Tag: child deaths

A system that neglects maltreated children: my testimony at the CFSA Oversight Hearing, February 21, 2024

Good afternoon! Thank you for the opportunity to testify today. My name is Marie Cohen and I live in Ward 6. After my first career as a policy analyst and researcher, I became a social worker and served in the District’s child welfare system until 2015. Soon after leaving that job, I joined the Citizen Review Panel on CFSA, on which I served for four years, and then the Child Fatality Review Committee, on which I served for six years. I began writing a blog, which later became Child Welfare Monitor. I am proud to say that my blog is read by some of the leading policymakers, advocates, and academics in the field.  I take a child-centered approach, placing the safety and wellbeing of the child above all other considerations.

On October 22, 2022, police were called to Stanton Road, SE, for a report of an unconscious child. By the time they arrived, Journey McCoy had already been transported to United Medical Center, where she was pronounced dead.[i] According to WUSA-9, Sasha McCoy, the child’s mother, reported that around 8:30 a.m. her daughter came from the back bedroom of the house and said she was hungry. McCoy gave her a Jell-O cup and went back to sleep. Around 1 p.m. she was awakened to two of her four children rummaging in the refrigerator. Instead of feeding them she put both children down for a nap and went back to sleep on the couch.  Such reports of parents sleeping through their children’s days, without regular bedtimes or mealtimes, are classic symptoms of what child welfare experts call chronic neglect. Sometime later, Ms. McCoy woke up again and found her child unconscious with yellow mucus coming out of her mouth.

On October 22, 2022, police were called to Stanton Road, SE, for a report of an unconscious child. By the time they arrived, Journey McCoy had already been transported to United Medical Center, where she was pronounced dead. According to WUSA-9, Sasha McCoy, the child’s mother, reported that around 8:30 a.m. her daughter came from the back bedroom of the house and said she was hungry. McCoy gave her a Jell-O cup and went back to sleep. Around 1 p.m. she was awakened to two of her four children rummaging in the refrigerator. Instead of feeding them she put both children down for a nap and went back to sleep on the couch.  Such reports of parents sleeping through their children’s days, without regular bedtimes or mealtimes, are classic symptoms of what child welfare experts call chronic neglect. Sometime later, Ms. McCoy woke up again and found her child unconscious with yellow mucus coming out of her mouth.

During the ensuing investigation, police learned that Sasha McCoy, was known in her neighborhood for using drugs and being constantly high. McCoy admitted to using Percocet daily, including the morning of the day her daughter died. When the CFSA investigator offered her a referral to drug treatment she responded, “this is not the time. I am going to get high as a “mother f-er when I leave.” Seven months later, the autopsy came back. The cause of death was fentanyl intoxication. McCoy was arrested and charged with first degree felony murder and cruelty to children. During the fatality investigation, CFSA and police learned that the mother was living with a known drug dealer. She admitted to the use of unprescribed drugs, which she failed to secure away from the children. The dead child’s sibling has been placed in foster care.

CFSA knew about McCoy before her daughter’s death, as described in the agency’s newest annual fatality report, which focuses on deaths of children in families known to CFSA in the previous five years.[i] Within five years of the three-year-old’s death, the family had three CPS investigations, one family assessment, and two open in-home cases. According to WUSA9, one of these cases was opened in 2020 when the same little girl as a baby ingested marijuana at a party McCoy was hosting. Social workers found three children unsupervised inside the home. The case was eventually closed. Another case was opened In August 2021 after McCoy’s newborn had symptoms of withdrawal. McCoy acknowledged using Percocet daily throughout her pregnancy. That case remained open until February 3, 2022, eight months before the fatality. Surprisingly, the agency did not observe any evidence of drug use or concerns for supervision during the two open in-home cases. (This is hard for me to believe, unless the mother evaded social worker visits, as happened with many of the cases I reviewed.) Nevertheless, CFSA reported that “case notes indicated the mother resisted the Agency’s efforts to engage her and she was inconsistent with participation in services.”  

“We are not here to save children.” That is what I was told on the first day of my training as a child protective services worker at CFSA. And indeed, the District of Columbia is on the cutting edge of the current movement in child welfare that considers child protective services as a “family policing system” that unnecessarily harasses and separates families, especially families of color. But some families do not provide a safe environment for children to grow and develop. In some of these families, children die. That is what happened to the 16 children whose cases are discussed in my recently released report.

Why do I study fatalities among children known to CFSA? For the same reason that CFSA studies these deaths. As the agency states in its 2023 Annual Child Fatality Report, seeing where the system may have broken down helps it identify strategies that may prevent such deaths in the future, which is why the agency makes recommendations at the end of these reports. But it is more than that. The same conditions that lead to child fatalities also lead to harm for many more children. In that sense, child fatalities are the tip of the iceberg of child maltreatment, giving us a window on what is happening to other children who may be invisible to us.

The report is based on information I received from CFSA on the deaths of 16 children between 2019 and 2021—before the death I described earlier.  These children came from families that had previous contact with CFSA. Their deaths were either ruled to be caused by child abuse or neglect or the Medical Examiner could not rule out child abuse or neglect as contributing to the cause of death.” District law requires the release of information on these deaths, but CFSA interpreted that law restrictively. Several deaths were not included because they were ruled to be accidents, although parental neglect clearly contributed to these deaths. For example, the death of seven-week-old Kyon Jones, whose mother told police that she threw his body in a dumpster after she rolled over him while high on PCP, was not included because his body was never found and could not be autopsied. A child was left in a baby swing for two hours was also included because his death was deemed accidental.

In addition to omitting some cases in which neglect or abuse played a role, CFSA heavily redacted the information it did provide, with many pages and large blocks of text blacked out. This included most information about the parents’ issues with drugs, alcohol, or mental health and almost the entire history of agency involvement in most cases. Despite the limited information provided, the redacted summaries included some disturbing new information.

Causes of Death

The most common causes of death among the 16 children were blunt-force trauma and opioid poisoning, each claiming the lives of three children.  This included Makenzie Anderson, who was murdered by her mother, and Gabriel Eason, who was the victim of long-term torture and beatings by his stepfather, as his mother stood by. The third case of blunt-force trauma was a three-year-old girl in the home of an aunt where she was placed by CFSA. Nobody has been charged for this murder. Another three children (a three-year-old girl, a three-year-old boy, and a three-month-old girl) died of poisoning by a controlled substance, with fentanyl implicated in all three cases. The remaining children died from drowning, asphyxia, “thermal and scald injuries,” injuries from a car accident, and unknown causes, a few of which may not reflect maltreatment.

Demographics

A quarter of the children who died were younger than six months old and half were one year old or younger. Another quarter were two or three. This is not surprising as young children are more vulnerable and similar results are found nationally. But older children were not invulnerable to abuse or neglect, including the seven-year-old who died in a car accident and a 12-year-old who died of an untreated bacterial infection and pneumonia.

All of the decedents were Black: fifteen were African American and one was classified as “African-biracial.” According to the latest data from Kids Count, 54 percent of children in the District of Columbia are Black. So Black children were overrepresented among the children who died of maltreatment or possible maltreatment. Yet, the District is trying to reduce racial disparities in system involvement. It sounds to me like a way to make Black children less safe, not more equal.

The prevalence of large families among those that lost a child due to abuse or neglect is striking, though not surprising, because research shows that large families are associated with child maltreatment. More than two thirds of the mothers of children who died by maltreatment had four or more children. The average mother in the group had 4.6 children, often with more than one father. This is not surprising, because larger number of children are associated with child maltreatment. The challenges of parenting multiple children clearly contribute to a child’s risk of being abused or neglected and dying of that maltreatment.

Histories of System Involvement

Most of the families that lost a child had experienced multiple reports prior to the fatality. Among the 16 fatalities included in this report, only six occurred in families that were the subject of five reports or fewer in the last five years. Five occurred in families that had between six and 10 reports, three occurred in families with 10 to 15 reports, and one family had 24 reports. Three of the families had experienced a previous child fatality–a shocking statistic considering the rarity of child fatalities overall.

Substance abuse by the parent or caregiver (including positive toxicology of a newborn) was the most frequent allegation CFSA received regarding the families in the five years before the deaths. Substance abuse by the parents was observed or alleged in the families of all but four of the victims included in this report. Inadequate supervision and educational neglect were the next most common. Ten of the 15 families had at least one report for educational neglect and ten for inadequate supervision before the child’s death. Another major theme was exposure to domestic violence, which was mentioned in nine of the 16 case histories as the subject of an allegation or in notes from social workers or police.

A 17-month-old boy died of “thermal and scald injuries.” His mother had no idea how he got injured. She said he was sleeping on the floor next to her bed when she went to sleep at 7:00 PM, but he often slept next to the radiator in the living room because she kept the air conditioning on high and he got cold. She reported that one of her five other children woke her at about 3:00 AM and showed her large pus bubbles on the child’s thigh and lower leg. She told the girl to bring him to another room and planned to clean the wound in the morning, for fear of being reported to CFSA. She reported having no idea why he was found in the bathtub with his face down at about 7:00 AM.

