The state agency charged with protecting Hawaii's children from abuse says it has made major policy changes and improvements since "Peter Boy" Kema died at the hands of his parents 20 years ago.
But critics of the agency continue to challenge that claim.
Back in 1997, Hawaii's Child Protective Services returned the 6-year-old boy and his siblings to Peter and Jaylin Kema, despite multiple warnings that the children were in danger.
Kema subsequently disappeared, in a case that became one of Hawaii's most well-known unsolved murder mysteries until his parents pleaded guilty to manslaughter.
The state says current policies now give abusive parents less time and fewer chances on the road to recovery, especially if a child is thriving in a foster home.
"If the child is in placement for 15 of the last 22 months, we move towards termination of parental rights," said Kayle Perez, state Child Welfare Services Branch Administrator.
If that term limit had been in place at the time of Peter Boy's disappearance, the Kema children may have been able to stay with their grandparents in Kona, where happy videos of them were taken. They had been in the custody of their grandparents for three years before CPS sent them back.
Perez said the agency has made other changes as well, including monthly, face-to-face meetings with children, parents and foster parents.
Had case workers conducted such meetings with Peter Boy, they might have noticed the festering wound the child had on his arm, one family members said later got infected and "spread to his wrist and became smelly and painful."
Police believe that wound ultimately killed him in June of 1997.
The practice of home visits were done with the Kemas -- case workers reported making numerous visits -- but the visits "failed to turn up any evidence of Peter Boy," and were apparently never followed up.
The court-appointed investigator into the case, special master Stephen Lane, said the monthly meetings were useless without someone following up on the findings.
"I can't say that I've seen any dramatic changes," Lane said. "This continues to happen with a degree of frequency that's very disheartening."
The position of special master was started in 2014 by a family court judge. The position is appointed to help investigate and represent children in the protective services system.
Child Protective Services administrators say the agency now does annual reviews, taking samples from about 100 cases, to make sure they are meeting federal standards. In 2000, they implemented "Ohana Conferencing" to engage other family members.
Kema's grandparents and other extended family members say they tried getting state workers to help Peter Boy after seeing wounds on him at family events, but their cries for help were ignored over and over.
The new attorney for Peter Boy's siblings, Randall Rosenberg, said that even though the agency has added new layers of protection, they're still short-staffed and case workers are often overwhelmed by the workload.
"We continue to see cases like this," said Rosenberg, who has a reputation for representing young victims. He said abused kids continue to get lost in the system.
CPS says they are working with the University of Hawaii to recruit social workers to fill spots, but it's not easy to retain case workers.