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THE CHILD FATALITY REVIEW PROCESS

By Christopher Sanchez,2014-08-12 19:34
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THE CHILD FATALITY REVIEW PROCESS ...

    Office of the Child Advocate

    and the

    Child Fatality Review Panel

    INVESTIGATION OF THE DEATH OF

    Joseph Daniel S.

    January 2003

CHILD FATALITY REVIEW PANEL

    MEMBERS

    Jeanne Milstein, Chairperson

    Child Advocate

    Kirsten Bechtel, M.D.

    Pediatrician

    Christopher Morano, Esq.

    Chief State‟s Attorney

    H. Wayne Carver II, M.D.

    Chief Medical Examiner

    Jane Norgren, Executive Director

    Child Care Center of Stamford

    Arthur Spada, Commissioner

    Department of Public Safety

OFFICE OF THE CHILD ADVOCATE

    Jeanne Milstein, Child Advocate

    Mickey Kramer, MS, RN-C, Assistant Child Advocate Julie McKenna, Assistant Child Advocate

    Moira O‟Neill, MSN/MPH, RN, Assistant Child Advocate

    Heather Panciera, Assistant Child Advocate Janet Santiago, Processing Technician Denise Scruggs, Administrative Assistant

    Faith Vos Winkel, Assistant Child Advocate, CFRP Staff

    EXECUTIVE SUMMARY

    On January 2, 2002, Joseph Daniel S. hung himself in a cluttered bedroom closet at his home. He was 12 years old. Although we may never know why this child took his own life, the Office of the Child Advocate and the Child Fatality Review Panel tried to determine how his death could have been prevented. The purpose of fatality review is to determine whether public agencies and professionals can do a better job keeping Connecticut children safe and well cared for. J. Daniel was a very small boy for his age, weighing only 63 pounds at his death. He tested with superior intelligence but also had an identified learning disability that prevented him from being able

    thto express himself on paper. When he was in the 6 grade, J. Daniel‟s grandparents died within one

    month of each other. His grandfather was the only male figure in the boy‟s life. In addition to being small, J. Daniel‟s appearance was dirty. He wore mismatched, dirty clothes. He acted different from the other children at school.

    As J. Daniel entered middle school and the schoolwork became more complex, special educational

    thsupports and oversight were stopped. At the end of 5 grade, he had been exited from special

    educational services without the benefit of testing to determine any change in his needs. J. Daniel‟s

    ththacademic performance plummeted in the 6 and 7 grades.

    At some point in the middle school transition, schoolmates began to pick on J. Daniel. Reports indicate that the boy was pushed, hit, choked, kicked, made fun of, and had his belongings stolen (to name a few offenses). J. Daniel fought back ineffectually. In addition to school suspensions for thfighting, J. Daniel began skipping school. In the 6 grade he missed 37 days and was tardy 42.

    thBefore the winter holidays of 7 grade he missed 44 days. When he did go to school he was shunned

    and picked on because of his appearance and odor. J. Daniel seemed to be soiling his pants. The school and J. Daniel‟s mother responded ineffectually to J. Daniel‟s needs for a full academic

    year and into the next before the school finally took mandated action and alerted the Department of Children and Families as well as the Superior Court for Juvenile Matters. Until that time, there was no medical evaluation, no involvement of the school nurse, no therapist, and no intervention targeting hygiene. School personnel at all levels were aware of J. Daniel‟s appearance, behaviors and poor academic performance. He seemed to be held responsible for his circumstances. When the Department of Children and Families and the juvenile court became involved, both agencies documented the problems, as if to confirm them, but did little. There were still no medical or mental health evaluations, school nurse involvement, therapist, or help with hygiene practices. There was very little communication between the school and DCF. There was no communication between the school and the court. DCF did not substantiate allegations of physical and educational neglect, even though they documented that the boy continued to be truant and that he was emotionally disturbed. Similarly, the juvenile court chose to only monitor the case, yet even monitoring was lacking.