System Failures

The information received suggests several areas where failures in policy and practice by CFSA may have allowed these deaths to happen. These areas include screening and investigation. Many reports on these families were screened out hotline staff, perhaps inappropriately. The Office of the Ombudsperson for Children (OFC) reports that it received complaints from constituents about referrals that were screened out inappropriately; OFC itself had concerns about several referrals that were screened out. OFC also heard from school staff who reported receiving no feedback after submitting multiple reports on the same family.

Flawed investigations may have also allowed these fatalities to happen, as these families had many unsubstantiated investigations. The details of most investigations were completely redacted, so I cannot give many examples of possible flaws. But Gabriel Eason, who was beaten to death by his stepfather, was the subject of an investigation five months before his death, after he showed up at childcare with two bruised ears. The CPS investigator did not seem concerned about the mother’s lack of knowledge of how the injury was acquired, her offering of multiple possible explanations, and the question of how playing rough with his siblings on running into furniture could result in bruises on both sides of his face.

Management of in-home cases was revealed by these fatalities as an area of concern for CFSA. Four of the deaths I reviewed here happened while an in-home case was open for the family, yet in three of these cases, workers struggled to complete face-to-face visits with the families because parents evaded these visits. Three other families had had one or more in-home cases that closed before the children were killed. In the Needs Assessment it recently released, CFSA focused on its in-home services and found little evidence for optimism about their potential to help children. By caseworkers’ own assessment, the most common barriers that caregivers display (daily parenting behavior, substance abuse, and mental health) barely change between the opening and closing of an-In-Home case.  Only a quarter of the In-Home cases reviewed by CFSA’s internal reviewers, demonstrated good progress according to these reviewers, despite the good clinical skills of the social workers. CFSA concluded that the lack of progress in the other three-quarters of cases was due to the lack of parental engagement in services.1 CFSA’s oversight responses show that of the 503 in-home cases closed in FY 2023 and the first quarter of FY 2024, 214 (or 40%) of the families were the subject of a hotline call after the case was closed.

In the three open cases where parents evaded social worker visits, social workers and supervisors could have used the “community papering” option to file a petition to involve the court. But they did not exercise this option–or they started too late. In one case, a three-year-old had been left alone on her stomach with a bottle while her mother went across the street to retrieve and smoke a cigarette. During the in-home case resulting from that fatality, the case manager made multiple unsuccessful attempts to see the mother and her three surviving children. Due to the mother’s failure to engage and the children’s continued absence from school, the case manager scheduled a meeting with legal staff to consider community papering. That meeting was scheduled for December 8, 2021 and was canceled after CFSA learned of the three-year-old’s death of fentanyl poisoning on December 3.

In the FY2025 Needs Assessment, CFSA stated that “[h]istorically, QSR reviews have shown that parents’ active participation and engagement in services, and their ambivalence to work with the Agency, remain a challenge for the In-Home Administration. Despite training inevidence-based skills [such as motivational interviewing] social workers continued to face multiple challenges for achieving positive outcomes. . . Challenges for the social work team and the families included complicating factors such as unresolved (or insufficiently addressed) family histories of trauma, substance use, mental illness, cognitive challenges, and parenting capacity with multiple children.

Recommendations

  1. The Council should change the law to mandate release of Information on child maltreatment fatalities. Sadly, CFSA’s internal fatality committee, which reviewed the full record of these cases, does not do a good job of making recommendations. The 2022 report had no recommendations for CFSA other than it should participate in districtwide discussions about violence prevention; its other recommendations referred to other agencies, like better information sharing and a safe sleep campaign. We certainly cannot rely on CFSA to learn from its mistakes. Therefore, my first recommendation is to the City Council, urging it to require that CFSA follow the example of states like Florida, Arizona, and Wisconsin, andrelease detailed historical information on child fatalities, with certain identifying information redacted.
  2. CFSA should Improve the hotline and investigations through training and specialization: I endorse the OFC’s recommendation for enhanced training for hotline staff so that reports are screened adequately to ensure the safety of children. In addition, school absences should be investigated regardless of the age of the child (requiring a change in the law) and their academic performance. Investigative workers could benefit from better training in forensic interviewing techniques that might help them better evaluate parents’ and children’s’ statements for veracity and perceive more subtle signs of abuse or neglect. Another option is to reinstate the Special Abuse Unit so that cases of physical and sexual abuse are handled by workers with forensic interview training.
  3. CFSA must recognize that in-home cases need to be more intensive and longer for chronically neglectful families: CFSA must also strengthen its in-home practice, perhaps by reinstating the Chronic Neglect Units, which were eliminated barely a year after they were implemented. These units would employ specially trained social workers with lower caseloads and longer time periods to work with families.
  4. The agency must reduce any barriers to the use of “community papering,” perhaps making court involvement routine after a certain number of missed visits or other instances of noncooperation, or if a family that is offered in-home services after an investigation refuses the offer. The case narratives make clear that social workers struggled to complete home visits to the families of the children who later died, and yet community papering was either not initiated, or initiated too late. According to the recent Needs Assessment, the agency presented over 300 children with in-home cases for community papering in FY 2021, FY2022 and the first quarter of FY2023.[iii] But my study suggests that these petitions must be made sooner and more often.

It is often said that we should not make policy based on extreme cases. But I have a different view. Extreme cases are the tip of the iceberg. Every child who dies, represents multiple other children who are suffering or at least failing to thrive as they live with abuse or neglect. Studying fatalities can help identify system failures that allow many more children to languish in abusive or neglectful homes, growing up in fear or pain, or without the essential nurturing necessary for normal child development.

  1. CFSA also found that when an In-Home case is opened, a family’s risk of child removal decreases by 15 percent within a year. But the likelihood of a new investigation increases by 10 percent within the year. CFSA speculates that perhaps the subsequent Investigation ends up prolonging the in-home case by starting a new In-Home episode.

CFSA’s 2021 Internal Child Fatality Report: How not to learn from the past

CFSA’s newest Child Fatality Review Report focuses on the deaths of 29 children and young adults whose families were known to CFSA within five years of their deaths and whose cases were reviewed in 2021. This report’s toll includes one mother who lost two little children in one year–one who died of fentanyl poisoning and another left alone with a four-year-old sibling and a propped bottle. It included four overdose deaths from synthetic opioids and ten “non-abuse” homicides including the shooting of a six-year-old at 11pm outside a liquor store. It included a twelve-year-old who died of an untreated bacterial infection but had signs of abuse on her body. Most of the dead children’s families had been reported to CFSA at least four times in the past five years. Many of them had experienced investigations and received CFSA-supervised services. Nevertheless, these children died within five years of their contact with CFSA. But the agency’s child fatality reviewers made no recommendations to improve screening, investigation, or services. That is not a surprise, given the agency’s current tendency to minimize intervention in the lives of troubled families.

When a child known to a child welfare agency dies, a natural question is whether the agency could have prevented that death if it had done more or different things. For that reason, fatality review is an important way to assess the performance of a child welfare agency, both internally and externally. According to an appendix to the report, the mission of the CFSA Child Fatality Review (CFR) Unit is “to reduce the number of preventable child fatalities in the District of Columbia through identifying, evaluating, and improving programs and systems responsible for protecting and serving children and their families.” CFSA’s 17th annual Child Fatality Review Report, based on the work of the CFR Unit, was released on January 30, 2023.1

Before 2019, CFSA followed the common practice of including in a given year’s CFR report all of the fatalities it reviewed during that year, even if they occurred during previous years. This makes sense as these deaths were never discussed in earlier reports. But for the third year in a row, CFSA chose to eliminate some cases from its analysis based on when they occurred. The new CFR report includes only those deaths that occurred during 2021 and were reviewed in the same year. That means their analysis includes only 29 child fatalities instead of the total of 51 fatalities they actually reviewed in 2021. The rest of those fatalities occurred in 2018, 2019, and 2020. See the Note on Timing appended to this commentary for further discussion of this issue.

Manner of Death

The manners of death2 of the 29 young people whose cases are included in the body of the report are displayed in the pie chart below. About a third of these decedents were victims of “non-abuse homicide;” six (or 21 percent) died of accidents; four (or 14 percent) died of natural causes; and three (or 10 percent) died of “neglect homicide.” The other six children’s manners of death were “undetermined” or “unknown.”

Source: CFSA, Child Fatality Review Report: Statistics, Observations and Recommendations: 2021, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2021%20Annual%20CFR%20Report%20Final.pdf; data plotted by Child Welfare Monitor DC=

Neglect Homicides

Three, or 10 percent of the deaths reviewed in this report, were labeled as “neglect homicides.”(There were no homicides attributed to abuse). All of the victims were age three or under, which is typical of child maltreatment fatalities nationally as well. One of the three was a 17-month-old with “thermal and scald” injuries. The two other fatalities both involved synthetic opioid toxicity, illustrating the spread of this crisis to the District of Columbia. The second fatality was a three-month-old who died of synthetic opioid (eutylone and fentanyl) toxicity and the third was a three-year-old boy dead of fentanyl toxicity. The families of the 17-month-old and the three-year-old both had more than ten hotline calls and had open in-home cases at the time of the fatality.

Non-abuse homicide

By far the most common manner of death reviewed in this report was “non-abuse homicide,” or homicide that was not the result of child abuse. Such “non-abuse homicides” were one-third of all deaths reviewed; eight of the decedents were male and two were female. One victim was only six years old; the remainder were aged 13 and older. Nine of these deaths were caused by gunshot wounds and one was caused by stab wounds. One of the victims was in foster care with a relative at the time of his death. He had been removed from his home in 2015 due to abuse and neglect.

