawba counties, where the Bakers lived, some social workers were carrying twice as many cases in recent years as the state recommended. The problem was highlighted in reviews of child deaths that occurred in those counties in 2006 and 2007. Current caseloads weren't available last week as DSS officials declined requests for interviews.
'In the Stone Age'
DSS leaders say reform efforts during the last decade have made kids safer.
They've bolstered training for social workers and adopted a holistic approach that aims to get more cooperation from families under scrutiny for abuse or neglect.
When children are not in imminent danger, the family-friendly initiative pushes social workers to offer services to help parents overcome problems such as substance abuse, unemployment and a lack of parenting skills.
Bradsher, the state DSS director, said the approach has helped protect children and kept families intact.
But child advocates counter that social workers continue to struggle with high caseloads and low budgets.
They note that North Carolina spends about $43 per capita on child protection, less than all but eight states, according a 2009 study by Every Child Matters, a Washington-based advocacy group.
Brett Loftis, who heads Charlotte's Council for Children's Rights, said children lack a strong constituency in politics.
Caseworkers simply do not have enough resources, Loftis said. "We are in the Stone Age as far as children go."
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