    There is an intricate system in Connecticut designed to keep children safe. That system or safeguard is made up of professionals trained to recognize when a child is at risk. Teachers, guidance counselors, doctors and nurses are some professionals who should recognize and intervene on a child‟s behalf. In fact, they are required by law to do so. State agencies such as DCF and the juvenile court make up the child welfare system specifically prepared and expected to ensure children‟s safety. While the network of professionals continues to be obligated to ensure a child‟s safety, DCF is

    ultimately accountable to children‟s safety and care.

    As a 12-year-old boy, J. Daniel‟s safeguards included his mother, his teachers and guidance counselor, the school nurse, the school administrators, his pediatrician, the school outreach worker, a DCF investigative social worker, and a probation officer. OCA examined the systems each represented according to specific concerns identified as warranting action in J. Daniel‟s life. Those concerns

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    included: a) risk of suicide and depression; b) bullying; c) physical health and personal hygiene; d) school success; and e) home safety. The safeguards failed to protect J. Daniel S. DCF was the one agency that could step right into J. Daniel‟s life and determine what was wrong. Instead, they ignored the evidence of dysfunction and chaos at home and the fact that a truant was scared to return to school. They did not follow up on reported threats against the boy‟s life. They ignored obvious symptoms of medical and mental health needs. When police arrived at the scene of J. Daniel‟s suicide, the officers were aghast at the conditions the boy was living under, the same conditions a child abuse and neglect investigative social worker had visited just one month before. Eventually, J. Daniel‟s mother was arrested. DCF personnel were cited for poor documentation and lack of resource use. The juvenile court did not review their handling of the case, and the school system was “satisfied” they had done all they could for the boy. No one took responsibility for the

    child‟s death. Everyone was responsible. J. Daniel‟s safeguards never came together to explore his thproblems or strategize solutions. On December 4, 2001 a Planning and Placement Team meeting

    was held. Everyone involved with the boy knew about the meeting. That was one opportunity to clarify concerns and discuss J. Daniel‟s circumstances. The probation officer was not at the meeting. No one from DCF attended. There were no health professionals at the meeting. No one seemed to recognize or acknowledge the breadth of J. Daniel‟s problems. In fact, many people held the 12-year

    old accountable for his woes.

    Upon review of J. Daniel‟s death, the Office of the Child Advocate and the Child Fatality Review Panel made the following findings and recommendations regarding the most concerning aspects of J. Daniel‟s circumstances, including depression and suicide; bullying; health and hygiene; school success, and home safety. Specifically,

     J. Daniel’s safety system, including his mother, the school, the state’s child

    protection agency, and the Superior Court for Juvenile Matters each neglected

    to conduct complete assessments of the boy’s emotional strengths and

    weaknesses. They failed to recognize that he was showing signs of emotional

    disturbance, possibly depression, and was at risk for suicide.

     J. Daniel’s safety system failed to recognize and acknowledge that he was a

    victim of chronic bullying and abuse. The 12-year-old sought help, showed

    signs of distress but was ignored, punished and held accountable for

    behaviors and conditions that may not have been under his control.

     J. Daniel’s safety system failed to acknowledge that the boy’s soiling was a

    health problem and failed to assure he had the means to maintain good

    hygiene. Consequently they allowed the creation of a considerable health risk

    to J. Daniel and his community.

     J. Daniel’s safety system failed to recognize his lack of school success as an

    indicator of poor mental health, well being, and a poorly accommodated

    learning disability.

     J. Daniel’s safety system failed to ensure he had safe, adequate housing and

    facilities for proper hygiene.

    Recommendations are put forth for improvements in practice among three systems, the educational system, the child welfare system (Department of Children and Families) and the court system, (Court Support Services Division of the Superior Court for Juvenile Matters).

Improvements for the Educational System

     An internal review must be conducted to assess the actions or inactions of all school personnel

    involved with J. Daniel, and whatever disciplinary action deemed necessary should be pursued.

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     All school personnel must be held accountable for knowing and abiding by school policy and

    state and federal law.

     Effective truancy reduction programs must be developed in all school districts. Children

    incurring excessive absences must be provided immediate access to those programs. Comprehensive training and ongoing in-service education programs must be initiated for school

    personnel regarding physical and mental health of children, mandated reporting, and special

    education law.

