Pilot CWS-R-SAP – v. 1 Current CWS, 11.11. Status of Child Fatalities

 

Pilot Child Welfare System Redesign

Strategic Action Plan

 

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11.11. Status of Child Fatalities

 

The following chart has been created from data in the annual Oregon Child Welfare Data Books for the years 2009 through 2019.

Status of Child Fatalities Chart
Status of Child Fatalities Chart

 

The main purpose of the Child Welfare System is to protect children from being abused or neglected. CPS Caseworkers spend long hours trying to identify children who have been abused or threatened with violence or neglect. Thus, it is particularly disturbing when a child dies at the hands of their family or others, even with the safeguards, in-home safety plans, parent training and education, and other services provided to maintain the family while providing safety for the child(ren).

 

Fatality Assessments

Detailed assessments are conducted following the death of a child, when the cause is homicide – murder. It is disturbing to discover that the deceased child had an earlier report of alleged child abuse that was not able to be fully assessed – most often due to the report being “screened-out” at Screening. However, perhaps even more disturbing is to discover that a child who has received a complete CPS assessment and was remaining at home with an in-home safety plan, was among the dead.

 

Fatalities After Reunited With Family

The above chart illustrates the variety of situations or statuses in which the child was within the Child Welfare System when they were killed. One of the situations is “Fatalities After Reunited with Family” which is represented by the gold bar at the top of each set of bars for a year in the chart. In the interest of maintaining the family, the focus of CPS has been to reduce the number of children taken from the home and placed in foster care, and to return a child who has been in foster care to their home when it appears that the child will be safe at home.

While a child is recovering from their abuse or neglect trauma in foster care, CPS is expected to provide the family with programs and services to ensure that the abusive and/or neglectful behavior is not repeated when the child returns to the home. Although over 50% of children leaving foster care return to their families with no issues, there are some cases where all the training, education, programs, and services allegedly provided to the family were not sufficient and the child is killed by one or more members of their family. This has occurred 3 times from 2009 through 2019, including one child’s death in 2009 and two deaths in 2015.

There is no data on how many children returning to their family following foster care are re-abused or neglected again; we only have data where the abuse and/or neglect has reached the stage of murder. If not already implemented, it is recommended that home visits be conducted immediately following the reintroduction of the child back into the family and weekly thereafter for at least a year until assured that the child is truly “safe at home.”

 

Fatalities in Families Receiving Preservation Services in the Preceding 5 Years

The next status, “Fatalities in Families Receiving Preservation Services in the Preceding 5 Years,” is represented by the brown bar (the second bar in the set of bars for each year). Unfortunately, this situation is all too common an occurrence among the child death statistics. Between 2009 and 2019, 36 children have been killed by a family member during or following the family receiving programs and services to preserve the family and ensure the safety of the child. And, most troubling of all, is that the highest occurrence of these child deaths have been within the last 5 years. Because it may be difficult to grasp the full extent of the issue from the above graph, data from each year is presented below:

  • 2019=5 deaths
  • 2018=7 deaths
  • 2017=7 deaths
  • 2016=6 deaths
  • 2015=6 deaths
  • 2014=2 deaths
  • 2013=1 death
  • 2012=0 deaths
  • 2011=1 death
  • 2010=0 deaths
  • 2009=1 death

 

There should have been a huge warning sign raised in 2015 when the death rate for this status dramatically increased from 2 children to 6 children. The warning is that the programs or services provided to the families do not work in the most extreme cases. 6 more children’s deaths in 2016 should have resulted in immediate changes to the CPS assessments for families where the programs or services do not appear to be working; alternate programs or services or removal of the child into a temporary foster care should have been instituted. It appears that no changes were made as the result of 2 years in a row of 6 children being killed during or after receiving the existing programs and services. Unfortunately, 7 more children were killed in 2017, another 7 children killed in 2018, and 5 more children were murdered in 2019. 19 children (perhaps 25 children) died needlessly because the warning signs were not seen or, if seen, no action was taken.

