Probe: DCF monitoring ‘inadequate’
Review of children’s deaths finds agency lacks safety planning in high-risk cases
An investigation following the death of a Connecticut baby from fentanyl poisoning has determined the state Department of Children and Families lacks adequate safety planning, public transparency and documentation in moderate and high-risk cases, according to a report released Thursday.
The state Office of the Child Advocate’s investigation also determined that 24 percent of the 99 Connecticut infants and toddlers who died in the past three years from preventable causes had been involved with DCF and the agency often covered up or omitted important information on its practices when publicly speaking about deaths, the report showed.
“What we’re talking about is transparency and accountability of one the government’s most important functions, the care of children,” Child Advocate Sarah Eagan said. “There has to be a framework on what they are doing to sustain and improve policies for children and you have to be open with the public about what’s going right and what’s going wrong.”
Based on her findings, Eagan is calling for DCF to engage in quality assurance reviews of its safety plans, regular public reporting of its safety practices and child fatalities and a public hearing to discuss more treatment options and supports for families under the agency’s purview.
“Inconsistencies in practice or lack of access to needed services increase the risk of poor, or even catastrophic outcomes, including preventable injuries or unnecessary and traumatic removals of children into foster care,” Eagan wrote in a 15-page letter to DCF outlining the findings of the investigation.
“Keeping young children home with their parents requires vigilant attention to highquality assessments, effective safety planning and timely service ... to these high-need families.”
Michael C. Williams, DCF’s deputy commissioner of operations, questioned the timing of the letter, saying it would’ve been more helpful when the incident occurred last year. Since the child’s death, he said, the agency has evolved in handling cases involving substance abuse treatment.
“The contents of the report really don’t speak to the actual casework, the family work, the substance abuse work and issues like that,” he said. “It sounds like what she’s asking for in this letter is some reporting that we make public to her and the public around the outcome of our [quality improvement] work, nothing instructive about our practice on casework.”
In terms of a publicly available analysis of these improvements, Williams said the agency has been working toward a dashboard that shows “key performance indicators” for a few years now and the agency is in the middle of upgrading its IT system.
“We can only go as fast as we have the people with the expertise and the technology to develop it,” he said. “It’s not a resistance, and this notion that I saw in her that we were hiding things, that I take complete exception against. We don’t hide anything; it’s just our capacity to do certain things are hampered because we don’t have the staffing that we need to do it.”
Eagan began examining DCF safety planning and monitoring practices in March after the death of a 1-year-old girl, Kaylee, in Salem who died from fentanyl poisoning in February 2022 while the child welfare agency was involved with her family.
As part of the investigation, the child advocate also reviewed a case involving another 1-yearold who nearly died of a fentanyl overdose while visiting their mother, who was prohibited from caring for the child alone, according to a DCF safety plan.
The child advocate investigation also included a 4-year-old who died from heart inflammation following an infection shortly after DCF had closed his family’s case.
In both of those cases, Eagan pointed to DCF’s lack of monitoring of the safety plans and insufficient in-home intensive treatment options for caregivers or parents who are suffering from substance abuse disorders.
In the case of the 4-year-old, there was no documentation that the family’s situation had improved when they were released from DCF, the agency did not seek legal or clinical consultations and no evaluations had been conducted, the report said.
In her letter, Eagan said she has not received reports on DCF’s new safety planning practices, which the agency told her in January was due to “resource limitations” and “managerial staff vacancies.”
“It is essential that there be consistent focused reviews of agency safety planning and support for families whose cases, like Kaylee’s, remain open with DCF,” Eagan wrote in the letter. “Given the practice deficiencies identified ... if resources are limiting DCF’s quality assurance and public disclosure efforts, then this must be addressed with policymakers and appropriators during the budget session.”
As part of the review of Kaylee’s death, Eagan discovered DCF caseworkers had not made an in-person visit to her family’s home in the two months prior to her death, according to the report. The case and virtual visits conducted by DCF during the pandemic has sparked a proposed law requiring caseworkers to do in-person home visits.
The Salem house where the child was living was “deplorable” state police said, laden with empty drug baggies, Methadone bottles, food waste covered in flies, 38 baggies containing an unknown powder substance that later tested positive for fentanyl and a trash bin with Captain Morgan whiskey “nips” bottles in the room where the child was sleeping.
A used canister of Narcan, a drug administered to reverse an opioid overdose, was found under the pack-and-play where the baby slept, suggesting someone knew the child was near death, state police said in arrest warrants charging her parents, Ricki Thomas and Travis Schubel with second-degree manslaughter.
Thomas had told a DCF caseworker that she was concerned about Schubel’s drug use and erratic behavior during a virtual visit on Jan. 26, 2022, arrest warrants said. The day before that visit, a urine sample he submitted to a treatment provider tested positive for fentanyl, the warrants said. The family missed a scheduled virtual visit on Feb. 2, according to Ken Mysogland, a spokesperson for DCF.
The caseworker rescheduled for an in-person visit on Feb. 9, which turned out to be one day after Kaylee had died. Last month, Mysogland said the agency “stood by their work” in the case and that changes had been implemented in training and safety planning.
Kaylee is among eight infants or toddlers who have died of fentanyl poisoning in Connecticut since 2020, records show. The children who died were all 2 ½ and younger, according to the Child Advocate.
DCF and Eagan were notified of all of the deaths, and several others that were considered “near misses,” but the child welfare agency didn’t start to examine how caseworkers were dealing with caregivers who had substance abuse issues until after Kaylee died, records show.
A review of a random sampling of cases that involved safety planning, including Kaylee’s, led Eagan to conclude that the DCF safety planning practices in high-risk cases and the documentation of them are “inadequate.”
DCF told Eagan in June as part of her investigation that the agency would conduct “ongoing structured” case reviews to monitor improvements in how caseworkers provided safety planning and documented their work.
But as of Thursday, Eagan said she had not received any reports from DCF on the reviews and she had not received a written response to her conclusions, which she presented to the agency on Feb. 6.
“As part of the OCA’s monitoring and critical incident review, we requested the safety planning quality assurance reports as well as a date regarding DCF’s ‘in-home visitation’ efforts, which DCF had previously reported to OCA would be reviewed on an ongoing basis to assess the efficacy of the agency’s in-home engagement with children and caregivers,” Eagan said in the report released Thursday.