     All school districts must develop comprehensive whole school anti-bullying plans with teachers,

    parents, and para-professionals.

     Nurses employed in school settings must be adequately educated and prepared to address the

    unique needs of their student population.

     Mental health consultants must be available to assist school personnel in identifying children at

    risk and determining appropriate action.

     School administrations must cooperatively develop a strategy for effective communication and

    coordination between public and private agencies, and families, regarding a child‟s safety and

    well-being.

     Improvements for the Department of Children and Families

     The DCF administration must review the role and responsibilities of supervisors within their

    infrastructure in order to ensure adherence to state and federal law, agency policy and best

    practice standards.

     The DCF internal review process must reflect the department‟s commitment to quality practice

    by providing a thorough and accurate analysis of case practice for the purpose of improving

    practice and safeguarding children.

     Disciplinary action should be pursued when it has been determined through a comprehensive

    review process that there has been a breach of relevant law and/or policy. All DCF personnel

    must be held accountable for knowing and abiding by agency policy and state and federal law.

     The current pre-service and ongoing in-service education curricula must reflect current trends

    and issues affecting children as well as best practice standards, applicable state and federal law

    and agency policy. Staff must be knowledgeable regarding physical and mental health of

    children, available resources, child and home assessment, and bullying.

     DCF must take the lead in developing a strategy for effective communication and coordination

    between public and private agencies, and families, regarding a child‟s safety and well-being.

    Improvements for practice in the Court Support Services Division of the Superior Court for Juvenile Matters

     An internal review must be conducted to assess the actions or inactions of all juvenile justice

    personnel involved with J. Daniel, and whatever disciplinary action deemed necessary should be

    pursued.

     CSSD must assess their current supervision practices to ensure proper oversight of probation

    services to children and adherence to applicable law, policy and best practice standards. All juvenile justice personnel must be held accountable for knowing and abiding by agency

    policy and state and federal law.

     CSSD must ensure adequate pre-service and ongoing in-service education and preparation of

    their juvenile justice staff regarding trends and issues affecting children as well as best practice

    standards, applicable state and federal law and agency policy. Staff must be knowledgeable

    regarding physical and mental health of children, communication and collaboration and bullying.

     CSSD must cooperatively develop a strategy for effective communication and coordination

    between public and private agencies, and families, regarding a child‟s safety and well-being.

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    JOSEPH DANIEL S.

    11/20/89 - 1/2/02

    12 YEARS OLD - SUICIDE

    THE CHILD FATALITY REVIEW PROCESS

     1The Office of the Child Advocate (OCA) commenced an investigation into the death of Joseph

    Daniel S., age 12, on January 3, 2002 upon receiving notice of his death from the Office of the Chief Medical Examiner. The notice indicated that the child‟s death resulted from his hanging himself in his bedroom closet. On February 20, 2002 the Child Fatality Review Panel unanimously voted to join the Child Advocate in the investigation of Joseph Daniel‟s death. Extensive media coverage at the time implicated bullying in school as a possible contributing factor. A second suspected factor was alleged negligence of the boy by his mother. She was arrested on April 23, 2002 and charged with one count of risk of injury to a minor. Approximately eight weeks before his death, the school had referred Joseph Daniel to the Department of Children and Families alleging truancy, educational neglect, poor hygiene and being beyond the control of his mother. The school also made a referral to the Superior Court for Juvenile Matters for truancy.

