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,; 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,

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,; 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,; 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,

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.”


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.


  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.