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

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