    INVESTIGATION METHODS

    This joint investigation included extensive personal and confidential interviews with individuals who had knowledge or had been involved with J. Daniel and his family, including:

     Personnel from the Department of Children and Families

    (DCF) including the investigative social worker and the

    social work supervisor

     Personnel from the Court Support Service Division

    (CSSD), probation officers, and probation supervisors

     Personnel from Meriden Public Schools including, social

    worker, guidance counselor, school psychologist,

    principal, outreach worker, mentor, nurse, assistant

    principals, and teachers

     Family and school mates

    A comprehensive record review was conducted. All records were obtained through written requests or issuance of a subpoena to relevant agencies including:

     The DCF case file and investigative report

     The Court Support Services Division case record

     The Educational/school records

     Health records/medical records

     1 Pursuant to Connecticut General Statute 46a-13k et seq., the Office of the Child Advocate (OCA) and the Child Fatality Review Panel are mandated to “review the circumstances of the death of a child placed in-out of-

    home care or whose death was due to unexpected or unexplained causes, to facilitate development of prevention strategies to address identified trends and patterns of risk and to improve coordination of services for children and families in the state.” “Upon the request of two-thirds of the members of the panel, the

    Governor, the General Assembly or at the Child Advocate‟s discretion, the Child Advocate shall conduct an in-

    depth investigation and review and issue a report with recommendations on the death of a child.”

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     Legal documents

     Police records

     Medical examiner records

    Finally, a literature review was conducted on the topics of adolescent development, youth suicide, bullying, encopresis, and related risk factors. Additionally, professional practice standards for social workers, teachers, and nurses were reviewed.

    THE PURPOSE OF THE INVESTIGATION WAS TO IDENTIFY

    WHETHER THERE WERE INADEQUACIES IN THE PROTECTION AND

    SUPPORT BY THE SYSTEMS TO WHICH JOSEPH DANIEL WAS

    KNOWN. THE PRIMARY PURPOSE OF A FATALITY INVESTIGATION IS

    TO DEVELOP RECOMMENDATIONS TO IMPROVE CHILD

    PROTECTION AND CHILD WELFARE PRACTICES IN CONNECTICUT.

    BACKGROUND

    Joseph Daniel S. known as “J. Daniel” and “Daniel” was born in Lynchburg, Virginia on November 20, 1989. He was the youngest of four siblings, but for most of his life he lived with his mother and one sister who was five years older than him. J. Daniel‟s father reportedly left the family when the boy was three months old. The father was reportedly jailed for a period of time and on occasion J. Daniel and his mother would visit him. The case record did not indicate why J. Daniel‟s father was

    incarcerated. J. Daniel‟s mother reported to OCA that she had sole custody and that his father never played any significant parental role in the boy‟s life.

    J. Daniel‟s mother recounted during an OCA interview that for the first three years of J. Daniel‟s life the family was living in a fairly rural part of Virginia. She described their home as being somewhat devoid of typical amenities such as television. Ms. S. described J. Daniel at the time as a happy child who enjoyed the outdoors. In an early educational intake form J. Daniel‟s mother wrote,

    during my pregnancy with Daniel - for that matter my entire marriage to Daniel‟s father was

    very abusive. There was verbal and physical abuse almost constantly. This stopped when Daniel

    was three months old due to the fact that that was when his father abandoned us.”

    Originally from Connecticut, Ms. S. returned with two of her children to the greater Waterbury area expressing a desire to be closer to her aging parents. She reported that J. Daniel had a close relationship with his maternal grandparents until their deaths in August and December 2000, one year before his own death. His grandfather was the primary male figure in J. Daniel‟s life whose death was described as very difficult for the boy.

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ELEMENTARY SCHOOL EDUCATION

Preschool

    Educational records reflect that in 1993, as a preschooler aged three-and-a-half, J. Daniel was

    2referred for an early intervention assessment. J. Daniel was described at the time as

    “showing adequate skills in all areas of development. As with all young children, he needs

    continued support and encouragement to develop his skills further. This support is being provided

    in his home environment and Daniel is also ready to attend a school program. The pre-school

    program can meet his needs. No special education services are recommended at this time. He show

    (sic) age appropriate receptive and expressive language skills. It is suggested that the assessment of

    his sound system be completed in the fall of 1993 to determine any needs that may exist at that

    time. Daniel demonstrate (sic) no deficits in motor skills though re-evaluation is always available if 3that status changes.”

On a pre-screening form it was recorded that J. Daniel‟s special interests were Batman and Ninja

    Turtles. He knew his numbers up to 10. He was able to dress himself and take care of his hygiene needs. The evaluator described J. Daniel as a “sweet child”. The educational record indicated that J. 4Daniel was absent 19 days and tardy 13 days during pre-school.