Natural Causes

Three fatalities, or 10 percent of the deaths included in the report, were due to natural causes. All of these children had congenital anomalies. They included a four-day-old girl and a three-year old boy who were both born prematurely and were medically fragile. Both of their families had open cases with CFSA. The three-year-old had been placed with a foster parent experienced in caring for medically fragile children after his mother was determined to have neglected him and was determined to be ill-equipped to care for a medically fragile child.

Accidental Deaths/Unsafe Sleep:

The manner of death was deemed to be accidental for six, or 21 percent of the deaths reviewed. Unsafe sleeping arrangements were involved in three of these six deaths of babies whose ages ranged from 19 days to two months old. In all of these cases, asphyxia was included as a cause of death. Of the remaining accidental deaths, two girls aged 16 and 17 died of opioid overdoses. Both deaths were part of a spate of fatalities in June 2021 that the police attributed to a tainted batch of fentanyl. The final accidental death was that of a four-year-old child who was hit by a car. An observer reported that he wandered away from his mother and two younger siblings before being hit.

Undetermined and unknown

Four of the fatalities were classified as undetermined because the autopsy findings were inconclusive. In one case, the mother left an 11-month-old and her four-year-old sibling sleeping alone in the home, and returned to find the baby unresponsive and foaming at the mouth. In a re-enactment using a doll, the mother demonstrated placing the child on her stomach with a bottle in her mouth in a way that could have impeded her breathing, but the medical examiner was unable to confirm asphyxia as a cause of the baby’s death. In the wake of the fatality, CFSA opened an in-home case to help the mother and her children. But that was not enough to save her three-year-old, who died within six months of opioid toxicity while the in-home case was still open, and was one of the three neglect homicide victims mentioned above. Unsafe sleep environments were involved in two of the other deaths for which the manner was undetermined.

The fourth death for which the manner was undetermined involved a twelve-year-old girl who reportedly collapsed after choking while eating soup. However, the hospital physician observed bruising on the child’s abdomen, back and legs, the mother was found to have abused her, and two siblings were removed from the home. The official cause of death was an untreated bacterial infection coupled with pneumonia but the manner could not be determined.

There were three deaths for which the manners were unknown. A seven-week old boy was reported missing by his father and is presumed dead. The mother was charged with suspected concealment or removal of the body and her other three children were removed from her. Unless there were two babies close to two months old who were reported missing in 2021 under the same circumstances, this is a case that received considerable media attention. The mother told the baby’s father that he had been removed by CFSA. Eventually she told police that she accidentally rolled over her son while under the influence of PCP, then panicked and threw his body into the trash. She was initially charged with murder but the charges were dropped as a body was never discovered. According to police, the mother was stabbed to death by the father in April 2022.

The remaining deaths for which the manner is unknown involved a newborn removed by Caesarian from a mother dying of Covid-19 and a seven-year-old who died in a house fire, for whom autopsy results are pending.

Decedents in Foster Care at TIme of Death

Two of the decedents were in foster care at the time they died. One was the eighteen-year-old who was living with a relative after being removed from his abusive mother, and who was the victim of a non-abuse gun violence homicide. The other victim was the medically fragile two-year-old, who was dependent on a gastrostomy tube and a tracheostomy vent, who died of natural causes and was living with a foster parent who specialized in caring for medically fragile children.

Family Risk Factors

The report provides some demographic information about the parents of the children who died, and that information is in line with research evidence that teen parenting, large families, and a parent’s history of maltreatment as a child are risk factors for child maltreatment. Parents of the children who died tended to be very young when they started having children. Sixty-nine percent of the mothers and 58 percent of the fathers were under age 21 at the birth of their first child. The youngest mother was 13 years old when she gave birth to her first child and the two youngest fathers were 16. Many of the dead children came from large families, which is more common among those who start having children at an early age. All but four of the 29 decedents had two or more siblings. Thirteen had four or more siblings; three had seven or more siblings, including two with 12 siblings and one with 10 siblings. A parent’s maltreatment history as a child is also known to be a risk factor; 13 of the 29 birth mothers had CFSA involvement as children, and both parents of two of the decedents were involved with CFSA involvement in their childhood.

Parents’ CFSA History as Caregivers

Nine of the 29 families reviewed in the report (or about a third) were involved with CFSA at the time of the fatality. Of these nine families, two had an open investigation and five had an open in-home case. Two had an open foster care case, but those are presumably the families of the two children who died while in foster care.

Source: CFSA, Child Fatality Review Report: Statistics, Observations and Recommendations: 2021, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2021%20Annual%20CFR%20Report%20Final.pdf

Table 7 shows that 10 families (or more than a third of the 29 families) had CFSA involvement within 12 months of the fatality – only one more family than was involved at the time of the fatality. It appears that all of them had an investigation within that period. However, with fewer families reported to have an in-home or foster care case than in Table 6, there must be some errors in the data; CFSA has not yet responded to a request for clarification.3

Source: CFSA, Child Fatality Review Report: Statistics, Observations and Recommendations: 2021, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2021%20Annual%20CFR%20Report%20Final.pdf

Looking at the 17 families that did not have CFSA involvement at the time of the fatality (Figure K in the report)4 CFSA found that the time since they were involved varied from 1 to 56 months, and that 11 of these 17 families (65 percent) were last involved with CFSA more than 18 months before the fatality.

As shown in Figure J, the majority of the families had four or more reports to the hotline (known as referrals) during the five years preceding the fatality. Many of these reports were screened out, as shown in Figure Q. All but 4 of the 29 families had referrals that were screened out during the five-year-review period and ten of those families had five or more referrals screened out.

Source: CFSA, Child Fatality Review Report: Statistics, Observations and Recommendations: 2021, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2021%20Annual%20CFR%20Report%20Final.pdf
Source: CFSA, Child Fatality Review Report: Statistics, Observations and Recommendations: 2021, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2021%20Annual%20CFR%20Report%20Final.pdf

Table 8 summarizes the results of the reports received regarding these families. The large majority of these families (23 families or 79 percent of families) were investigated at least once , with an additional 6 families investigated twice. Twelve families (41 percent of families) had in-home cases within five years of the fatalities, with eight having one case, three having two cases, and one having three cases.5,6

Source: CFSA, Child Fatality Review Report: Statistics, Observations and Recommendations: 2021, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2021%20Annual%20CFR%20Report%20Final.pdf

Figure L in the report (not reproduced here) shows that 16 families, or slightly more than half of the families, had at least one substantiated allegation in the five years before the fatality. Ten of these families had only one substantiation and the remaining families had between one and four substantiated allegations. The most common substantiated allegations were inadequate supervision and educational neglect (four families each), followed by physical abuse, failure to protect, medical neglect and indadequate food/clothing/hygiene (three families each).

“4+ Staffings“

One CFSA practice that is designed to prevent further harm to children known to the system is the “4+ Staffing.” CFSA conducts these meetings for families that have four or more referrals, with the last referral occurring within the past 12 months. These staffings are supposed to uncover gaps in past practice or service delivery that may have contributed to the repeated maltreatment and to find strategies to prevent future maltreatment. In the 2020 CFR report, CFSA stated that of the decedents’ families who had qualified for such a staffing during the five years before the fatality, all had received a 4+ Staffing. Clearly, this figure casts doubt on the effectiveness of these staffings. Unfortunately, the analogous section of the current report appears to focus on the percentage of eligible families that received a 4+ staffing after the fatality, a fact that is less relevant to the purpose of CFR.7

Siblings removed after child fatalities

A new report section states that 11 children were removed from four families in the wake of the child fatalities reviewed in the report.

  • After an 11-month old girl was left alone with a four-year-old sibling and a propped bottle, the agency opened an in-home case for the family. But when her three-year old brother died of fentanyl intoxication within six months of his sister’s death, the other children were removed and placed with kin. At the time of the writing of the report, their goal was reunification with the parent, who was said to be “receiving services, including grief counseling for the loss of more than one child within a short time frame, as well as substance use and housing.”
  • The siblings of the 12-year-old girl who died of an untreated bacterial infection but also had signs of physical abuse have already been returned home. CFSA states that the mother and children have received mental health services and the mother has completed court-ordered parenting education.
  • Of the three siblings of the infant boy who disappeared, one child was with her father at the time of the report’s being written and the other two were placed in foster care with a goal of reunification.7
  • The 17-month-old who was scalded to death had four siblings, ranging in age from five months to twelve years old, who were all removed from the mother in the aftermath of the toddler’s death. Two were placed with kin and two in a mysteriously named “non-foster care placement,” which probably connotes placement with kin outside the foster care system. There is no mention of reunification; perhaps this case qualified for the exemption from reunification that is allowed under certain aggravated circumstances.8

CFSA’s Findings and Recommendations

In its Summary of Critical Findings, the CFR report discusses specific areas that received “additional focus” in 2021, including screened-out referrals. Concerns about the accuracy of hotline decision-making have been expressed in the District and around the country. In a 2016 study, conducted by the Center for the Study of Social Policy, the court monitor in the LaShawn class action suit, reviewers disagreed with CFSA’s decision to screen out the referral in 27 percent of the referrals studied. However, the report does not suggest any review of policy or practice in screening out referrals. Instead, it cites the “prevention services” provided by the collaboratives and the family success centers. The report also devoted special focus to families involved with CFSA at the time of the fatality, unsafe sleep fatalities, and gun violence, but the report makes no suggestions about how to avoid such fatalities involving these factors.

