Five Child Deaths Were Preventable, According to National Child Welfare Expert
TULSA, OK — A shocking new report by a national child welfare expert has revealed that several children who suffered abuse and neglect in Oklahoma group homes and institutions were never seen by a Department of Human Services (DHS) investigator — while many others waited weeks or even months for a response. Additionally, the state failed to adequately protect nearly 20 percent of potential child victims while investigating claims of abuse and neglect in foster homes, and failed to safeguard 40 percent of children in congregate care.
Furthermore, this new report closely examined the nine children who died due to abuse or neglect between 2007 and 2009 while in state custody, ultimately finding that at least five of those deaths could have been prevented had DHSnot missed opportunities to take additional preventative action.
Today’s independent study (PDF), authored by 40-year child welfare veteran John Goad and released by the national advocacy group Children’s Rights, also found that staff within the agency charged with responding to abuse claims in institution-like settings routinely fail to interview alleged victims’ caseworkers and other key witnesses. In a recent deposition, the head of that agency admitted, “We don’t know who the caseworker is. And, frankly, we don’t care.”
On the heels of a recently released report that revealed one out of eight children in a massive case record review suffered confirmed abuse or neglect in Oklahoma state custody, Goad’s review found that because the state handles abuse allegations in foster and relative homes separately from those in congregate care settings, the rate of maltreatment among children living in group homes, residential treatment centers, and shelters is never publicly reported by the state, according to the new report.
“We can now add the findings of yet another independent child welfare expert to the deafening chorus of voices affirming what we have been saying for three years,” said Children’s Rights Executive Director Marcia Robinson Lowry. “Abused and neglected children are suffering and dying while DHS denies the problems and continues to defend its dysfunctional child welfare system.”
Several of the nine child deaths reviewed in Goad’s report — all of which occurred in a home that had at least oneprevious abuse or neglect allegation — highlight the potentially fatal consequences of continuing to operate a child welfare system as badly broken as Oklahoma’s:
- Five-year-old D.S. died from massive injuries and blunt force trauma just five weeks after being returned to his parents for a trial reunification. DHS returned D.S. to live with parents who had repeatedly and severely abused him in the past, without a reasonable reunification plan. D.S.’s caseworker visited him only once in the five weeks before his murder.
- R.P., just one and a half years old, was killed after being hit by a truck near his foster family’s home. Records show that just nine days prior to R.P.’s death, DHS screened out an allegation from a child welfare worker that R.P. and six other young children were left alone in this foster home with no adult supervision.
- S.W., a two-year-old girl, drowned in her foster family’s backyard pool, which did not have a protective fence, despite repeated documentation of the pool’s hazard in case files. Nine months after S.W.’s death, yet another child — three-year-old J.T. – drowned in a different foster family’s pool because it also lacked a safety fence.
Goad attributed many of the missteps in each of the individual child fatality cases to broader, systemic failures amongDHS’s responses to reports of child maltreatment in foster placements — which often left children stranded in potentially abusive and neglectful situations.
Among the most alarming systemic findings in the report are the many problems resulting from the bifurcated system Oklahoma currently uses to investigate abuse and neglect of foster children.
While DHS’s Child Protective Services (CPS) is responsible for investigating licensed foster and relative homes, a completely different entity within DHS – the Office of Client Advocacy (OCA) — is charged with responding to claims of maltreatment in settings like group homes, residential treatment centers, and shelters.
As Goad points out, OCA’s investigations and findings are kept in a computer system separate from CPSinvestigations and other child-welfare related information — therefore underreporting the state’s rate of maltreatment in foster care both publicly and to the federal government.
“It is appalling to hear DHS rely on numbers it knows to be inaccurate at the same time it is completely ignoring the suffering of an entire group of children in its care,” said Lowry.
Goad also notes that OCA staff do not specialize in child welfare or receive adequate training on how to investigate abuse or neglect. Investigations of harm in institutions and group homes “lack any sense of urgency, are haphazard, and superficial,” wrote Goad. “OCA’s failure to conduct even marginally adequate child protection investigations for this vulnerable population is far outside any reasonable standard.”
Among these disturbing trends in both CPS and OCA investigations highlighted in today’s report:
- There are often unacceptably long gaps between allegation and contact with the alleged victims in congregate care settings. For one in three alleged victims reviewed by Goad, it took OCA staff a month or more to make contact — and eight alleged victims were never seen at all.
- Investigations of foster and relative homes lack a sense of urgency and take far too long to complete.Alleged child victims living in foster homes wait an average of more than a month before CPS’ investigation is complete, with more than 25 percent taking at least 46 days.
- DHS fails to adequately protect children while investigating claims of abuse and neglect. CPS investigators failed to take appropriate steps to protect nearly 20 percent of alleged victims in foster and relative homes, while approximately 41 percent of children needing protection never received it from OCA.
- Both CPS and OCA investigations are often incomplete and poor in quality. Nearly half of CPSinvestigations of foster and relative homes ignored or discounted credible evidence of abuse or neglect. Additionally, OCA investigators almost never review the child abuse history or criminal background of staff after being accused of harming children in their care.
- DHS staff routinely fail to interview key sources and other individuals close to children who have reportedly suffered abuse or neglect. During investigations, CPS staff failed to contact nearly a quarter of vital sources with information about the alleged victim — such as doctors, law enforcement, caseworkers, and other residents in the placement. Shockingly, OCA staff failed to contact more than half of the sources with potentially critical information about the case.
- DHS often makes decisions about abuse allegations without ever looking for reported injuries. Both CPSand OCA staff regularly fail to even look at, or have a doctor observe, a child’s body when it is relevant to an abuse allegation. And, because it takes so long for DHS to initiate investigations, any evidence of abuse often is long healed by the time staff would attempt to look for the injuries.
Additionally, the report found that in 2009 DHS screened out nearly 55 percent of abuse and neglect allegations in foster care — deciding those claims didn’t warrant an investigation. This is an increase of nearly 12 percent from 2006, and far higher than the national average of about 38 percent.
After reviewing the decision-making process among these screened-out cases, the report’s author found that at least 11 percent and as many as 32 percent of the decisions to screen out cases in 2009 were faulty — either made without gathering enough information or simply wrong. The author notes that this increase may explain the recent sharp decline in the state’s reported rate of maltreatment in foster care, and “strongly suggests that OKDHS has withdrawn the protection of CPS investigation from many children.”
Goad, a social worker and consultant with extensive child welfare experience as both an administrator and front line caseworker, conducted this review in conjunction with the Juvenile Protection Association (JPA).
Children’s Rights joined local Oklahoma law firms Frederic Dorwart Lawyers and Seymour & Graham and the international firm Kaye Scholer in filing a federal lawsuit in February 2008 seeking widespread reforms throughout the Oklahoma child welfare system on behalf of more than 10,000 abused and neglected children statewide who depend on the system for protection and care. The federal judge presiding over the case denied a motion by DHS to dismiss the case in January 2009, and, in May 2009, ruled that the case could proceed as a class action on behalf of all children in DHS custody. DHS subsequently appealed that decision, and a federal appeals court unanimously upheld the district court’s decision in February 2010, allowing the case once again to proceed as a class action.
The full text of the new expert report released today and more information about Children’s Rights’ efforts to reform Oklahoma’s child welfare system can be found at www.childrensrights.org/oklahoma.