Poor Practice, Flawed Investigations Continue to Mark New York City Child Deaths, New Report Reveals
PRESS RELEASEState child fatality reports show continuing failure of child welfare agency to learn from mistakes and of state to require changes.
A new report released today by Children's Rights, Inc. (CRI), a national advocacy group for children, reveals the continuing failure of New York City's child welfare agency to make careful casework decisions, and the failure of the state oversight agency to require necessary changes. The report analyzes the most recent state records available on the deaths of 201 children in 1997 and 1998 in New York City. By synthesizing the information prepared by the state agency from individual reports, CRI was able to identify recurring systemic problems in child welfare practice that undermine the safety and well-being of children. Many of the cases in which ACS was already involved with the family prior to the child's death are shown to have histories that "virtually scream danger for the children," yet caseworkers failed to take appropriate action.
The report is based on reviews of individual cases conducted by the state agency with oversight responsibility for the Administration for Children's Services (ACS), the New York State Office of Children and Family Services (OCFS). In the vast majority of those cases in which the child did not die from a long-standing illness, OCFS found the City had violated applicable regulations or standards of practice in either the services provided to the child or the investigation of the fatality.
OCFS recently released aggregate child fatality reports for 1997 and 1998, which consist of descriptive statistics with little or no analysis of the significance of these numbers, let alone what was done well or poorly in these cases. The reports also fail to indicate whether OCFS identified significant problems in either ACS's protection of children before they died or the fatality investigations themselves. In contrast, the CRI report describes the actions that transpired in individual cases, assesses their appropriateness and significance for the safety of the affected children, and identifies the common skills, knowledge and judgment that are absent from a range of cases. "Rather than requiring specific corrective action from the city, the state report simply reiterates general recommendations that have been repeated year after year," said Marcia Robinson Lowry, director of Children's Rights. Among recurring patterns of failure in many cases:
*Failure to gather essential information needed to make critical decisions;
*Failure to understand the information that is gathered; and,
*Failure to comply with minimum requirements.
The CRI report was written to provide a basis for responsible public discussion to remedy these systemic problems and to serve as a tool for monitoring and oversight of both the state and city agencies as part of the settlement of the class action lawsuit, Marisol v. Giuliani.
"This report shows that through 1998 the city practices in these cases continued to violate state laws and regulations in cases in which child deaths were involved," said Ms. Lowry. "The state has got to demand extremely rigorous corrective action from the city and the city has to address these serious problems in practice. We believe these problems extend across all areas of child welfare practice, also resulting in children being removed inappropriately from families, kept in foster care too long, or receiving inappropriate services."
The problems identified in the report occurred in a variety of settings. Individual case descriptions are given as a sample of fatality cases that exhibited the problems they exemplify. The three most common and recurring patterns of failure are:
1. Failure to Gather Essential Information Needed to Make Critical Decisions
The inadequacy of information-gathering by ACS occurs across the spectrum of child welfare activities - investigation, assessment of the child's safety and evaluation of children's and families' service needs. OCFS repeatedly cited ACS's failure to interview all individuals who might have information about a fatality; to attempt to reconcile discrepancies in factual reports, even when the death was suspicious; and to collect other types of essential information, including whether other children in the family were safe.
On November 22, 1998, three-year-old Jamal L. (all names are pseudonyms) died, according to his parents, by choking on a piece of ice. The treating physician and medical examiner independently informed ACS that this was virtually impossible, and upon examination, it was found that Jamal had old rib fractures and rickets, indications he had been neglected and abused.
ACS never obtained the autopsy report and never questioned the parents about the medical evidence found after his death showing Jamal had previously been abused or about the impossibility of their explanation for his death.
2. Failure to Understand the Information that is Gathered
Unless the caseworker, supervisor or manager responsible for making a decision understands the significance of the information that has been collected, the process of gathering evidence is futile and the decision-making will be of poor quality. This is precisely what is observed at every level and in all aspects of case practice described in the fatality reviews. The inability to evaluate the meaning and significance of information may be a consequence of inadequate training, excessive caseloads, poor supervision, lack of access to experts who can focus decision-making or a combination of factors.
Five-year-old Uniqua S. died on July 26, 1998 due to child abuse syndrome with multiple bruises to head, torso and extremities and blunt impact to the head. The mother was indicted for second-degree murder.
Uniqua died after ACS twice accepted her parents' statement that her six-year-old brother had injured her by striking her with a hanger, failed to address the domestic violence in the home and did not monitor the home.
3. Failure to Comply with Minimum Requirements
There are cases in which the process of gathering information and assessing a potential foster home is done so poorly that inappropriate families are certified and subsequently murder the children placed in their charge. Contract agencies fail to monitor what is occurring in foster placements or to respond to the needs and circumstances of children who are at heightened risk, and the children die. Children's needs are not the central focus that drives the agencies' practice. Instead, routinized responses and diminishing attention to difficult, hard-to-engage youngsters determine the quality of care provided to these children whose safety and health are entrusted to ACS and its contract agencies.
Terry W. died on March 29, 1997 at the age of five years and nine months. He died of fatal child abuse syndrome and neglect with starvation and malnutrition. He had bruises all over his body in various stages of healing. There were puncture wounds in each temple and two on the back of his head. This homicide occurred while the family was subject to Court Ordered Supervision by ACS.
Terry's family was indeed well known to ACS. Prior to Terry's death there were six reports concerning one or more of the children alleging abuse and neglect. A caseworker made a visit to the family's home nine days before Terry died, but he was not present. The mother told the worker Terry was visiting his father and refused to give the worker the father's name and address. The worker did not take any action based on this refusal. Nor does it appear the worker understood the potential danger to Terry based on the fact he had not been seen for two months, the mother refused to provide information concerning his whereabouts, and he had been seriously enough abused before to warrant the removal of all the children.
"Children whose families are known to the child welfare system are dying every month, quietly and without the media attention focused on the deaths of Lisa Steinberg, Elisa Izquierdo and a handful of others," concludes the report. "There are volumes of regulations, huge practice manuals and layers of supervision and management, yet the same preventable mistakes have continued to occur."
Under the stipulation of settlement in Marisol v. Giuliani, a federal lawsuit that successfully challenged ACS's and OCFS's failure to meet legal mandates, ACS is now required to bring its practice into compliance with accepted standards. OCFS is required to demand corrective action when the fatality reports demonstrate ongoing patterns of poor practice. Under this settlement, with the assistance and monitoring of an external panel of nationally recognized experts, the problems identified in this report should surely be among the significant ones addressed by this intensified reform effort.
Children's Rights works throughout the United States in partnership with national and local experts, advocates and government officials to document the needs of children in the care of child welfare systems. Children's Rights helps develop realistic solutions and, where necessary, uses the power of litigation to ensure that reform takes place.
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