Based on its fatality reviews, CFSA’s ICFR Committee approved three recommendations: revision of the critical event and child fatality review policies, integration of child fatality review data into the new computerized case management database currently being developed, and finalizing a Memorandum of Understanding with DC Health “to provide monthly data on applicable fatalities to CFSA to facilitate the timely review of child fatalities.” It is notable that all these recommendations address the child fatality review process itself. There are no recommendations for changes in policy or practice related to screening, investigations, or services. It is also significant that the following language about the purpose of ICFR recommendations which was included in the 2020 report does not appear in this one: “The CFSA ICFR committee makes recommendations concerning appropriate actions that may possibly avert future fatalities.” Perhaps this language was deleted because none of this year’s recommendations are aimed at averting future fatalities, just about amending the fatality review process.

Conclusions

It is important to remember why we study child fatalities. These tragic deaths are the tip of an iceberg – the visible consequence of recurring abuse and neglect after at least one incident of alleged maltreatment was reported to the agency. When a child remains in the home after services end, we may not know that maltreatment has continued unless the child dies. Some children known to CFSA die for causes that are not related to abuse and neglect, like the newborn delivered early from the mother dying of COVID-19, or the three children with congenital abnormalities who died of natural causes. But research shows that simply having a report of child maltreatment increases the risk of deaths from all causes, not just abuse or neglect. Thus, many of the fatalities included in the report may be a consequence of ongoing maltreatment, even if the manner of death was not found to be maltreatment.

Some of the deaths with a manner labeled as accidental or unknown may have been due to neglect, like some of the eight babies who died while sleeping in unsafe arrangements. In total, CFSA reported that unsafe sleep factors were present in eight of the 10 deaths to children aged two or under. In my years of service on the citywide Child Fatality Review Committee,1 I have seen numerous cases of children dying in unsafe sleep environments in families with histories of child welfare involvement. Almost invariably, the parents have used marijuana, alcohol or other intoxicants before lying down with the baby, and they failed to wake up as their children struggled to breathe. With unimpaired parents, these sleeping arrangements might not result in death. This is why a study found that adjusting for risk factors at birth (including low birth weight and late or absent prenatal care), the rate of Sudden Unexplained Infant Death (SUID) was more than three times greater among infants who had been previously reported for past maltreatment than among infants who had not been reported.

And then there are the ten deaths from “non-abuse homicide.” The connection between child maltreatment and violent death became obvious to me soon after I started sitting on the citywide Child Fatality Review Committee. I learned that many young victims of homicide grew up in families with long histories of reports to CFSA regarding lack of supervision, school absences, physical abuse and other concerns. In some cases CFSA screened out the reports or found no maltreatment; in other cases services were provided. But the maltreatment continued. Many of these families exhibited chronic child neglect, which occurs “when a caregiver repeatedly fails to meet a child’s basic physical, developmental, and/or emotional needs over time.” Many of these children, with histories of trauma and little support at home or connection to school, eventually found belonging in the streets and took up violent and illegal activities.

Of course, we do not know how many of the gun violence victims included in this report came from abusive or neglectful homes or were involved in violence themselves. But according to police reports, motives for five of the nine homicides included retaliation for robbery and gang-related activities, implying the victims were involved with such activities. Relatives of the 18-year-old female victim of another homicide indicated that she was involved in a “volatile” relationship with her killer. The six-year-old whose death is reviewed here was obviously an innocent bystander. But she was shot while walking to a liquor store with her parents late on a Friday night. And federal prosecutors stated that the father of the six-year-old shot on July 16, 2021 was involved in the violent drug trade on the street where his daughter was shot, and the judge indicated that he did not understand what the child was doing in that area at 11:00 PM.

The four-year-old who was hit by a car when he wandered away from his mother might also be a victim of neglect, but we do not know because no case details are provided in this report. And as for the teenage girls dead from tainted fentanyl, we will never know what kind of home environment they had and if that contributed to their drug use. But the connection between childhood maltreatment and later substance abuse is well-known.

Of course CFSA understands the linkage between abuse and neglect and all causes of death. That’s why it studies all deaths of children known in the past five years, not just those due to maltreatment. CFSA had many opportunities to intervene in the lives of the 29 children discussed in the report and their families. Nine of the families were involved with CFSA at the time of the fatality. Ten of the families were involved with CFSA within a year of the fatality. Within five years of the fatality, 25 of the families had at least one screened-out report, 23 of the families had at least one investigation, and 12 of the families had at least one in-home case.

Obviously it is concerning that two fatalities occurred in families that were being investigated by CFSA and five occurred in families that had an open in-home case, In which a CFSA worker is expected to visit a family from weekly or twice a month, depending on its perceived need. One has to wonder whether any red flags were missed by the workers who were investigating or monitoring these families. Among the families that had an open in-home case at the time of the fatality were the families of both the 17-month-old and the three-year-old who died of synthetic opioid toxicity. One cannot help wondering how frequently and thoroughly the in-home workers interacted with the families, without noticing that the parents were still using opioids. Nobody wants to remove more children, but perhaps they needed to be removed, and some of these children may have had a protective relative ready and eager to receive them.

I do not mean to say that CFSA could have saved all of the children that they touched who later died. But perhaps it could have prevented some of these deaths. The agency could have chosen to devote special attention to parents who were very young when they started childbearing, families with many children, and parents who were involved with CFSA as children. It could have screened in more referrals, substantiated more allegations, opened more cases, monitored families more effectively, provided more intensive and effective services, or involved the court in more in-home cases. And if necessary it could have removed more children, preferably to a protective relative or other known adult.

The total of 29 children who were known by the end of 2021 to have died after being touched in some way by CFSA will certainly rise as more fatalities are identified and reviewed. (The total for 2020 is 40 so far.) But if present practices continue, the remaining fatalities will not be included in an annual report, except for one or two tables in the appendix. Therefore, the annual reports understate the number of children who died after being touched by CFSA. Strangely, the report authors do not seem to understand the significance of the smaller universe, making comments like “There was a decrease in total infant fatalities in 2021.” That decrease, from 16 to 10, may not mean much when the total number of fatalities reviewed was 29 instead of 40.

It is concerning that all of the report’s recommendations concern the practice of fatality review itself. There are no recommendations to improve CFSA’s practice in conducting the hotline, investigations and in-home and foster care cases. It is hard to avoid thinking that CFSA’s ideology of non-intervention and family preservation has contributed to both these deaths and the lack of recommendations aimed at preventing such deaths in the future. No child welfare agency has a crystal ball. They all have to strike a balance between the harms caused by intervening in families where there is no maltreatment and not intervening in maltreating families. But CFSA has declared its preference clearly. As stated in the report, “For over a decade, CFSA has invested in safely keeping families together and developing robust prevention strategies to help support them.” But these “robust prevention strategies” were not enough to protect the children who died in 2021. For CFSA, these deaths may simply be collateral damage.

The information about the siblings who were removed from their families after the fatalities – a new addition to the report – is quite disturbing. The idea that the agency is still working for reunification with the mother who lost two children in one year – one left alone with a four-year-old and a propped bottle and the other poisoned by fentanyl – and had ten hotline reports in the five preceding years is concerning. And that the siblings of the abused child who died of a bacterial infection are back with their mother after she received mental health services and parenting education is concerning as well. But it is not clear what CFSA could have done differently without action from the DC Council. The DC Code requires CFSA to make “reasonable efforts” to reunify children with their families except in certain aggravating circumstances which probably would not have been found in these cases.9

As always, CFSA’s internal child fatality report is distressing. It includes two deaths in one year to the same family, ten non-abuse homicides, several deaths involving unsafe sleep, and two high-profile child deaths: an infant whose body was disposed of by the mother and a six-year-old who was killed as part of a drug war involving her father. We learned of four deaths – two of small children and two of teenagers – involving the new scourge of fentanyl and other synthetic opioids. CFSA has made the decision to avoid intervention and prioritize family preservation above child safety, and the report contains no recommendations for improving the agency’s efforts to spot and address abuse and neglect. If CFSA is not going to make any recommendations to protect children in the CFR report, then one might question the report’s purpose and utility.

Notes

  1. It is important to distinguish CFSA’s internal child fatality reports from the annual reports of the citywide Child Fatality Review Team, which covers all deaths of young people up to age 18 and some deaths of those aged 19-21.
  2. ‘Manner of death” refers to the circumstances that caused the death, as opposed to “cause of death,” which refers to the specific disease or injury that led to the death.
  3. It is also unclear why only one child is counted as having a foster care case since two of the children were in care at time of death.
  4. This count of 17 families that did not have CFSA involvement at the time of the fatality is inconsistent with Table 6 and the associated text, which says that 20 families did not have active CFSA involvement at the time of the fatality. 
  5. The heading “Reports” in this table is confusing but I have followed the lead of CFSA in describing the Table’s data and am awaiting clarification from the agency.
  6. Family assessments were an alternative to an investigation for low-risk cases, and are no longer being used by CFSA.
  7. I have asked CFSA to clarify the meaning of their data on families that received a 4+ staffing but have not received an answer as of the date of this publication.
  8. If this is indeed the case referred to earlier, this reunification will not take place as the mother has been killed by the baby’s father. It is possible that the oldest daughter’s father is a different person and that she can remain with him.
  9. See DC Code § 4–1301.09a. Reasonable efforts, https://code.dccouncil.gov/us/dc/council/code/sections/4-1301.09a#:~:text=4%E2%80%931301.09a.-,Reasonable%20efforts.,the%20family%20by%20the%20Agency.

