Until recently, I was one of three “community representatives” on the District of Columbia’s Child Fatality Review Committee. Community representatives are the only members who are not paid to sit on this panel; the rest are agency representatives who sit on it as part of their jobs. My service on the panel was an important aspect of my advocacy for abused and neglected children in the District. But this work ended abruptly for me in March of this year when I was told that my service was over. As described below, I have some ideas about why the panel decided to dismiss perhaps its most engaged, passionate and productive member.
On March 2, 2023 I got a call from the Director of the Mayor’s Office of Talent and Appointments (MOTA). He said he was calling about my position on the District’s Child Fatality Review Committee (CFRC). I told him I had already received a call several weeks earlier from a MOTA staffer telling me that she was working on my reappointment, which should have happened earlier but was backlogged due to the pandemic. She asked me to submit an updated resume and told me she would be back in touch shortly to help me prepare for my DC Council confirmation hearing. But on March 2, the Director told me there had been a mistake. I was not being reappointed to the committee, and since my term had already expired, I was now off the panel.
When I asked why I was not being reappointed, I was told that it was time to give other people a chance to serve. This explanation made no sense. I was one of only three “community members” on the panel, out of eight authorized by DC Code. In her 2017 report, the DC Auditor noted the many vacant seats for community members and the importance of these community representatives, who are not tied to a specific agency. In her remarks preceding the 2017 report, CFRC Co-Chair Cynthia Wright wrote that “the addition of new community members [of which I was one] who provide a fresh perspective to our work …. has increased the vitality of the CFRC.” I doubt that there are five people lined up waiting to be appointed, or even one person ready to replace me. It’s not surprising that there is no long line of community members who want to volunteer two to four hours of their time each month in meetings about children who die, not to mention reading the sad case histories before the meetings. It was clear that my expulsion was not intended “to make room for somebody else.”
My de facto expulsion certainly did not stem from a lack of commitment or shoddy performance. I attended all 13 meetings of the Child Fatality Review Team in FY 2022 and the first quarter of FY 2023. According to the government’s responses to the oversight questions posed by the Committee on the Judiciary and Public Safety, the two other community members attended nine and seven out of 13 meetings respectively. I read every case study in advance of the meeting, and came prepared with questions and comments. Based on the questions asked at the meetings, it was clear that most members never read the case histories (sometimes as long as 20 single-spaced pages) and instead relied on the quick presentations given by Committee staff. In addition, I was a main source of new ideas on the panel; indeed, the two most recent presentations before the committee before my exit stemmed from my suggestions.1 So there must be another reason I was not reappointed. And I think I know what it is, but let me first say something about the Committee and why I joined it.
As described on the website of the Office of the Chief Medical Examiner (OCME), under which the CFRC is located, the goal of the CFRC is to “reduce the number of preventable child fatalities in the District of Columbia through identifying, evaluating, and improving programs and systems, which are responsible for protecting and serving children, and their families.” Based on the information it reviews about the histories of children who died, the CFRC makes findings and recommendations to prevent such deaths in the future. The CFRC is comprised of two teams, the Infant Mortality Review Team (IMRT), which reviews deaths of District infants from birth through twelve months, and the Child Fatality Review Team (CFRT), which reviews the deaths of children aged one to 18 years old as well as youths aged 18 through 21 who were known to the child welfare system within four years of their deaths or to the juvenile justice system within two years of their deaths.2 Their are child fatality review teams in all 50 states and some tribal nations as well.
I joined the CFRC because of my concern about children who are abused or neglected and my belief that CFRC had the potential to have a broader impact beyond preventing fatalities because the conditions that lead to child deaths also cause harm to many more children who do not die. The DC Auditor reported hearing this from several individuals who likened the fatality cases that are examined to a “canary in a coal mine.” I had a particular interest in monitoring the work of the Child and Family Services Agency (CFSA), which is charged with protecting maltreated children in the District. When I joined CFRC, I had recently left my job as a social worker at a private agency that provided foster care as part of the child welfare system led by CFSA. In that capacity, I had heard children’s lawyers express their fear that due to the recent sharp drop in removals of children from theirt homes into foster care, many were being left in dangerous situations that might eventually result in deaths or irreversible emotional or physical damage.
