Friday, May 20, 2011

Investigation into the Death of Alex B.

released March 12, 2001
conducted by Connecticut's Child Fatality Review Panel
Key elements of the report:
Executive Summary
Findings
Recommendations
The full, 17-page investigative report, is available for viewing or download in Microsoft Word format by using the following link: Alex B.

Executive Summary
Alex B. was a three-year-old victim of homicide while in the custody of the Department of Children and Families (DCF). On September 8, 2000, DCF placed Alex in the care of a Florida couple. Less than three weeks later, Alex died and the prospective adoptive father was arrested and charged with first-degree felony murder.
Alex was born on January 25, 1997 and was placed with a foster family in Connecticut shortly after birth. When Alex was seven months old, DCF moved him to Maine to live with a maternal uncle and his partner, who had expressed interest in adopting Alex. Shortly after moving to Maine, Alex was diagnosed with numerous special health and developmental needs.
DCF ultimately decided to remove Alex from his relative’s care after three years and, without appropriate assessment or preparation, placed him with prospective adoptive foster parents in Florida. Within a week of leaving Maine, Alex was dead.
The fatality review investigation revealed that DCF made errors throughout the course of Alex’s life. The most significant mistakes, which led to Alex’s death, include the following:

    DCF failed to obtain even basic information about Alex’s prospective adoptive parents before sending him to live with them.
    DCF violated the requirements of the Interstate Compact of the Placement of Children that would have protected Alex from harm in order to expedite his placement in Florida.
    DCF provided inadequate supervision of the caseworker’s decisions.
    DCF failed to ensure that Alex had health insurance or providers in Florida to meet his special needs.

The mishandling of Alex’s case predates the Florida placement and began with his placement in foster care. The investigation found the following:

    DCF failed to adequately monitor his care by the foster family in Maine.
    DCF failed to provide support or guidance to the foster family despite Alex’s complex needs.
    DCF must address these problems in an effort to prevent other tragedies from occurring. Recommendations include the following:
    DCF needs to ensure that all employees understand and obey the Interstate Compact requirements.
    DCF must clearly communicate to its employees that existing rules for monitoring and visiting the child apply equally to children placed with out-of-state families.
    DCF must simplify the voluminous and often irrelevant policies that dictate employees’ daily practice. Employees also need ongoing training so that they understand the policies they are expected to implement.
    DCF should develop a management system that allows supervisors to obtain accurate information upon which to evaluate case practice decisions and employee performance. With access to objective, independent information, supervisors will be able to ensure that employees engage in sound case practice and that agency policies are followed.

A single failure connects the many mistakes that led to Alex’s death: DCF failed to recognize and act in the best interests of Alex. DCF treated him as a case to be processed and not a child to be nurtured.
DCF was Alex’s legal parent. The agency was responsible for providing a safe, nurturing home for him. Yet, DCF failed to act like a responsible parent.
No responsible parent would send a three-year-old child 1,500 miles away to live with strangers. No responsible parent would fail to monitor the child’s care by relatives in another state. No responsible parent would ignore the obvious needs of the relative caregivers for guidance and support.
In this case, the failure to focus on Alex’s best interests, combined with poor judgment, resulted in a tragedy. The most urgent issue that must be addressed is the inadequate supervision of caseworker decisions. Supervisors rely almost exclusively on the caseworker for information about the case and the child. This lack of objective information prevents supervisors from effectively monitoring performance and case practice. In addition, DCF policies are voluminous, unclear, and poorly communicated, making practice inconsistent and noncompliance routine.
______________________________
Jeanne Milstein, Child Advocate
Chairperson, Child Fatality Review Panel
Findings

    DCF inadequately documented events in Alex’s life.
    DCF placed Alex with relatives in Maine when he was seven months old. Soon thereafter he was identified as having emerging special health and developmental needs.
    DCF did not maintain regular contact with Alex’s relative foster family nor did they ensure that Maine authorities were providing oversight of Alex’s placement through Interstate Compact.
    DCF was concerned about the quality of care that Alex was receiving in his relative foster placement as early as July 1998. Yet he remained in this placement for 2 more years with minimal state oversight.
    In the transfer to Florida, DCF failed to follow the policies and procedures established by the Interstate Compact on the Placement of Children.
    DCF failed to adequately assess the suitability of Alex’s prospective Florida adoptive family to parent him and to meet his special needs. Key indicators of potential parenting problems were ignored.
    DCF failed to ensure that Alex had the necessary health insurance to meet his special health and developmental service needs in Florida.
    DCF failed to adequately supervise Alex’s caseworkers in their case management of a child determined to be "medically fragile" and placed out of state, for whom they were the statutory parent.
    Supervisors lack an independent source of information upon which to monitor case practice and evaluate job performance.
    DCF workers are overwhelmed with the volume of policy and procedural information disseminated through the internal computer system.

Recommendations

    DCF must obey the requirements of the Interstate Compact on the placement of children.
    DCF must ensure adequate supervision of employees.
    DCF must ensure tht their employees understand and effectively implement DCF policy and procedures.
    DCF must improve external and internal communication.
    DCF must develop policies and procedures for placement and oversight of children in out-of-state foster care.
    DCF must ensure that Connecticut children placed in out-of-state foster care have adequate medical insurance coverage.

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