A Note about Timing

Until 2019, CFSA’s internal child fatality reports covered the agency’s reviews of all fatalities of children whose families were known to the agency within five years of their death. This is normal for child fatality review panels, which often have a long time lag before reviewing a case. But in 2019, ICFR decided to include in its review only the deaths that actually occurred in the year they were reviewed. As I have described, one problem with that approach is that it is clearly impossible to review all deaths that occurred in a given calendar year during that same year. Deaths that occur or become known near the end of the year clearly cannot be reviewed during that same year. Perhaps as a result of that realization, the CFR Unit included in the 2020 child fatality report those child deaths that occurred in 2020 and were reviewed during the same year or in the first three months of CY 2021. That decision gave them a total of 40 cases that were included in the report. However, this year, CFSA, as in 2019, including only the cases reviewed during the calendar year, missing any cases that were reviewed in the first quarter of 2022 or later. This is particularly strange because this report was released so much later than the last report with respect to the calendar year reported on – January 2023 as opposed to October 2021. So they had more time, not less, to include an extra quarter of reviews.

There is another problem with limiting reviews to the current calendar year, which is that deaths occurring in earlier years are missed. In Appendix A and B, the ICFR reports that it actually reviewed 51 deaths in 2021. Thirteen of these deaths occurred in CY 2020 and were apparently reviewed in the first quarter of 2021 and included in the 2020 report. However another 14 fatalities that occurred during 2018 and 2019 were presented to the ICFR committee during 2021 but not included in the report. These fatalities were never included in previous analyses, nor will they be included in the future, so most of the information on these fatalities will never be released to the public, aside from some demographic and cause and manner of death data provided in Appendix C.

There is also an internal inconsistency between the 2021 report and the appendices. The report contains reviews of 29 cases. Appendix A states that “the ICFR Committee reviewed 51 fatalities during CY 2021; all 51 fatalities helped to inform practice and policy recommendations that potentially reduce future child fatalities.” It states that 13 of these fatalities occurred in 2020 and were included in the previous report, and another 14 of these fatalities occurred in 2018 and 2019. That means that out of the 51 fatalities reviewed in 2021, only 24 (51 minus 27) occurred in 2021. Yet, the 2021 analysis includes 29 fatalities. I have asked CFSA about the discrepancy but have not received an answer as of the date of publishing this commentary.

CFSA’s Internal Child Fatality Report for 2020: a missed opportunity to learn from mistakes and inform the public

CFSA’s Internal Child Fatality Report for 2020 was released on October 27, 2021. It provides information on 40 deaths of children and young adults whose families were known to CFSA within five years of their deaths. The report shows that most of these families had been reported to CFSA multiple times in the past five years. Many of them had experienced investigations and received CFSA services through in-home and foster care cases. Despite these interventions, these children had died within five years of CFSA’s ending its involvement. The report contains the lessons that CFSA drew from these deaths, but a careful reading suggests that the agency has not taken full advantage of this opportunity to improve future practice. Moreover, the report does not provide the information that interested readers need to make their own conclusions about agency practices and needed changes.

CFSA’s internal fatality report is different from the annual report of the citywide Child Fatality Review Team, which covers all deaths of young people up to age 18 and some deaths of those aged 19-21. The CFSA report focuses on fatalities of young people up to age 24 whose families were known to the agency within five years of their deaths. These fatalities are reviewed by the agency’s Internal Child Fatality Review (ICFR) Committee, and this report summarizes the results. As the report explains, the internal fatality review process “is one of CFSA’s strategies for examining and strengthening child protection. It provides the Agency with specific information that helps to address areas in need of improvement and to identify any systemic factors that require citywide attention – all with the goal of reducing preventable child deaths.”

The 2020 child fatality report includes only those child deaths that occurred during Calendar Year (CY) 2020 and were reviewed by the ICFR Committee during 2020 or in the first three months of CY 2021. An additional fifteen deaths that occurred in CY 2018 and CY 2019 but were reviewed in CY 2020 are summarized briefly in an appendix but are not included in the narrative and data charts provided in the body of the report. I discussed this timing issue in depth last year, when the report excluded half of the deaths reviewed during 2019. This year CFSA has improved the coverage of its report, at least in part by including cases reviewed up to March 31 of 2021: this report includes 40 (or 72 percent) of the 55 deaths reviewed between January 1, 2020 and March 31, 2021. But it is still hard to understand the purpose of leaving out more than a quarter of the deaths reviewed during the period covered by the report. All of these deaths took place in 2018 and 2019, not many years in the past. The report states that the ICFR Committee reviewed these earlier cases “as part of its internal continuous quality improvement (CQI) efforts,” but also that “[i]n line with CFSA’s CQI efforts and based on the known fatalities that occurred during CY 2020, ICFR Committee members made practice recommendations to potentially help reduce future child fatalities.” So it appears that the 15 fatalities from 2018 and 2019 were reviewed as part of CQI, but were not used to develop recommendations, which is the main purpose of CQI! Leaving out these cases accomplished nothing but giving the committee a smaller group of cases upon which to make recommendations and reducing the amount of information available to the public in the annual report.

Manner of Death

The manners of death* of the 40 children whose cases are included in the body of the report are displayed in the pie chart below. Half of these children were victims of “non-abuse homicide;” nine (or 22 percent) died of natural causes; five (or 12 percent) died in accidents; three (or seven percent) died because of abuse or neglect; and one died by suicide. The other two children’s manners of death were “undetermined” and “unknown.” While children who die from abuse and neglect after having previous contact with child welfare draw the most public concern, research shows that children who have prior contact with child welfare also tend to die more often from all causes than children with no such involvement, as I discussed in my post, Report of maltreatment: a major risk factor for child mortality.

Source: CFSA, Internal Child Fatality Report: Statistics, Observations and Recommendations: 2020, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2020%20CFR%20Annual%20Report%20vF%20-%2010.26.21.pdf; data plotted by Child Welfare Monitor DC.

Abuse and Neglect Homicides

Abuse and neglect homicides of children known to CFSA often draw public concern because the agency’s primary role is to protect children from abuse and neglect. But they are a small proportion of the deaths to children who were involved with CFSA in the past five years. Three, or seven percent of the deaths reviewed in this report, were abuse or neglect homicides. The ICFR Committee also reviewed one abuse or neglect homicide that occurred in 2018 or 2019 and is addressed only in the appendix to the report. We know nothing about this case, not even whether the death was caused by abuse or by neglect. The two abuse homicides that occurred in 2020 were young children who died by blunt force trauma. The information provided suggests that the 11-month-old was Makenzie Anderson. Shortly after Makenzie’s death Petula Dvorak reported in the Washington Post that other residents of the Quality Inn that was then serving as a shelter for homeless families knew that Makenzie was in danger. But CFSA refused to disclose whether anyone had reported their concerns to the hotline. This report tells us that somebody, sometime, did report their concerns about Makenzie’s family, but that is all it reveals.

Given what is publicly known, the other abuse homicide discussed in the report – a two-year-old African-American male who died from multiple blunt force injuries – was probably Gabriel Eason, who died on April 1, 2020. An autopsy showed old and new injuries to Gabriel’s body, including swelling of the head and brain, abrasions and contusions to the head and torso; lacerations of the kidney and liver; injuries to the heart and vena cava; cuts on the face and neck; blunt trauma to the genitals; and 36 rib fractures. We know that Gabriel’s childcare center called the CFSA hotline on October 9, 2019, six months before he died, but we do not know what action CFSA took or if there were other calls. Unfortunately this report does not tell us anything new.

The neglect homicide included in the report involved a seven-year-old African-American boy killed in a car accident. The child and his younger siblings were passengers in a car driven by their mother in a long drive back to the District from another jurisdiction. None of the children were in car seats and the mother had alcohol in her system. The mother was charged with first-degree vehicular homicide, seatbelt violations, and driving under the influence. She was taken into custody and the remaining children were placed with relatives. The report does not tell us when and how often CFSA received reports in this family or how the agency responded.

Gun Violence

By far the most common manner of death for fatalities reviewed in this report was “non-abuse homicide,” or homicide that was not the result of child abuse or neglect. Such “non-abuse homicides” were half of all deaths reviewed, and all 20 of these deaths were caused by gun violence. Unlike in cases of abuse homicide, the media rarely asks about the history of gun violence victims with CFSA. However, the connection between child welfare history and gun violence death became obvious to me as soon as I started sitting on the citywide Child Fatality Review Committee. I learned that many of the young victims of homicide grew up in families with long histories of reports to CFSA. Reports on one family often include allegations of physical abuse, positive toxicology of a newborn, lack of supervision, and extensive unexcused school absences. Many of these reports were unsubstantiated; others were confirmed but resulted in nothing but a referral for voluntary services; others resulted in the opening of in-home cases that eventually closed; and others resulted in children placed in foster care and later returned home. But the abuse and neglect continued. Many of these families fit the pattern of chronic child neglect, which occurs “when a caregiver repeatedly fails to meet a child’s basic physical, developmental, and/or emotional needs over time, establishing a pattern of harmful conditions that can have long-term negative consequences for health and well-being.” Many of these children, with little support at home, histories of trauma, and disconnected from school, find their companionship in the streets and take up violent and illegal activities. Of the male decedents reviewed in the 2020 CFSA report, four were known to have been involved with the juvenile justice system and two were known to be involved in criminal activity when they were killed.