Kindergarten (1994-95)

    J. Daniel entered kindergarten in September 1994. There were no educational records provided to the OCA regarding kindergarten performance. J. Daniel was absent 8 days and tardy 10 days during his kindergarten year.

     st1 Grade (1995-96)

    There were no educational records provided to the OCA regarding J. Daniel‟s first grade performance. School health records indicate that the nurse saw J. Daniel in November and January for “accidental BM in his pants” on two visits and “accidentally wetting his pants” once. Attendance records

    reflected that J. Daniel was absent 12 days and tardy 1 day during first grade.

nd2 Grade (1996-97)

    The first record of any problems developing at school was from J. Daniel‟s second grade year. On

    January 17, 1997, as a second grade student, J. Daniel was referred to the elementary school child study team with,

    “very poor writing skills, is weak in reading and strong in math… J. Daniel is easily distracted; he

    has a hard time sitting in his seat. He often wanders away from his desk. His academic strengths

    were noted to be good math skills. He is an excellent problem solver. He has a lot to offer in

    discussions about books and various curriculum areas.”

    J. Daniel‟s organizational skills were reported as poor. He was described as getting along well with other children, but that “sometimes when someone is unkind to him he cries.”

     2 An early intervention assessment will evaluate a child to determine if therapeutic services are necessary to ameliorate developmental delays. 3 Early Childhood Team Assessment Report April 1993 4 A Student History was provided by the School District to OCA after J. Daniel‟s‟ death. Attendance was noted on this document for each school year.

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    5On January 23, 1997 a Planning and Placement Team (PPT) Meeting took place. The stated reason

    for referral to PPT was “academic concerns in the areas of written language, and fine motor skill, distractibility issues.” The classroom teacher had completed a baseline assessment, and had initiated preferential seating for J. Daniel in an attempt to keep him on task. The teacher also decreased the peer group size in reading and instituted peer tutoring, but the record reflected that all of the interventions attempted prior to the PPT referral were unsuccessful. The record stated that despite the interventions, J. Daniel made no significant change in behavior or academic performance. The PPT 6decision was that “J. Daniel is in need of a psychological and educational evaluation. Also, an OT evaluation is

    necessary. Articulation evaluation is also needed.”

    In February 1997 J. Daniel‟s testing as outlined in the January PPT commenced. Over the next month, psychological, academic, and speech and language evaluations were conducted. On March rd23, a follow-up PPT was held to review the results of the testing. Areas of concern included reading, written language, fine motor skills and distractibility. J. Daniel was described as exhibiting very strong skills in math, verbal language and reasoning skills. The overall,

    “academic profile indicates that he has strengths in the areas of math skills, general information

    especially in the area of science, excellent comprehension and good receptive and expressive language.

    Weakness exists in the areas of reading and written language. The discrepancy between his

    intelligence scores and these areas of weakness are considered significant. Processing difficulties in the

    areas of visual perception and memory have been observed. Some difficulty concentrating and some

    impulsivity may also be affecting his ability to succeed in certain academic areas as well. J. Daniel

    qualifies for services in the learning disabilities program based on the discrepancy model as outlined by 7the state guidelines for special education.”

    During the psychological testing J. Daniel reported that he liked school and enjoyed playing with his friends. The school psychologist described J. Daniel as impulsive and inattentive. The formal testing placed J. Daniel in the superior range of intelligence with a verbal IQ of 129 and performance IQ of 8142 with a full scaled IQ of 139. The recommendations included assistance in breaking down

    academic material, checking for understanding of verbal information and providing an opportunity to paraphrase directions where possible. It was also recommended that visual information be presented along with verbal instruction, making behavioral expectations clear to J. Daniel with specific consequence and rewards. Finally, discussing the possibility of attention deficit disorder with J. 9Daniel‟s family was indicated.

    J. Daniel also received a speech evaluation as part of the comprehensive evaluation process. Speech services were not recommended. It was, however, suggested by the speech pathologist that teachers offer the second grader occasional reminders to correct and say mispronounced words.

