Analysis: Child Death Review Improvements Could Save Lives

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CIRT 2The death of a neglected or abused child is the ultimate sign that something has gone tragically wrong – not just within a family, but often within the child protection system itself. Realizing that many child maltreatment fatalities can be prevented, the state passed sweeping child welfare reforms over the past couple of years.

The goal was to improve the quality of the child protection workforce, and to increase the transparency and expert review of the child protection system. Ideally, all would learn from errors made.  Ideally, there would be increased accountability. Ideally, changes would be made rapidly to save children’s lives.

Implementation of the law has yet to reach those lofty standards, an analysis by The Children’s Campaign shows  ̶  especially in the area of Critical Incident Rapid Response Team (CIRRT) reporting, as well as the posting of CIRRT reports and data on the Florida Child Fatality Prevention Website.

More CIRRT Reviews Needed

So far in 2015, the number of Florida child deaths is on track to be as many as last year. Yet, only 33* child deaths have received a CIRRT review, which is a small fraction (roughly 13%) of child maltreatment deaths. By initiating CIRRT reviews only for child deaths involving verified abuse and neglect within 12 months, critical data is being overlooked that could shed light on why reports of abuse and neglect are not being verified. Child maltreatment deaths where there has been prior DCF involvement with the child appear to be on the upswing since 2013, while deaths involving verified abuse and neglect seem to be declining.  Could more lives be saved by looking beyond the tip of the iceberg?

Although the Department of Children and Families Secretary has statutory discretion to direct CIRRT investigations for more child deaths other than the narrow statutory criteria, it has not been exercised often.  For instance, there were several requests from child advocates and others for a CIRRT investigation following the tragic death of Jenica Randazzo who was reportedly beaten to death with a tire iron after several red flags were missed.  Why was this not done?  No explanation has been given.  To date, no CIRRT review has been assigned to review Jenica’s death or the 173 other child deaths involving families with prior DCF contact.  In fact, the state has little expert review of these fatalities, which account for about 75% of child deaths.

Time Lapse of Posting Reports to Website

Just as troubling is the lapse of time between the completion of a CIRRT report and its posting to the state’s child fatality prevention website.  There are very specific timeframes outlined in statute regarding how quickly the CIRRT investigation must begin following the report of the death to DCF (within two business days).  Also specified is the timeframe (within 30 days) that the preliminary CIRRT report must be delivered to the DCF Secretary following the start of the investigation. However, there is no specific timeframe prescribed for posting CIRRT reports to the child fatality website.iStock_000008851542_Large

The result? Only one completed CIRRT report has posted to the website within 30 days following the start of the investigation. Only 60% of the CIRRT reports have been posted to the website at all. Roughly 80% of the CIRRT reports that are more than 106 days past the date of the fatality remain unposted. This time lapse makes it difficult for professionals outside of DCF to review the data in a timely fashion to weigh in on proposed improvements and solutions.

When questioned, DCF Press Secretary Michelle Glady has stated to both The Children’s Campaign and news media that reviews listed on the child fatality website as “CIRRT Complete/Investigation Pending” are not posted because the criminal death investigation is still pending.  We question this policy and its impact on creating an unnecessary and unwarranted delay.  It would seem that public disclosure of information as it relates to the child protection response (or lack thereof) in a specific case would not compromise the investigation by law enforcement.  Their investigations can take months or even years.  The purpose of CIRRT is to review and disclose actions taken and to address flaws that may have led to these children’s deaths.  Sticking to that mission and not hampering it by actions being taken by other parties could better protect children still living in high risk situations.

System Flaws Remain

A trend analysis of completed CIRRT reports conducted by The Children’s Campaign reveals several “process-related” issues remain throughout the child welfare system. A majority of CIRRT reports cite staffing shortages and lack of training as contributing factors to the deadly outcome. In about half of the reports, critical case file information was not used when making safety and services decisions.  Other issues that appear in multiple cases include failing to reconcile discrepancies noticed in the case file, not reading critical reports, lack of services and transportation, and missing information in case files.

Because these errors appear repeatedly throughout the CIRRT reports, The Children’s Campaign believes they speak to larger, systemic flaws and technology gaps rather than idiosyncratic human error.

Substance Use is the Underlying Cause of Many Deaths

iStock_000002574372_LargeThe cause of death presented on the state’s child fatality prevention website can present a misleading picture to casual observers who don’t dig deeper into the actual death investigation reports. For example, there is nothing “natural” about a mother testing positive for cocaine at the birth of her baby, especially one who died five days after being delivered at only 22-weeks gestation.  Yet, the child’s death is listed as “natural causes”.

Medical personnel were unable to conclude that substance use contributed to the infant’s death because she was unable to be screened due to lack of urine. However, there is a strong link between cocaine use and premature births. Sadly, there were seven reports in the prior two years involving concerns for other children in the home and parental substance abuse. The last report prior to the baby’s death had resulted in the removal of a 2-year-old who was found wandering around a park unsupervised while both parents were said to be passed out drunk.

In addition, listing the cause of the 2015 deaths of a 16-month-old and a 25-month-old as drowning on the child fatality website may be technically accurate. However, given the family’s extensive history with the child welfare system involving allegations of substance abuse, operating a meth lab and inadequate supervision, the true cause of death seems to be far different from mere accidental drowning. The CIRRT report reveals that prior investigations into this family uncovered they routinely left the sliding glass door open to allow pets to go in and out of the home – despite being counseled not to do so.

The Children’s Campaign CIRRT Report analysis revealed that substance use by caregivers occurred in 75% of cases involving children who died from unsafe sleep, 66% of the children who drowned and 60% of children who died from “natural causes” (the majority of which had mothers testing positive for substance use).

These underlying “root causes” and contributing factors are not presented anywhere on the CIRRT data section on the child fatality prevention website. Can policymakers and advocates truly participate in proposing solutions that address all root causes of child deaths when they are not fully acknowledged and publicly released?

On the Positive Side

The good news is Florida ranks in the top 20% among states regarding the transparency of child welfare system.  In a 2014 State Secrecy and Child Deaths Report in the U.S. by the Children’s Advocacy Institute, Florida earned a solid B+ rating regarding state policy and practices surrounding public disclosure of fatalities resulting from child abuse or neglect.

Continued examination of child fatalities due to abuse and neglect by teams both inside and outside DCF offer more opportunities to identify ways to strengthen child protection efforts and to prevent future harm.

For more information about CIRRT and The Children’s Campaign’s trend analysis of completed CIRRT reports, visit the Take Action Center today.


*All CIRRT data in this article is as of 11/13/15.


This Top Story brought to you by Karen Bonsignori, Amanda Ostrander, and Roy Miller

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CIRRT analysis provided by Amanda Ostrander, Melissa Becker and Nicki Harrison
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Analysis: Child Death Review Improvements Could Save Lives