HomeMy WebLinkAboutMINUTES - 01162007 - D.4 v
TO: BOARD OF SUPERVISORS Contra
���• l -- - -•°�
FROM: Joe Valentine o: iuyh Costa
Employment and Human Services Director .;
County
DATE: January 16, 2007
SUBJECT: OCTOBER 27, 2006 CHILD FATALITY REFERRAL
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECOMMENDATION:
CONSIDER accepting a preliminary report from the Employment and Human Services Director on the
October 27, 2006 child fatality referral.
FISCAL IMPACT:
None
BACKGROUND:
Employment and Human Services filed a report on October 31, 2006 with the State regarding a child
fatality that occurred on October 27, 2006 that may have been due to child abuse or neglect. There had
been prior Child Protective Services referrals, but the last referral received had been closed for over eight
months prior to the time of the fatality.
The County Child Welfare staff were stunned and saddened by this horrific tragedy. As soon as they were
advised of the death, they began an immediate internal review of the procedures that were followed in prior
involvements with this family. This report will summarize the results of this internal review and outline the
steps they will be taking to reduce the possibility of such a tragedy occurring again.
CONTINUED ON ATTACHMENT: _YES SIGNA RE:
v RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S): // `
ACTION OF BO D N 4(G O rl APPROVE AS RECOMMENDED OTHER
U —1 ftk-pw � G ��
VOTE OF SUPERVISORS
I HEREBY CERTIFY THAT THIS IS A TRUE
UNANIMOUS (ABSENTJ�l7f1 / — ) AND CORRECT COPY OF AN ACTION TAKEN
AND ENTERED ON THE MINUTES OF THE BOARD
AYES: NOES: OF SUPERVISORS THE DATE SHOWN.
ABSENT: ABSTAIN:
ATTESTED
JOHN CULLEN,WK OF YHE BOARD OF
SUPERVISORS ANO COUNTY ADMINISTRATOR
Contact Person:
CC:
BY: �' �� DEPUTY
ADDENDUM TO DA.
JANUARY 16, 2007 (CHILD FATALITY REPORT)
On this day the Board of Supervisors accepted a report from the Employment and Human
Services Department Director on the October 27, 2006 Richmond child fatality.
Joe Valentine, Employment and Human Services Director and Ms. Valerie Earley,
Director, EHSD Child Welfare,presented preliminary findings and policy changes in
response to the October 27, 2006 death of an 8-year-old. Mr. Valentine told the Board
EHSD would strengthen their procedures to lessen the possibility of such a tragedy
occurring again. He stressed Child Protective Services can only be as effective as the
information that is available to them. He also told the Board of Supervisors that in
discussing the details of the case he is restricted to information contained in the state
report. He said, "our basic finding in this case is that all of our procedures were
followed. However,that's not satisfactory to us". Mr. Valentine noted Family Court had
been involved with this family for the past couple years and results from any independent
psychological evaluations or assessments that had been ordered were not forwarded to
Child Protective Services, adding that the Court is not legally required to share that
information.
Supervisor Uilkema asked if preschool, head start or childcare institutions are included in
the scope when situations are unidentifiable.
Mr. Valentine responded all teaching staff is provided training on how to be alert to
potential risks and how to make referrals. He said EHSD gets that information out to
child abuse prevention services, community outreach childcare centers and preschools.
Supervisor Uilkema asked staff who might fit the profiles that could have been excluded
and should be included on the remedial list.
Ms. Earley said none is excluded,but the problem lies when a child is home schooled.
Supervisor Glover said he finds it very disturbing in this particular instance and given the
death of a 2-year-old girl on December 13, 2006 after she ingested baking soda at her
Pittsburg foster home, the measures outlined for steps to take to reduce the possibility of
such a tragedy occurring again were not enough. He said there are gaps within the County
regarding individuals when red flags aren't raised to warrant a more thorough
investigation. He said he was particularly concerned that a County health clinic doctor
who saw the girl a week before her death noted her low weight but did not report it,
according to health officials. Supervisor Glover said he appreciates the report but said he
is looking for something more inclusive. He pointed out that Health Services Department
should be involved in the discussion. He spoke of Social Services Departments linking
with the other departments to do a thorough review of the process. He said he would like
to look at a process inclusive of the County's EHSD system to make sure the County
would investigate when there are red flags for issues within the County's Child Welfare
Addendum to D.4
Page—2-of 4
January 16, 2007
system. "This is really unacceptable that we have a system that fails and we lost the life
of two individuals in such a short period," he said.