Of course, not all of the children included in this report who died from gun violence came from abusive or neglectful homes or were involved in violence themselves. Some of them died because they lived in a neighborhood plagued by gun violence or were in the wrong place at the wrong time. The eleven-year-old mentioned in the report might have been Davon McNeal, who was caught in the crossfire of a gunfight. And Davon was probably not the only bystander among the 20 who died. But perhaps some of the other deaths could have been prevented with more aggressive CFSA action. For example, the agency could have offered better, more intensive and long-lasting services to the parents, with court supervision to ensure they were taken up. And crucially, the agency could have refused to give second, third, and fourth chances to parents who repeatedly failed to take advantage of these services.

Natural Causes: Nine fatalities, or 22 percent of the deaths included in the report, were due to natural causes. Three of these deaths were due to prematurity and another three were due to medical conditions at birth. One might think that these deaths could not have been prevented by CFSA action, but research suggests otherwise. A population-based study using data from 3.4 million births in California found that, controlling for baseline risk factors like low birthweight and preterm births, infants with more than one CPS report were more than three times more likely to die of medical causes than those without a CPS report. The researchers also found that among infants reported for maltreatment, periods of foster care placement reduced the risk of death from medical causes by roughly half. Unfortunately, as described by child welfare expert Dee Wilson, medically fragile children are often born to the parents that are worst equipped to care for them. Thus, some of these deaths might have been prevented with more aggressive interventions, including foster care, in earlier contacts with the agency.

Accidental Deaths/Unsafe Sleep: Five of the CY 2020 fatalities, or 13 percent, were deemed accidental. Unsafe sleeping arrangements were involved in four of these deaths. (The fourth was a 20-year-old riding a moped without a helmet). In total there were five fatalities related to unsafe sleep. The other one was classified as “undetermined.” On the citywide child fatality review panel, I have seen numerous cases of children dying in unsafe sleep environments in families with long histories of child welfare involvement, often for numerous children. We tend to focus on unsafe sleeping arrangements (such as bed sharing) as the cause of death, but the reality is much more complex. Almost invariably, the parents have used marijuana, alcohol or illegal substances before lying down with the baby, and they fail to wake up when the children are struggling to breathe. With unimpaired parents, these sleeping arrangements might not result in death. That is why another study found that adjusting for risk factors at birth (including low birth weight and late or absent prenatal care), the rate of Sudden Unexplained Infant Death (SUID) was more than three times greater among infants who had been previously reported for past maltreatment than among infants who had not been reported. And that’s why more intensive interventions (including foster care placement) with families that abuse substances might have prevented some of these deaths.

Suicide: The CFR Unit reviewed one death by suicide; incredibly the decedent was an 11-year-old girl who hanged herself from the shower rod in her home. One population-based study estimated that children with any CPS history were three times as likely to end their own lives than children without such a history, and an eleven year old taking her own life suggests that something must have been amiss in her family that the agency might have been able to observe. “The family received grief services,” according to the report. That is nice to know, but it would be more important to know what type of trauma could have caused the suicide of an eleven-year-old, and what CFSA knew and should have known about this family before the child took her own life.

Undetermined and unknown: One child’s cause of death was unknown because the child died outside of the District; that child was in foster care. One fatality was classified as undetermined because the autopsy findings were inconclusive. The decedent was two months old and was found unresponsive after being swaddled for about two hours in a motorized baby swing with a blanket propping up a pacifier so that it would stay in the infant’s mouth. Unsafe sleep practices may have contributed to the infant’s death, according to the CFR Unit. This case raises the same issues as the accidental deaths discussed above. Any family that would leave a two-month-old unsupervised in a swing for two hours with a propped bottle has severe parenting deficiencies beyond their knowledge of safe sleep practices–deficiencies that required aggressive intervention in order to protect the child.

Parents’ CFSA History as Caregivers

Nine of the 40 families reviewed in the report (or about 23 percent) were involved with CFSA at the time of the fatality. Of these nine families, five had an open foster care case, two had an open investigation, one had an open in-home case and an open investigation, and one had an open permanency case and an open CPS investigation. Obviously it is concerning that these fatalities could occur while CFSA was actively involved with the family. One has to wonder whether any red flags were disregarded. But without knowing the details of CFSA’s involvement with these families, it is impossible for readers of this report to make any conclusions about agency practice.

Source: Source: CFSA, Internal Child Fatality Report: Statistics, Observations and Recommendations: 2020, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2020%20CFR%20Annual%20Report%20vF%20-%2010.26.21.pdf.

In addition to the nine families who had an open investigation or case at the time of the fatality, four families (10 percent) had a case or investigation closed within three months of the fatality, four families had a case or investigation closed within four to nine months of the fatality, and another four families had a closure within 10 to 12 months of the fatality. It is concerning that so many families had such recent contact with CFSA; one wonders whether the case closures were premature and whether any red flags were missed. One family was not included in these calculations because it had four referrals that were screened out and no investigations or cases. It is concerning that a family with a later fatality had four reports screened out and it would be interesting to know when those referrals came in and whether the CFR unit looked at why they were rejected. There has been some concern about the accuracy of hotline decision-making. In a 2016 study, conducted by the Center for the Study of Social Policy, the court monitor in the LaShawn class action suit, reviewers agreed with the decision to screen out the referral in only 73 percent of the 223 screened-out referrals studied.

Note: One family was not included because they had no open case or investigation during the five years before the child fatality. The family did have four screened-out referrals.
Source: CFSA, Internal Child Fatality Report: Statistics, Observations and Recommendations: 2020, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2020%20CFR%20Annual%20Report%20vF%20-%2010.26.21.pdf; data plotted by Child Welfare Monitor DC

The chart below shows the frequency of CFSA involvement for the families with fatalities. All of the families had more than one report to CPS within five years of the fatality, 31 families, or 77 percent of the families, had four or more reports. So these families were very troubled, and there were many opportunities for CFSA to intervene.

Source: CFSA, Internal Child Fatality Report: Statistics, Observations and Recommendations: 2020, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2020%20CFR%20Annual%20Report%20vF%20-%2010.26.21.pdf; data plotted by Child Welfare Monitor DC

What happened as a result of these reports? All but two of the families had referrals that were screened out, with 40 percent having four or more such screened-out referrals. About 83 percent of the families had at least one investigation. Sixty-five of the families had between one and three family assessments, an alternative to traditional investigation that has been dropped by CFSA. Forty-three percent of the families had one or two in-home cases, and 33 percent had one or two permanency (foster care) cases. Again, this table shows that CFSA had many opportunities to assess and intervene with these families before their children died.

Source: Source: CFSA, Internal Child Fatality Report: Statistics, Observations and Recommendations: 2020, https://cfsa.dc.gov/sites/default/files/dc/sites/cfsa/publication/attachments/2020%20CFR%20Annual%20Report%20vF%20-%2010.26.21.pdf.

According to the table shown above, 33 families were the subject of investigations in the five years before the fatality. In Figure One of the report (not reproduced here) CFSA found that 19 families had at least one substantiated allegation in the five years before the fatality. That 33 of these families had investigations but only 19 (or about 58 percent) had at least one maltreatment finding suggests that many of these investigations may have failed to find existing abuse or neglect. Physical abuse was the type of allegation that had the largest number of substantiations (eight). Unfortunately, we do not know how many families received those eight substantiations; it could have been one family that received them all or several families could each have received a smaller number of substantiations. The other most frequent types of maltreatment substantiated were ‘failure to protect’ (five), and four each for inadequate supervision, substance use by parent or caregiver, unwilling/unable caregiver, positive toxicology of a newborn, educational neglect and exposure to domestic violence. It would also be valuable to see the number and subject of unsubstantiated allegations as well since a large body of literature documents the difficulty of accurately determining whether a child has been maltreated, which is why scholars often prefer to use referrals (rather than substantiations) as a metric for the rate of maltreatment.

It is no surprise that many families of children who died within five years of CFSA involvement had a long history of reports to child protective services. The known high risk level for children in a family that has multiple reports is the reason that CFSA requires a “Four-Plus staffing,” which is a special meeting for families with four or more allegations, when the last report occurred within 12 months. According to the report, these staffings “focus on gaps in practice or service delivery that may have contributed to a family returning to CFSA’s attention.” Among the 40 families included in the report, 15 met the qualifications for a Four-Plus staffing, and all of them received such a staffing. This result raises questions about the efficacy of these staffings in addressing families with multiple reports to CFSA.