    Second grade attendance records reflect that J. Daniel was absent 6 days and tardy 1 day during second grade.

     5 The Federal Individuals with Disabilities Education Act (IDEA) requires early testing and referral of special education children, under the “child find” section of that law [20 USC sec. 1412(a) (3)]. For a child experiencing academic trouble or behavioral problems (multiple suspensions, expulsions, truancy etc.) the school is required to convene a Planning and Placement Team (PPT) meeting, evaluate the child in any area of suspected disability [20 USC 1414(b) (3) (c)] and develop an Individual Education Plan for any child with a disability who by reason thereof needs special education and related services [20 USC 1401]. 6 OT Occupational Therapy. 7 Learning Disabilities Initial Report, February 1997 8 The Intelligence Quotient (IQ): A measure of intelligence based upon relating testing scores of a population. 9 Confidential Psychological Report, February 1997

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rd3 Grade (1997-98)

    A March 1998 Learning Disabilities Progress Report indicated as a third grader J. Daniel continued to have a learning disability and that he required supports in the areas of reading and written language. His effort and attention were described as good when working on reading tasks, but he had difficulty focusing on written assignments. Testing revealed that J. Daniel had made good overall progress in reading, and his written work had shown some growth. However, the report stated:

    “(I)t is very difficult to get J. Daniel to complete written assignments. He often gets frustrated or

    distracted. Some letters are still made inaccurately and he has difficulty organizing his written

    work spatially on paper. Usually there are not spaces between his words even though he has been

    given strategies to help him with this task. Although orally he has a lot to contribute, he finds it

    difficulty (sic) to get things down on paper. Consultation with the classroom teacher indicates that

    this is an ongoing problem. Getting homework turned in is another area of difficulty. It may be 10worthwhile to have an informal evaluation done by the occupational therapist.”

    J. Daniel‟s annual PPT in April of 1998 recommended that he continue to receive services for

    11children with learning disabilities. His Individual Education Plan (IEP) included a consultation for

    his teacher with an occupational therapist and the school psychologist to develop modification for handwriting, spatial organization tasks and behavior modification strategies to aid J. Daniel getting his written work completed and homework turned in. The IEP did not outline direct services for J. Daniel but only consults for his teacher.

    School health records indicated that the nurse saw J. Daniel five times between October and June. Four visits were for “accidentally wetting his pants,” and in June he had “BM in his pants.” In late 1997,

    the nurse contacted J. Daniel‟s mother after an incident of wetting his pants. It was recorded in the health record that she would take him to a physician for a check up. According to medical records, J. Daniel was referred to a urologist to address urine incontinence in 1997. No treatment was provided. The urologist indicated in his notes that J. Daniel‟s mother reported the condition was improving so the plan was for observation only. J. Daniel‟s mother was instructed to return her son to the

    urologist for evaluation if the problem was to worsen.

J. Daniel was absent 4 days and tardy 4 days in third grade.

     th4 Grade (1998-99)

    J. Daniel began fourth grade in September 1998. There is no documentation regarding how J. Daniel was progressing until a March 1999 evaluation that reported:

     “J. Daniel continues to struggle with the completion of written tasks. His effort is not often good

    and he finds it difficult to attend… J. Daniel continues to struggle getting things on paper. He has

    difficulty spacing, but does not use strategies that have been taught to him. Because of his spacing

    difficulty, his writing is at times difficult to read. He wastes a lot of time thinking in the resource

    room. It is extremely difficult to get him to complete a task. Use of a tape recorder has been tried,

    but ended up taking more time and not benefiting the end result. Spelling skills has (sic) improved

    slightly, but are inconsistent. His spelling in context is poorer than in isolation. J. Daniel has

    some wonderful ideas, but is not putting effort getting them on paper. It is believed that the resource

    room is not being a benefit to him or his weakness. The PPT should discuss the possibility of

    discontinuing service.”

     10 Learning Disabilities Report, March 1998 11 Individual Education Plan: See footnote # 5.

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