Supervisor Gioia said he observed 1)the flow of information among law enforcement
agencies to Social Services agencies were untimely; and 2)the issue of cumulative
history versus a pattern of looking at each contact in isolation. He stated"cumulative
history"needs to be defined. He asked Ms. Earley when an agreement with law
enforcement agencies to improve information sharing and case coordination would be
completed with the Police Departments.
Ms. Earley said an old agreement exists and she hopes to have a discussion with the
Police Chief first week of February to develop a plan.
Supervisor Gioia asked Ms. Earley when the results of the community child death review
team panel would come in.
Ms. Earley said both the autopsies were released last week and she hoped this matter
would be scheduled for their review next month.
Supervisor Gioia asked Mr. Valentine if there was a statewide protocol that would
address issues being dealt with in the follow up steps.
Mr. Valentine stated EHSD is going above and beyond with the legal mandates.
Supervisor Gioia asked Mr. Valentine what his beliefs are about particular inherent biases
in social workers that may affect children being placed out of their homes based on their
race.
Mr. Valentine noted a disproportionate number of African-American children are
removed from their homes and placed in foster care throughout the country. He said
EHSD staff have been trained to assess factors from cultural and legal standpoints.
Supervisor Gioia asked Mr. Valentine if there was departmental bias to err on the side of
not removing a child if there is some question about whether to do so or not.
Mr. Valentine responded EHSD's goal is the safety of children.
Supervisor Bonilla said the second action mentioned under Follow Up Actions to
"modify the existing protocol and forms used by the investigating social worker to
expand on their written findings from their investigation. We will ask the social worker
to not only.summarize the results from the current investigation but compare the referral
to any history to identify potential trends in risk factors" is not specific enough. She
Addendum to D.4
Page—3-of 4
January 16, 2007
explained once the second call has been reached for one address or family there should
immediately be a red flag for extra scrutiny. She said when a child says he is hungry—it
is a form of abuse and something should be done beyond a phone call.
Mr. Valentine said because the details of any particular investigation are confidential,
EHSD was unable to provide in this report other collateral calls that were made that led
thein to decide to not send out a social worker. He said EHSD is responsible to conduct a
Child Protection Investigation. He agreed all the recommendations need to be translated
into specific procedures and guidelines for social workers so they know what is expected
of them.
Supervisor Glover suggested protocol for departments to work together to catch these
situations before they become life-threatening or life-ending. Supervisor Glover asked
Mr. Valentine to bring together the various Departments to come up with some of those
protocols, understanding there are confidentiality issues involved.
Chair Piepho said she would like to see a report back to the Board of Supervisors soon
with additional and ongoing efforts that are being reviewed.
Supervisor Gioia suggested referring this matter to the Family and Human Services
Committee for ongoing questioning and monitoring.
Chair Piepho requested Health Services Department to be included for ongoing
involvement.
Supervisor Uilkema requested EHSD contact either Alameda Contra Costa Medical
Association or their Board of Directors to offer some refresher programs for the medical
community to heighten awareness.
Supervisor Gioia discussed the need for better after-hours service, including a system to
let social workers easily access case histories at night. He stressed the importance of
having cumulative history available to the Police Officer in charge.
County Administrator John Cullen said the County may need to adopt something similar
to the zero-tolerance policy on domestic violence, to jump-start community awareness of
child abuse and better coordinate services.
Mr. Valentine noted involving as many different organizations and parent education and
training as possible. He said this requires a community-wide approach.
Supervisor Uilkema suggested today's recommendations could come back through the
Family and Human Services Committee.
Addendum to D.4
Page—4-of 4
January 16, 2007
Supervisor Bonilla said she would like to extend the Board's understanding to the social
workers involved in this matter. She said there should be critical follow up action
because the Board would like to make sure county employees are getting the best
possible care after going through these circumstances.