Even if action was taken in each year from 2016 through 2019, the data shows that none of the actions resulted in stopping the murder of those 19-25 children. It is recommended that a comprehensive study be conducted for the 36 children who died while under CPS family programs and services or shortly following the family programs and services. Determine, for each of the 36 families involved (presuming one child per family), what characteristics of those families are similar and can be used to identified potential other families in a similar state BEFORE another child is killed. It is unconscionable that 5 sequential years of data did not result in any effective changes to the family programs and services. Carefully analyze every year’s statistics, decern patterns and trends, and take action to stop the pattern of abuse or neglect leading to these deaths.

 

Fatalities with Child Abuse/Neglect Referral within One Year

The third status, “Fatalities with Child Abuse/Neglect Referral within One Year,” is represented by the reddish-brown bar (the third bar in the set of bars for each year). Fortunately, this status or situation has only occurred once in the 2009-2019 period. In 2014, 4 children in this status were killed. There have been no further fatalities in this status since 2014, so whatever corrective action was taken at that time appears to have been successful. Well done.

 

Fatalities in DHS Custody

The fourth status, “Fatalities in DHS Custody,” is represented by the dark blue bar (the fourth bar in the set of bars for each year). There were 3 children’s deaths, 1 in 2011 and 2 in 2015, while the child was in DHS custody for the years 2009 through 2019. It is recommended that DHS remain diligent in its protection of children under its care.

 

Fatalities with an Open Assessment

The fifth status, “Fatalities with an Open Assessment,” is represented by the light blue bar (the fifth bar in the set of bars for each year). This is another status or situation in which too many children are killed, although in this case the deaths are more random. Again, due to the difficulty of comprehending the data from the above chart, the child deaths for each year are presented below:

  • 2019=9 deaths
  • 2018=3 deaths
  • 2017=0 deaths
  • 2016=0 deaths
  • 2015=7 deaths
  • 2014=1 death
  • 2013-0 deaths
  • 2012=2 deaths
  • 2011=2 deaths
  • 2010=7 deaths
  • 2009=4 deaths

 

The fact that last year had the highest number of deaths in this status, after 1 year of 3 deaths and 2 years of no deaths, is great cause for concern.

Although the numbers appear random, there is a slight pattern: a couple of years of 0 or 1 deaths, then an increase one year, followed by a spike in the next year, after which is another period of no or few deaths.

Although it is difficult to presume a cause for this significant fluctuation, one possible impact could be the frequency of visitations during the assessment process. For example, when there is a spike in children’s deaths in one year, DHS staff are told to increase their frequency of visitations, which continues for a couple of years. Then overloaded staff start reducing the visitation frequency a little one year, with a slight increase in children’s deaths. However, workloads increase, and visitations decrease the next year, leading to the spike in child murders, which calls for an intensive focus on frequent visitations again.

It is recommended that weekly visitations become the standard every year – even when the data shows no child deaths from that status. No deaths means the weekly visitations are working, so keep it up.

 

Fatalities with an Open Child Welfare Case

The sixth status, “Fatalities with an Open Child Welfare Case,” is represented by the yellow bar (the sixth bar in the set of bars for each year). This is another status with relatively low child deaths. There have been a total of 7 child deaths while there was an open child welfare case for them over the period 2009-2019: 1 death in each of 2011, 2014, 2015, and 2016, and 3 deaths in 2017. Although not as disturbing as some of the other child death statistics, there may be some benefit to determine if there were any similarities in the families of the 3 murdered children in 2017 and/or in specific procedures or practices in place in DHS during that year.

 

Total Fatalities from Child Abuse

Moving to the bottom bar in each set of bars for each year, the bright blue bar represents the “Total Fatalities from Child Abuse” for that year. The data we have reviewed thus far have been within the 6 statuses of conditions in which the murdered child was receiving or had been receiving attention from DHS, trying to reduce or eliminate the child abuse or neglect the child was suffering.