And indeed, upon joining CFRC, I found a number of reasons for concern about CFSA’s effectiveness in protecting children. It was astounding to learn how many children died after having some contact with CFSA. According to CFRC’s annual reports, 69 percent of families of decedents reviewed by CFRT in 2019 had prior CFSA involvement; that figure could not be calculated for IMRT reviews. Of the cases reviewed by the CFRC3 in 2020, 15 out of 18 (or 83 percent) of the decedents’ families had prior CFSA involvement. Reading the CFSA histories of these families often revealed as many as 20 reports to the hotline over the years. Many of these reports were not even accepted for investigation. Those that were investigated were often not “substantiated” or verified by the investigators, which is required for opening a case, despite what seemed like ample evidence of abuse or neglect cited in the case summaries. Even when a report was substantiated and a case was opened for in-home services, more calls often came in about the same families and investigators continued to find dangerous conditions and parenting practices. Even after the cases closed, the reports would continue to arrive, suggesting that nothing had changed as a result of CFSA’s intervention. And even when children were removed to foster care, they were often returned home with no evidence of improved parenting or conditions, and the reports continued to come in.
But when I expressed my concerns about CFSA’s response to frequently reported families and suggest that a finding or recommendation might be in order, I was repeatedly accused of “picking on” CFSA. It is as though CFSA was a child needing protection from bullying rather than an agency responsible for protecting children. Perhaps I shouldn’t be surprised. In its July 2017 report on CFRC, the DC Auditor reported this exact concern — that several panel members believed “defensive or territorial behavior remains an impediment to productive deliberations.”
It was perhaps during my second term at the CFRC, starting in 2020, that another set of issues arose that also put me outside the mainstream of CFRC members. The District was already at the forefront of a national movement to drastically reform what was described as a racist child welfare system by reducing foster care placements and government intervention in the lives of families. The murder of George Floyd and calls to abolish the police intensified this movement, with some even calling for the abolition of child welfare agencies, which were labeled as a “family policing system.” An effect of this type of thinking was an unwillingness to suggest that parents were unfit, no matter how abusive or neglectful they may have been, or to suggest that CFSA should have intervened more aggressively to protect children who later died. While my concern was for the safety of children, other members of the committee were more interested in demonstrating their opposition to governmental interference in the lives of families, regardless of the cost to children’s lives or safety.
When I joined the panel in 2017, there was more tolerance for diverse viewpoints and more concern for the needs of vulnerable children, regardless of race. There were frequent discussions about how to work with the parents who were repeatedly reported to CFSA but did not ever seem to change. Such families are well-known in the child welfare literature as “chronically neglectful,” “chronically maltreating” or “frequently reported” families. Many of these parents had problems with substance abuse, mental illness, domestic violence, or some combination of these three factors that impaired their ability to parent. They had been offered numerous services to help address these issues, which they either declined, dropped out of or completeded without any apparent benefit. Discussions of these families often led to suggestions that the agency make more use of a tool called “community papering,” which means filing a petition for court intervention to compel parental participation in services when a child is not being removed from the home. This resulted in a recommendation in the 2017 report that CFSA should use this tool more consistently for families that need some pressure to participate in services. In the same report, the panel also recommended that CFSA strengthen its policy and practice to “ensure families with multiple referrals to Child Protective Services receive an intensive historical review.” After 2017, there were no more recommendations for strengthening CFSA interventions with frequently reported families.
The changing ideological climate manifested itself in other ways. Serving on the CFRC, I soon realized that a striking number of child fatalities happen in extremely large families, with six, seven or as many as 12 children. Perhaps it is not so surprising. It’s hard to imagine safely caring for that number of children, especially if they are closely spaced. There was a time when this topic could be discussed, especially on the IMRT, whose members were concerned with protecting vulnerable infants. In the 2016 report, two paragraphs described discussion by the IMRT of “the concept of developing a public service media and marketing campaign focused on the health and economic benefits of family planning for all age ranges.” Clearly there was not enough support for this idea to result in a recommendation, but the discussion was robust enough to warrant inclusion in the report. Even in my earlier years on the Committee, this issue was occasionally raised by public health professionals. But it was no longer apparently an acceptable topic for discussion by the time my service ended in 2022.