By a unanimous vote with none absent the Board of Supervisors took the following
action:
ACCEPTED a preliminary report from the Employment and Human Services Director on
the October 27, 2006 child fatality;
DIRECTED this matter be referred to the Family and Human Services Committee for
ongoing questioning and monitoring;
DIRECTED Health Services Department and Alameda Contra Costa Medical
Association to be involved in all discussions related to this matter;
DIRECTED the EHSD Director to meet with various Department Heads to collaborate
and work together through the EHSD System; and
INCLUDED referrals to Family and Human Services Committee
EMPLOYMENT AND HUMAN SERVICES
CONTRA COSTA COUNTY
DATE January 3, 2007
TO Contra Costa County Board of Supervisors
FROM Joe Valentine, Director
SUBJECT Preliminary Report on the October 27, 2006 Child Fatality Referral
Summary:
On October 31, 2006 we filed a report with the State regarding a child fatality that
occurred on October 27 that may have been due to child abuse or neglect (attached).
There had been prior Child Protective Services (CPS) referrals, but the last referral
received had been closed for over eight months prior to the time of the fatality.
Our County Child Welfare staff were stunned and saddened by this horrific tragedy. As
soon as we were advised of the death, we began an immediate internal review of the
procedures that were followed in our prior involvements with this family. This report will
summarize the results of this internal review and outline the steps we will be taking to
reduce the possibility of such a tragedy occurring again. However, any final
conclusions regarding the cause of the child's death will have to wait the final Coroner's
report and the independent review of the fatality by the County's "Child Death Review
Team."
Background:
On October 27, 2006 we received a report from law enforcement regarding the death of
an 8 year old boy due to possible abuse/neglect on the part of the mother. In reviewing
our records, we identified that we had received previous referrals on this family back in
2005 and in January of 2006. Briefly, these were:
✓ March, 2005: Allegations of sexual abuse by an adult male were substantiated, but
the mother was found to be actively trying to protect the child and was cooperating
with the police investigation.
✓ May, 2005: Complaint received alleging that the child was physically abused, but
complainant did not see any physical marks. Complainant also alleged that the child
was digging through garbage for food. The information obtained during the initial
telephone screening did not meet the criteria for a follow-up home-visit investigation.
✓ September, 2005: A report was received stating that back in July of 2005 an officer
had responded to an allegation that the child was playing alone at a McDonald's
restaurant. The officer returned the child home and talked to the mother. The
written report, received two months later, did not indicate that any abuse or neglect
had occurred.
Report to Board of Supervisors on October 27 Child Fatality Case
January 3, 2007
Page 2 of 4
✓ November, 2005: A referral was received alleging that the child had run away due
to a lack of supervision. An in-home investigation was completed by a social worker.
As a part of the investigation, the social worker learned that the mother had
reported the child missing as soon as she discovered he was gone. The
investigation did not result in a finding of neglect.
✓ January, 2006: Allegations were made of physical and emotional abuse by both
mother and father due to an altercation between them. During our investigation the
police were contacted to obtain more information. They had a report on file
indicating that the parents fought during an exchange of the children for a visit. A
social worker conducted an in-person investigation and spoke with the child as part
of the investigation. No evidence of abuse or neglect was found, but the social
worker referred the mother to a community based provider for counseling services.
There was a "transition visit" involving the mother, the social worker, and the
community caseworker on February 22, 2006 and the referral was closed.
Review Process:
• An intensive internal review by the Department was initiated immediately upon being
informed of the death.
• The entire case file was reviewed by senior management.
• Review meetings were held with Children's Services managers and supervisors and
all aspects of our involvement with the family were discussed in detail.
• The Child Welfare Director interviewed all the staff and supervisors associated with
our previous involvement.
• A Child Welfare Director from another county reviewed the entire file, participated in
the review meeting, and gave us recommendations.
• The County Administrator's Office participated in the review.
• The State Department of Social Services conducted an independent review of all of
the information in the full electronic case file to determine if all proper protocols and
state policies were followed.
Findings:
1. All of the applicable department policies and procedures were complied with
regarding the investigation of Child Abuse and Neglect referrals, and all of the legal
mandates were followed.
2. Multiple referrals had been received on this case during the prior year, but there
were no substantiated referrals involving the mother. Each referral was properly
screened and/or investigated, although it is not clear to what extent the cumulative
history of referral allegations were taken into consideration.
3. The last referral on this family had been received eight months prior to the death
and no referrals of any kind had been made to CPS after that.
Report to Board of Supervisors on October 27 Child Fatality Case
January 3, 2007
Page 3 of 4
4. When the January 2006 referral was closed in February, the mother was referred to
a contracted community based provider for counseling services. The Department
contracts for these services when it has not substantiated abuse or neglect but feels
the family could benefit from support services in order to address potential risk
factors. Participating in these services is voluntary for the family.