However, the larger numbers, the “hidden abuse” is illustrated only by a number not captured in the annual Child Welfare System Data Books: the number of children killed each year, for which DHS had no assessment.

It is recommended that this statistic be captured each year: “Fatalities with No DHS Action.” In addition, the cause for the “No Action” should be captured: “No child abuse report call received,” “Child abuse report call received but screened-out,” “Child abuse report screened-in, but CPS assessment not completed,” “Child abuse report assessed, but determined ‘unfounded’ by CPS.”

DHS needs to become aware of the children who have died while waiting for help or rescue.

These statistics should be used as training materials to modify procedures and practices that screen-out about 40,000 reports every year or do not create a report from a child abuse call, or are considered “unfounded” because they were unable to talk with the family (or whatever reason).

 

DHS is charged with reducing child abuse, and one way to determine how successful they are at doing their job is to understand how many of the children’s murders may have been avoided if DHS modified procedures, processes, and guidelines to err on the side of screening-in rather than screening-out children for whom someone saw the need to make a child abuse report to DHS.

 

Fatalities Age 5 or Younger

Returning to the chart, there are two of the most disturbing bars left to review. The reddish-orange bar just above the long bright blue bar represents “Fatalities Age 5 or Younger.”

What is most disturbing about this set of data is the “trivial” treatment it receives in EVERY Child Welfare System Data Book from 2009 through 2019. In every book there is a statement that accompanies the latest horrific statistic: For example, from the 2019 Data Book: “There were 17 victims (73.9 percent) that were age 5 and younger, demonstrating the vulnerability of this age group.

 

EVERY Data Book since 2009 carries that same message. Yes, 5-year-old children and younger are “vulnerable” – don’t just say that while the statistics keep climbing year by year. DO SOMETHING to protect those children aged 0-5 about whom there is a child abuse report.

 

It is recommended that EVERY child abuse report involving a child 0-5 be automatically screened-in for assessment – no questions about whether there is sufficient data, just screen-in all child abuse reports for the demographic DHS already knows is “demonstrating the vulnerability of this age group.” Develop special procedures for assessing families in which there is a child 0-5 years old – even if the child is NOT the child for whom the child abuse report was created. Provide mandatory parenting training and education classes for the parents, increase the frequency of visitations to weekly, ensure the child 0-5 years old is seen, photographed, and examined at every visitation. Protect the vulnerable – reduce the number of child deaths in this category.

How bad are the statistics? Here are the numbers from every year from 2009 through 2019 about the children aged 0-5 who were murdered that year and the percentage of all child deaths those 0-5-year-olds represent:

  • 2019=17 of 23 deaths (80.8%)
  • 2018=21 of 26 deaths (80.8%)
  • 2017=17 of 30 deaths (64.4%)
  • 2016=13 of 19 deaths (68.4%)
  • 2015=20 of 27 deaths (74.1%)
  • 2014=11 of 13 deaths (84.6%)
  • 2013=7 of 10 deaths (70%)
  • 2012=12 of 17 deaths (70.6%)
  • 2011=10 of 19 deaths (52.6%)
  • 2010=17 of 22 deaths (77.3%)
  • 2009=11 of 13 deaths (84.6%)

 

Who can look at those statistics and not be moved to DO SOMETHING to stop the murder of those “vulnerable” children? Look at the chart and compare the red-orange bar with the bright blue bar; the red-orange bar represents children 0-5 years old who were murdered before their life truly started. The difference between the end of the red-orange bar and the end of the bright blue bar represents the murders of children ages 6 through 18+.

 

Fatalities Age Younger than 1

As if the previous bar weren’t enough to instill serious modifications to the handling of child abuse reports for children 0-5 years old, the final bar we are reviewing, the gray bar representing “Fatalities Age Younger than 1” should expedite the process because there isn’t much time between birth and one-year-old when a significant number of infant murders occur.

