Victor Lizotte, a 5-year-old boy who was beaten as a baby by his mother and allegedly shot to death a week ago by a man claiming to be his father, was a possible victim of a state human services system that has grown too big, too powerful and too autonomous to assist the most helpless people it is supposed to be serving.

He also may have been a casualty of a judicial system that never was intended to make decisions in the gray, emotional turbulence of family relationships and responsibilities.

He definitely was killed by ignorance. Because of the secrecy that often conveniently shrouds nearly every action taken by the Department of Human Services and the courts, the blame for Victor Lizotte’s death may rest with political and social decisions that have been reached in a near vacuum of information.

The public probably never will learn why circumstances were so out of the control of the department that Victor died violently at the hands of the man in whom that state had entrusted the boy’s custody for more than three years, because the entire process — the names and events and judgments that culminated in his death — is legally secret. State statute can be construed in such a manner that it can forbid anyone with relevant information from making it public.

What went wrong in the case of Victor Lizotte? Why did this little boy die? The questions echo off the institutional Catch-22 that conceals DHS and everyone it touches:

The only people with access to Victor’s tragic history are the same people who are part of the process that failed him.

DHS may be clumsy or wrong, but ultimately it is above effective reproach because there are no facts available on which it can be pinned down. The agency controls the facts.

For the public and for lawmakers who are watching the Lizotte case struggle to unfold, this should be a totally unacceptable situation. No government should have an agency that is its own master. But Maine has the Department of Human Services.

What should Maine do?

There needs to be an immediate investigation of the DHS system as it relates to child protective services. Sen. Charles Pray in the last session of the Legislature proposed a comprehensive study of the department. The state couldn’t afford the $300,000 cost of that examination then, and can’t now, but it should fund a more modest, independent investigation of the human services system where it directly impacts the lives and safety of children. This will allow the public to get at the facts without violating standards of confidentiality.

DHS has no permanent public watchdog. It needs one. This is the largest agency in Augusta. It spends a quarter of the state budget. It directly influences the welfare of thousands of citizens, but it functions without effective public scrutiny. The latest state budget recommends defunding of the only state agency that exists to advise the governor and the Legislature on matters affecting DHS. Human Services simply is too important and its failures potentially too destructive not to be under constant, effective, independent public observation.

There is no effective policy to protect the security of caseworkers, who are on the front lines in these emotional confrontations between family members. These workers, in addition to carrying excessive caseloads and being worn down by a deepening statewide crisis in shattered and dysfunctional families, are frequently placed in situations of personal jeopardy, a fact dramatically illustrated in the Lizotte tragedy. The department, perhaps using law enforcement procedures as a model, should afford its workers the fundamental protection of policy and procedure for potentially dangerous situations.

The people served by DHS and who feel shortchanged by the agency, but who are afraid to criticize it for fear of retaliation from the bureaucracy, now have only one place to turn, the child welfare services ombudsman. This is a relatively new office with just one ombudsman and one staff person. Yet the ombudsman, Jane Sheehan, has in 16 months built a file of 270 cases. This office needs more support.

Foster parents, many of whom have had their morale devastated by tragedies such as Victor Lizotte’s and also by the heavy hand of DHS, are aggressively pursuing the concept of family courts and other alternative forms of resolution for these deeply personal, often explosive custody disputes. Their argument, that the existing court system is set up to resolve property disputes and therefore treats children as chattel, not as human beings with rights, should be harkened to by the Legislature.

Maine had 32,000 complaints of child abuse and neglect last year. After 75 percent of them were screened out, the state was still left with thousands of new human problems to be handled by an agency that effectively shuts out public scrutiny.

Can the services DHS provides be improved?

Definitely. But it will require an independent examination of the agency to determine how that can be accomplished.

Is the Maine taxpayer getting value for his dollar invested in DHS?

Without the facts that DHS guards, that question is impossible to answer.

What went wrong in the case of Victor Lizotte?

The people of this state should demand to know how the process failed. Even in a department as large as DHS, the error rate should not tolerate even one child’s death.