5. Community based organizations that have a contract with Children and Family
Services to provide services to families are required to provide a feedback report on
whether the families that have been referred to them have followed through and
participated in services. Currently, we only use these individual reports to extract
information for statistical summary reports on all of the families that have been
referred for community services.
6. Family Court had been involved with this family for the past couple of years. The
results from any independent psychological evaluations or assessment that had
been ordered were not forwarded to Child Protective Services. However, the Court
is not legally required to share this information.
Follow Up Actions:
Although our preliminary review concluded that all of the appropriate procedures were
followed in this case, it is difficult for us to accept the death of any child we might have
been involved with. Our commitment to ensuring the safety of children has driven us to
scrutinize all aspects of our existing procedures and our coordination with other
organizations that come into contact with children and families at risk. As a result, of
this review, we are planning on taking the following steps:
1. Modify the existing screening protocol and forms so that the initial phone screener
includes a more detailed history of past referrals on the referral form that is given to
the investigating social worker.
2. Modify the existing protocol and forms used by the investigating social worker to
expand on their written findings from their investigation. We will ask the social
worker to not only summarize the results from the current investigation but compare
the referral to any past history in order to identify potential trends in risk factors.
3. Provide training to staff on how to use the modified protocols so that they are better
able to assess the level of risk a child might be facing from all possible perspectives.
4. Provide adequate and timely "critical incident stress debriefing" to the staff involved
in tragic incidents in order to better help them cope with the emotional impact of
these incidents and better apply lessons learned to future assessments.
Report to Board of Supervisors on October 27 Child Fatality Case
January 3, 2007
Page 4 of 4
5. Modify the requirements for the community based organizations we contract with to
provide services for families so that we are notified within a shorter time frame if a
referred family has not participated in services.
6. For families who have not participated in services, determine whether we should
send a "Community Engagement Specialist" to the home to see if they can provide
any assistance to the family in accessing services. Although Community
Engagement Specialists are different from CPS Social Workers, they are mandated
reporters and could generate a re-referral if the situation warrants it.
7. Build on the existing memorandum of agreements with law enforcement agencies to
improve information sharing and case coordination. Such agreements now exist
with many of the local police departments, and the Richmond and San Pablo Police
Chiefs have agreed to enter into similar agreements. These agreements call for
timely information sharing, a dispute resolution process if an officer has concerns
with our handling of a case, and a process for regular information sharing meetings
between social workers and the officers assigned to investigate child abuse and
neglect complaints.
8. Build on the existing Memorandum of Agreement with Family Court to facilitate the
cross sharing of information in cases in which both CPS and the Family Court are
involved. Accompany this expanded Agreement with enhanced training for both
CPS and Family Court staff to better understand the legal requirements, needs and
services of each program.
Next Steps
1. All of the above improvements can be implemented with no additional funding and
with no changes in laws or county ordinances. The Department has already moved
ahead to begin planning for development of the recommended changes.
2. Once the County's Child Death Review Team receives the Coroner's report and
conducts its independent external review of the case, the Department will cooperate
fully with the review.
There are other improvements in systems, protocols, and training that we'll be
proposing as part of our updated "System Improvement Plan." These improvements
will further strengthen our ability to respond to child safety needs. Updates to the
County's child welfare "System Improvement Plan" are required by the California
"Child Welfare Performance Outcomes and Accountability Act." Our 2007 Plan will
be submitted to the Board of Supervisors and to the State sometime in the next
couple of months.
JV:ah
Attachment
cc: John Cullen, County Administrator
Valerie Earley, Director, Children & Family Services
11/02/2006 02: 39 9166572291 PUBLIC AFFAIRS PAGE 02/04
� P.01i01
OCT-31-2006 17.30 SOCIRL SERVICE DEPT.