CFSA’s Recommendations

Based on its fatality reviews, the ICFR Committee makes recommendations each year for CFSA and other District agencies for actions that might avert future fatalities. This year the committee made only three recommendations: provide support to child welfare professionals who experience traumatic stress; improve information sharing between DC government agencies, and encourage use of a comprehensive medical information platform among hospitals and medical providers in the District. The report explains that the last recommendation would address the problem of abusive parents who bring their children to different medical providers. It is possible that this recommendation was prompted by the case of Gabriel Eason, whose mother brought Gabriel to two different emergency rooms for his injuries, thus making it less likely that abuse would be suspected.

These are all good recommendations. But it is rather surprising that there are no recommendations to improve CFSA’s practice in conducting investigations and in-home and foster care cases. Given that nine of these decedents had an open investigation or case at the time they died, and another 12 had an open investigation or case within a year of the fatality, there is reason to wonder if anything could have been done differently in these cases. But without knowing the details of CFSA’s involvement with these families, it is impossible for reader of this report to make any conclusions about agency practice. The ICFR Committee was given the details on each case. Is it possible that they found no flaws in case practice that would lead to recommendations for the future? That is hard to imagine.

Even without being privy to case details, there are some potential recommendations that come to the mind of an educated reader. Given the fact that all 15 families that qualified for a Four-Plus staffing because of the extent of their history with CFSA actually had such a staffing, and a child died nevertheless, one might wonder if Four-Plus staffings are achieving their purpose. A reasonable recommendation might be to change these staffings or eliminate them entirely and replace them with something else. Given that among the allegations about the 40 decedents’ families by far the most allegations involved abuse, a potential recommendation might be that the agency heighten scrutiny for families that were reported for abuse. There is other evidence for such a proposal: one study found that children with a previous allegation of physical abuse sustained fatal injuries at 1.7 times the rate of children referred for neglect. Several years ago, the agency eliminated its Special Abuse Unit, which investigated allegations of physical and sexual abuse; one wonders if this was a step in the wrong direction.

Perhaps I am being too critical of CFSA’s internal child fatality report. It is difficult for an agency to criticize itself and recommend changes that may go against its ideological orientation. That is why some states give a Child Advocate, Ombudsperson or Inspector General the duty of investigating certain child fatalities in which the family was known to the child welfare agency. The City Council established the Children’s Ombudsperson in the 2020 legislative session and I advocated for that office to be given that responsibility. After putting that requirement in the original draft, the bill’s framers removed that provision. I hope the Council will consider amending the legislation to ensure that an impartial, independent party reviews some of these deaths and makes the reviews available to the public.

Reviewing the fatalities of children who were involved with CFSA in the five years preceding their deaths provides an opportunity for CFSA to suggest changes in its practices. However CFSA has not taken full advantage of this opportunity this year. First, by eliminating over a quarter of the cases it reviewed based on an arbitrary timeframe, the fatality review committee deprived itself of vital fodder for recommendations and withheld important information from the public. Second, the committee made no recommendations for changes in the agency’s investigative and case management practices that may have allowed serious red flags to be missed, leaving children vulnerable to serious maltreatment during or after their involvement with CFSA. Finally, the report represents a failure to inform the public about the performance of an agency that it pays for. Not only does CFSA’s 2020 internal fatality report fail to derive all the available lessons from CFSA’s mistakes but it does not provide the details necessary to enable members of the public to draw its own conclusions about agency performance. That’s why the City Council should give the new Children’s Ombudsperson the responsibility for investigating and reporting about such fatalities.

*”Manner of death” refers to the circumstances that caused the death, as opposed to “cause of death,” which refers to the specific disease or injury that led to the death

CFSA’s Internal Child Fatality Report leaves out more than half of dead children known to system

On September 10, 2020, the Child and Family Services Agency (CFSA) released its internal child fatality review report for 2019. This report raises many issues and concerns. Some relate to the scope and coverage of the report. Others concern the cause and manner of death, the existence of families with repeated CFSA involvement that nevertheless have a child death, the predominance of large families as a correlate of child deaths, and the suggestion that unrelated adults in the home may have perpetrated a child fatality.

Child fatality review is an important way for an agency to assess the quality of its work. CFSA states in the report that “the fatality review process is one of CFSA’s strategies for examining and strengthening child protective performance. It provides the Agency with specific information that helps to address areas in need of improvement and to identify any systemic factors that require citywide attention–all with the goal of reducing preventable child deaths.” But the goal of child fatality review should be broader than reducing child deaths. Child fatalities should be seen as the tip of the child welfare iceberg. For every child who dies, there may be many others who are left in abusive or neglectful homes with no monitoring or support.

There are two child fatality review reports issued in the District. The District of Columbia’s Child Fatality Review Committee (CFRC) is located in the Office of the Chief Medical Examiner. CFRC reviews all deaths regardless of cause of all District residents from birth through 18 years, as well as the deaths of youths aged 19 to 21 who were known to child welfare within four years of the fatal event or those known to intellectual and disability services or juvenile justice programs within two years of the fatal event. Each year CFRC reports on all the fatalities reviewed in that year, but these fatalities could have occurred in any previous year. In the most recent report, on 104 cases reviewed in 2018, the deaths reviewed were from 2014 through 2018.

CFSA’s internal child fatality review reports are based on information gathered by the CFSA’s Child Fatality Review (CFR) unit and recommendations developed by the agency’s Internal Child Fatality Committee (ICFR). These reports focus on a smaller subset of child fatalities–all known fatalities of children whose families were known to CFSA within five years of the child’s death. In the past, the report included all fatalities reviewed in each calendar year. As stated in last year’s internal fatality review report, which has been removed from the CFSA website: “Historically, every CFR annual report has also included review data outside of the calendar year, depending on when the CFR Unit received notification of a child’s death. For [Calendar Year] 2018, reviews included fatalities from years 2015 to 2018.” However, the new report, includes only those fatalities that occurred during 2019. This is only 13 of the 33 fatalities the Committee reviewed during 2019, as the agency explains in a footnote. The other 20 fatalities reviewed occurred in previous years and will therefore never be included in a CFSA child fatality report unless the previous practice of including deaths from previous years is reinstated.

Cause and Manner of Death

Of the 12 fatalities for which cause and manner were known, the causes were equally divided between maltreatment, natural causes, non-abuse homicides, and accidents.

  • The cause of death was abuse or neglect by a caregiver for three of the children who died in 2019, 25 percent of the 12 children whose cause of death was known. All of these children were under the age of three. For two of these children the cause of death was abuse by blunt force trauma. The other child died of fentanyl poisoning due to neglect.
  • Of the 12 children with a known cause of death, three (or 25 percent, died of natural causes. Two of these were children between one and five years old, while the third was a young adult over 18.
  • Non-abuse homicides accounted for 25 percent of the fatalities in CY 2019. All of the victims were males living in Ward 8. One was aged 11, another was 16, and the third was 20.
  • All three accidental deaths were infant fatalities and all involved unsafe sleeping arrangements.

Demographic Characteristics

The children who died disproportionately resided in Ward 8 (seven children), Ward 7 (four children), Ward 5 (one child), and Maryland (one child). All of the children who died were African-American. None of these facts are surprising since they reflect the demographics of CFSA’s clients. Most of the children were living at home at the time of the fatality, except two that were living with relatives. All of the children who died had siblings. Nine of the decedents (about 69 percent) had three or more siblings; seven (54 percent) of them had four or more siblings, and four had six or more siblings. Many of the siblings were half-siblings. Twelve of the 13 decedents had at least one-half sibling.

Source: CFSA, Child Fatalities: Statistics, Observations, and Recommendations, 2019, page 6.

CFSA History

Over three quarters of the decedent’s families (10 families) had an open case or investigation within five years of the fatality. The other three families had one or more screened-out referrals only.

  • Six families had four or more reports to CFSA within five years of the child fatality. Nine families had two or more reports.
  • Eight families had at least one CPS investigation; of these families, one had a total of 10 investigations, another had seven investigations and two had five investigations.
  • All of these investigated families had at least one substantiated allegation of abuse or neglect. Most substantiations were for neglect; the neglect categories with the most substantiations were inadequate supervision and caregiver incapacity. There were two substantiations for physical abuse and two for “mental abuse.”
  • Of the eight families that had a CPS investigation, Family Assessment, or case closed within five years of the fatality, the time between investigation or case closure and the fatality ranged from four to 13 months.
Source: CFSA, Child Fatalities: Statistics, Observations, and Recommendations, 2019, page 14. The frequency of CFSA involvement refers to the number of hotline reports received.

Four of the 13 decedents’ families (31 percent) were involved with CFSA at the time of the child’s death. All of these families had open Permanency (foster care) cases. According to additional information provided by the agency, one of these children, a three-year-old, was in foster care with a relative. Her death was classified as an abuse homicide due to blunt force injuries, but it was not known if the injuries were caused by the relative or another adult in the home. Another decedent, a 17-year-old male, had run away from foster care and been missing for 17 days when he was shot to death. The other two decedents were living at home at the time of their deaths: one was an accidental death (asphyxia due to unsafe sleep) and the other decedent’s manner of death was undetermined. According to additional information provided by the agency, in both of these cases the non-custodial parent lived in a different household and had an open permanency case for the decedent’s half-sibling.