The numbers:

  • 2019=12 of 23 deaths (52.5%)
  • 2018=14 of 26 deaths (53.8%)
  • 2017=10 of 30 deaths (33.3%)
  • 2016=6 of 19 deaths (31.6%)
  • 2015=14 of 27 deaths (51.9%)
  • 2014=5 of 13 deaths (38.5%)
  • 2013=5 of 10 deaths (50%)
  • 2012=5 of 17 deaths (29.4%)
  • 2011=0 of 19 deaths (0%)
  • 2010=8 of 22 deaths (36.4%)
  • 2009=8 of 13 deaths (61.5%)

 

Uncaptured Data

Currently, two major causes of child fatalities are not being counted: child suicides and “accidental” child deaths. Both categories of child fatalities should be included in every assessment of a child’s death.

A young child does not consider suicide unless the child sees no hope in the life they are suffering. Child murderers will cover-up their actions by claiming it was an “accidental” death. Investigate further into previous cases or reports, including reports screened-out, for any indication of prior abuse. For example, if the child “fell down the stairs,” check the home to determine if it actually has stairs.

 

Recommendations:

Action Step 11.11.1: Include data on how many children reunited with their family following foster care are re-abused or neglected again.

 

Action Step 11.11.2: CWS home visitations are conducted immediately following the reunification of the child back into the family following foster care and weekly thereafter, for at least a year, until assured that the child is truly “safe at home.”

 

Action Step 11.11.3: Conduct a comprehensive study of the 36 children who died while under CPS family programs and services or shortly following the family programs and services. Determine, for each of the 36 families involved (presuming one child per family), what characteristics of those families are similar and can be used to identify potential other families in a similar state BEFORE another child is killed. 5 sequential years of data did not result in any effective changes to the family programs and services. Carefully analyze every year’s statistics, discern patterns and trends, and take action to stop the pattern of abuse or neglect leading to these deaths.

 

Action Step 11.11.4: Make weekly visitations become the standard for families with an open assessment – even when the data shows no child deaths from that status. No deaths means the frequent visitations are working, so keep it up.

 

Action Step 11.11.5: A new statistic must be captured each year: “Fatalities with No DHS Action.” In addition, the cause for the “No Action” should be captured: “No child abuse report call received,” “Child abuse report call received but screened-out,” “Child abuse report screened-in, but CPS assessment not completed,” “Child abuse report assessed, but determined ‘unfounded’ by CPS.”

 

DHS needs to become aware of the children who have died while waiting for help or rescue. These statistics should be used as training materials to modify procedures and practices that screen-out about 40,000 reports every year or do not create a report from a child abuse call, or are considered “unfounded” because they were unable to talk with the family (or whatever reason).

 

DHS is charged with reducing child abuse, and one way to determine how successful they are at doing their job is to understand how many of the children’s murders may have been avoided if DHS modified procedures, processes, and guidelines to err on the side of screening-in rather than screening-out children for whom someone saw the need to make a child abuse report to DHS.

 

Action Step 11.11.6: Immediate, short-term implementation: EVERY child abuse report involving a child 0-5 is to be automatically screened-in for assessment – no questions about whether there is sufficient data, just screen-in all child abuse reports for the demographic DHS already knows this is “demonstrating the vulnerability of this age group.” Develop special procedures for assessing families in which there is a child 0-5 years old – even if the child is NOT the child for whom the child abuse report was created. Provide mandatory parenting training and education classes for the parents, increase the frequency of visitations to weekly, ensure the child 0-5 years old is seen, photographed, and examined at every visitation. Protect the vulnerable – reduce the number of child deaths in this category.

 

Action Step 11.11.7: Investigate all child suicides and “accidental” child deaths with the other causes of fatalities. Both categories of child fatalities should be included in every assessment of a child’s death.

 

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To submit questions or comments, please email Jo@Jo-Calk.com. I welcome all input, ideas, and suggestions. Thank you for caring for children.

Blessings,

Jo Calk