The changing ideological climate also seemed to affect the CFRC’s willingness to address substance abuse. Parental use of alcohol, marijuana or illegal substances is a common factor cited in the cases reviewed by the panel. That includes the case of Trinity Jabore, who was born with marijuana in her system and later found dead at only seven weeks old, having suffered starvation, thirteen fractured ribs, and severe diaper rash. As the prosecutor of her parents put it, “They deliberately chose not to feed or take care of their infant and to instead smoke marijuana, PCP, get high and take selfies all day.” In 2018, the IMRT formed a subcommittee to look at the impact of marijuana usage on families in the District, in light of concerns raised by the legalization of cannabis use. In the 2019 report, the IMRT expressed concern about the role of marijuana and illicit substances in inducing a deep sleep from which parents did not rouse even as their dying babies fought for breath. But in the 2020 Annual Report, parental substance use was mentioned only in two tables and the text briefly summarizing them.
In the past, CFRC had recommended data sharing between agencies to improve coordination of services for the most troubled families, who are often involved with multiple agencies. In its 2016 report, reflecting the period just before I joined the panel, the CFRC recommended that the District “should allocate funding for the implementation and utilization of DC Cross Connect throughout the human services and public services cluster agencies” in order to better meet the needs of vulnerable children and families. (The recommendation was directed to the Department of Human Services (DHS), which did not have jurisdiction over the other agencies included in the recommendation, and DHS did not respond to that part of the recommendation.) Cross-Connect is an effort to integrate care between DHS, the Department of Behavioral Health, and CFSA, incuding the sharing of data. In 2022, I became aware that a similar proposal for a citywide database to track information on anyone served by DC government agencies is a key element of the Gun Violence Reduction Strategic Plan prepared for the District by the National Institute for Criminal Justice Reform, and I suggested that we might consider such a recommendation. My suggestion resulted in a presentation by the CJCC but not a new recommendation for sharing data between agencies in the District. This new ideological climate, where there is great suspicion that data sharing can be used against marginalized populations, rather than to protect their most vulnerable members, was not fertile soil for such a recommendation.
It is unfortunate that I cannot relate specific details behind the generalities that I have reported here, except those taken from published annual reports. Strict rules around the confidentiality of meetings and information shared govern the operations of CFRC. Before every meeting, members sign a confidentiality agreement promising not to disclose any information discussed during the meeting. Those rules are clearly excessive. The panel is given case histories with no names provided. These case studies can and should be available to the public (with the redaction of any information that could give away the identity of the families.) The public deserves to know that the funds it spends on child protection often fails to protection children. Hiding this information merely protects the agencies involved. That’s why I’m hoping that the DC Council will pass legislation allowing the release of the summaries provided to CFRC (with redaction of any information that would clearly give away the identity of the decedents and their families.)
In his preface to the CFRC’s 2018 report, Chief Medical Examiner Roger Mitchell stated that “the CFRC is moving toward being a leading voice in the prevention of child fatalities in the District of Columbia.” But until committee members are willing to put the needs of children first, CFRC will never be such a leading voice in preventing child fatalities in the District. Now that I am off the CFRC, I hope that other members will be courageous enough to stand up for the rights of children to be safe and well cared for, even at the risk of becoming a gadfly–which was clearly the reason for my removal.
Notes
- These presentations focused on: (a) Criminal Justice Coordination Committee on DC’s Gun Violence Prevention Plan and its work to implement it; and (b) the US Attorney’s ATTEND program to reduce school truancy.
- There was no on-boarding or training when I entered the pane, so it took me at least a year to realize that I was eligible to join the IMRT as well as the CFRT. Once I understood that CFRC members are eligible to participate on both teams, I began attending the IMRT meetings as well.
- This includes only those cases reviewed in full by the IMRT; this information was not available for those that were included only as part of a statistical review, which is used as a way of studying the deaths of most infants who died of natural causes. Many IMR cases are reviewed statistically not individually; for example 14 out of the 51 cases reviewed in 2019, (the last normal year before Covid) were reviewed statistically. In 2020, during which the committee missed six months of case reviews, 29 of the 47 cases reviewed were statistical reviews of infant natural deaths.
Child Welfare Monitor DC 