CFSA’s Recommendations

CFSA’s Internal Child Fatality Review Committee (ICFR) makes recommendations based on the information it reviews; these recommendations are approved by the Agency Director. There were surprisingly few recommendations based on 2019’s child fatalities. One of them calls for the agency to “ensure that practitioners identify and evaluate all adults living (or potentially living) in the same home as a child in foster care.” CFSA’s Communications Director told Child Welfare Monitor DC that a three-year-old decedent in kinship care died of blunt force trauma that may have been inflicted by an adult that was living in the home. Based on the recommendation, we can assume that adult was not evaluated as part of the foster care licensing process. During my tenure as a social worker in foster care, foster parents (including kin caregivers) not informing their licensing agencies of adults living in the home was a common concern. Often this information is purposely kept from social workers because the adult (often a boyfriend) has a criminal or child abuse record that would prevent the home from being licensed. To address this problem, CFSA plans to have supervisors “continue to work with social workers to identify adults who live in or spend significant time in the home and ensure all adults are evaluated.”

Analysis

This report raises many issues and concerns. These include the exclusion of 20 cases from years prior to 2019, the many children who died of causes that might have been prevented by CFSA, the deaths of children in families with long histories of CFSA involvement, the large size of many decedents’ families, and the possible role of an uncleared adults in the home in a child fatality.

Scope and Coverage of Report: While the ICFR Committee reviewed 33 fatalities during 2019, the report covers only those 13 fatalities that actually occurred in 2019; all of the other 20 occurred in prior years, mostly 2017 and 2018. Unless CFSA returns to its earlier practice of including all fatalities reviewed in a calendar year in that year’s report, these 20 fatalities will never be covered in a future report. This is the first year the ICFR left out all deaths that did not occur in the same year as they were reviewed. Like the citywide Child Fatality Review Committee, until this year the ICFR reported on all of the fatalities it reviewed in a calendar year–not just the ones that occurred in the same year they were reviewed. Leaving out more than half of the fatalities of children known to CFSA in its annual fatality report every year deprives the public, policymakers and stakeholders of crucial information that, if acted upon, could help prevent fatalities and harm to children in the future.

Lack of Case Detail: The lack of detail on the individual cases is a major problem in making sense out of the information provided in this report. Statistical data on such a small number of cases is of limited utility, but knowing the history of CFSA involvement in each case would enable readers to pinpoint the opportunities that may have been missed to prevent the fatality and lessons for the future. The public should know such details, as long as personal information redacted. Some states, like Texas, Florida, and Washington are required to post fatality reviews for children who died of abuse or neglect following involvement with the child welfare agency, as described by Child Welfare Monitor. Detailed fatality case studies on child deaths with agency involvement (without identifying information) are provided in other jurisdictions by independent agencies like the Office of the Child Advocate in Rhode Island and Connecticut and the Inspector General for the child welfare agency. Legislation to establish an independent Ombudsperson for CFSA was introduced in 2019 by Councilmember Brianne Nadeau. Such fatality reports were not included in her original legislation, which was never put to a vote, but could be added to the next version.

Cause of death and preventability: The cause and manner of death were known in 12 of the 13 cases and were distributed evenly between four categories–natural causes, accidents, abuse homicides, and non-abuse homicides. The deaths from natural causes were very likely not preventable by CFSA action. Deaths in the other three categories, however, could possibly been prevented if CFSA had responded differently to these families when they came to the agency’s attention. Clearly the fatalities from abuse or neglect raise the question of whether CFSA terminated its involvement without ensuring that the maltreatment that led to the initial allegation had ended. Accidental deaths can reflect neglect. For example, all of the accidental deaths in this report reflected unsafe sleep practices..

Preventability of non-abuse homicides: We don’t know the details on the tragic deaths of an 11-year-old, a 16-year-old and a 20-year-old of non-abuse homicide. Was the youngest victim (most likely an innocent bystander and possibly the case that appeared in media reports in June 2019) exposed to violence because of the lifestyles of the adults who were caring for him? Were the two older youth themselves involved in violence and criminal activities, as is the case for many young victims of violence? Three of the families were involved with the Department of Youth Rehabilitation Services (DYRS), suggesting that one child (perhaps not the decedent) in those families was involved in illegal activities. I spent five years working as a social worker in foster care and almost four years serving on the citywide Child Fatality Review Committee. In this work I have seen numerous examples of young people who became involved in crime and violence after growing up in families that were repeatedly involved in child welfare due to drug activity, domestic violence, mental illness, and abusive or neglectful parenting. Cases were opened and closed, and children were in and out of foster care, but none of these interventions resulted in any substantial change in parental behavior. Perhaps some of these tragic deaths could have been prevented if better, more intensive and long-lasting services had been provided to the parents, or if the children had been removed from these homes after their parents failed to take advantage of offered services.

Families with Repeated CFSA Involvement: It is clear from the extensive history of some of these families with CFSA that the agency is failing to identify some children who are in danger in their homes. Some investigations may fail to identify the family’s most severe problems; some cases may be opened for foster care or in-home services but may close before the parents succeed in changing their behaviors. CFSA requires a “4+ staffing” for all families that have four or more allegations with the last report occurring within the past 12 months. There was concern in previous years that families with child fatalities had more than four allegations but there was no documentation of a 4+ staffing. As a result, ICFR in 2018 recommended that the agency “make 4+ staffings more consistent,” a recommendation that was reported as “complete” in this year’s report. CFSA reports that five of the families with a child fatality in 2019 were eligible for a 4+ staffing. Of these families, four were documented as receiving such a staffing, but there was no explanatory documentation for the family that did not receive one. If the agency is indeed more consistently holding these meetings, it may be time to evaluate their effectiveness.

Unknown adults in a kinship home: Information provided by CFSA indicates that one of the abuse homicides was perpetrated in a kinship home and that it is not clear whether the perpetrator was the relative or another adult in the home. Evidence suggests that many abuse homicides are perpetrated by other adults living in the home, particularly nonparent partners, as described in Within Our Reach, the report of the Commission to Eliminate Child Abuse and Neglect Fatalities.

Large families: There is considerable evidence that the deceased children tended to come from larger families. Not only did 70 percent of the decedents have three or more siblings but more than half of the decedents had four or more siblings. The average number of children in a family is only 1.9 in the United States. Large numbers as well as close spacing of children are correlated with more abuse and neglect. Many of these mothers started having children as teenagers. Often, the medical providers used by low-income women lack access to the more modern, effective modes of contraception such as Long Acting Reversible Contraceptives (LARC’s) at all, or require a second visit to obtain these methods.

Recommendations

  1. Cover all fatalities reviewed: CFSA should return to its previous practice of covering all deaths of children known to CFSA within five years–not just those that took place in the year of review. This would probably at least double the number of cases included, providing a much larger basis for making conclusions.
  2. Provide detailed case studies by a neutral party: The public needs to have access to a detailed case study of each fatality in a family with which CFSA had recent involvement. Such a case study would include a chronology of agency involvement and a description of touchpoints where the agency could have done something different and perhaps averted the death. This is particularly important for legislators, who might want to take action to avert future deaths, and for members of the media, who are often the ones that make the public aware of gaping holes in our child safety net. Ideally, such an analysis would be performed by a neutral party, such as the child welfare ombudsman’s office that was proposed last year.
  3. Pay attention to those with repeated CFSA reports: CFSA should assess the nature of the 4+ staffings to determine whether they are having any impact on families with multiple allegations, whether the current guidance for such meetings needs to be changed, and whether other measures should be implemented to ensure that families with repeated allegations get more attention.
  4. Evaluate all adults in the home: The IFRC suggested that the agency “ensure that practitioners identify and evaluate all adults living (or potentially living) in the same home as a child in foster care.” To implement this recommendation, the report states that CFSA plans to have supervisors “continue to work with social workers to identify adults who live in or spend significant time in the home and ensure all adults are evaluated.” More specific guidance may be needed for supervisors and workers as to how to identify such adults.
  5. Increase access to effective birth control methods: The large size of many decedents’ families highlights the need for policies to increase access to modern, effective and long-acting birth control options for all women in the District. Some of the saddest moments in my life as a foster care social worker came from hearing that a mother struggling to get her existing children back from foster care was pregnant again. Clearly expanding access to family planning is in the bailiwick of the Department of Health (DOH) rather than CFSA. However, even in the absence of DOH initiatives, CFSA could collaborate with DOH to ensure that the parents involved in cases have access to effective contraception as soon as their cases are opened and are educated about the deleterious effects of close child spacing and large families, and that family planning is included in case plans.

Studying fatalities among children known to a child welfare agency is an important way to find out how well an agency does its job of protecting children and to suggest changes to protect children better in the  future. CFSA’s review of a limited number of child fatalities (probably less than half) among children known to CFSA in FY 2019 suggest that the agency could have done more to identify and protect some children in danger. And for every dead child, several more may be suffering from abuse and neglect that will poison their future. Leaving out over half of the children whose deaths were reviewed in 2019 just because they died in previous years is an unnecessary loss of information that could be crucial in saving lives in the future. And without a detailed study of each case, it is impossible for legislators and members of the public to evaluate whether CFSA did all that it could to prevent these deaths and protect the many other children in these homes.

This post was modified on October 15, 2020 to incorporate new information provided by CFSA on the families of decedents who had open permanency cases as well as to modify a statement regarding the scope and coverage of the report.