CAUrcpNU 05pAFftMEKT OF=01AL SE"C"
STATE OF CAU FOR NA MEALTM MID M�MAN SEANCES��� Ad9ChmaM A
California Department of Social Services
Childrean's Services Operations Bureau
Main Telephone Number. (916)061-9100
Fax Number. {916)6tl"'"
Child Fatality/Near Fatality Questionnaire
Based on Suspected Abuse or Neglect
Name of County Contact:
Telephone Number:(
(Person with knowledge cf incident)
O4(0f 24- 63at1.201117i6ounty' Co Cay
CWS Client Identifier: j`�
Child's Age: 8 Child's Date of Death:
Child's Gender: 7 Male ❑ Female Child's Race/Ethnicity:
Suspected cause of fatatlity/near fatality (injury or condition): Dr
d s d .rl c>
0
Brief Narrative of CWS History for the child and family: (Include # of referrals with dates; # of open
cases; reason(s) for referral(s) with disposition(s); date and description of last county )
Residence of the child at the time of the fatality/near fatality:_
[E'Home of Parent/Legal Guardian
❑ Foster Care/Out-of-Home Care
Cross Reporting Done on this Case (to or from):
Law Enforcement
❑ Community Care Licensing
❑ District Attorney
O Other
Cornments/Other: , d
SOC M29 i7/OC)
TOTAL P.01
11/02/2006 02:39 9166572281 PUBLIC AFFAIRS PAGE 03/04
' P.02ie3
:OCT-31-2005 17:2? SOCIAL SERVICE DEPT.
ealiEarni,Dcpsr¢ncnt of Soelat 5 e+"ius
Sln�of Grlifomu-}lealth end Hnrrma Services Agency Armchmnnt A
Califeraie Depa==nt of Social Serv"Oes
Childrer';s Services Operations Bureau
Brief narrative of CWS history attachment,
1, 0912512002: Allegations of physical abuse to 4 yoby mo's boyfriend
Evaluated Out as no marks or bruises noted by reporting party (Rp)
AllegationsWOMMOMW of sexual abuse to I yo Y step-fa
2, 03!02/2005:
Substantial risk to by fa. Failure to protect by mo.
Investigated and found that Sex�atbbse� nfoundaldl Case closed astmother
againatr Failure to prof y
protecting and cooperating w/Richmond PD. Mo and child referred to
therapy.
3. 0512312005: Allegation of Geral Neglect td, by mom. RP 8t'�
child physically abused by mo but has not witnessed any marks or bruises.
RP states seeing child digging through garbage for food, When asked, child
stated that he was hungry. Evaluated Out.
4. 09106/2005: DOJ report of 07/05 rec'd in screening 09/09/2005 regarding
allegations that child was found playing alone at McDonald's restaurant.
Child stated that he had run away from home because his babysitter had
handcuffed him to the bed while his mo was at work. PD returned child to his
home. Evaluated Out due to PD investigation and time la Pse.
5. 1112312005: Allegation of lack of s Epe-r ssi n D for 4 `m that child ran away
from home and mother failed to con
Investigated and found that mo had appropriately reported as soon as she
woke up to find that NOW was missing. PD and mo checked interior of the
home and did not find the child. Mo bcl�4ygd tb bE�ad,goine.to McDonald's
and in fact he had. Allegations unfounded.
— - __._6;- b1/26�� Last contact with CFS: Allegations of physical and emotional
abuse by mo and fa to Substantial risk by mo to
incident happened on 1/28/06 and mo reported to CFS on 1/29/06. Mo called
CFS to report to ERP after hours SW who followed up with PD. PD stated
that bey had a report on file which states that mo and fa got into a scuffle
when exchanging childt r or a visit-Per.court order, exchanges were
supposed to happen at a neutral setting. Fa did nat have a car seat so mo
transported child to fa's and wanted to see his apartment. Fa refused and
attempted to take the child form mo. Mo reported that the child sustained
some scratches in the scuffle.
Investigated and reported thatwas talked to,in private. He did not
report any concerns in the home to the Social Worker. He also reported that his
1
SOC 926
11/02/2006 02: 39 9166572281 PUBLIC AFFAIRS PAGE 04/04
SDC 1 AL SERU 1 CE DEPT.
Cblifornia Dertmcnt of social Scrviees
Pa
Atnchrr+a�t A
SWLI of Health and Hume'scrAwt A8�' of social SGtviCos
California Depaztmmt
Childsea's services Operratioas Bureau
mo takes good
care of him and tb�e ,=things Y do 1ings together". No abuse or neglect
iential gesponse/Path II services.
noted tc Family connected to Dffercaseworker and CFS social worker
Transition visit cort2pleted w/mo,community
on 2/22106: Case file closed on 2/23/2006 as'unf$lundedD� of General of
physical and emotional abuse. Substantiatedforg
11egleat/Sub6tanti.al Risk.
2
SOC 826