HELENA – Three months after child welfare workers received reports about methamphetamine use in a Great Falls low-income apartment, police found an infant girl dead in a freezing cold room with the window open in winter.
The baby’s mother had a previous conviction for possession of drug paraphernalia and her live-in boyfriend had been convicted of domestic violence. That gave the case virtually every red flag identified in a new analysis of the deaths of 14 Montana children whose plights had been reported to authorities within a year before they died.
The Montana Child and Family Ombudsman’s report released last week marks the first time the state has examined such deaths. But the report lacks key information that critics say shows the state needs to do more.
It doesn’t say, for example, how all of the children died during that 16-month stretch, in part because lawmakers two years ago decided against creating a commission to review child deaths and near-deaths attributed to abuse and neglect. Such a commission would have had access to medical and legal records that could provide that information.
Responding to complaints about the division, lawmakers instead directed the child welfare agency’s ombudsman to use agency records to review cases in which children died within a year of someone reporting concerns about their safety.
A four-member panel convened by state prosecutors examined 14 child deaths between July 1, 2015, and Nov. 8, 2016, concluding most died of abuse or neglect. Child and Family Services officials said they do not determine the cause of death.
No information about individual cases was made public in the report, but the January 2016 case in Great Falls is believed to be among them.
The girl’s mother has pleaded not guilty to felony criminal endangerment, Cascade County Attorney John Parker said.
The review team found that 12 of the cases involved more than one indicator of abuse including prior history with the agency, drug and alcohol abuse, domestic violence and housing or other financial instability.
The report recommends that within 24 hours of a child abuse report, caseworkers should check the criminal records of all adults in the house and whether previous reports exist involving the same children. When more than one red flag is raised, workers should get more help with their investigation.
“We really would like to honor these children’s lives by taking the information that we’ve learned from them and promoting a system that works better,” said Dana Toole, chief of the Children’s Justice Bureau, who served on the review panel.
The report also recommended more cooperation between the agency and courts, law enforcement and medical personnel.
“It’s a multi-system failure,” Toole said. “It’s not just our child protection system.”
The findings echo those of the Commission to Eliminate Child Abuse and Neglect Fatalities, created by Congress to review and recommend strategies to prevent child abuse deaths.
Federal data indicates 1,500 to 1,600 children die due to abuse or neglect each year. But the commission report says there are gaps in how the data is compiled and the true number could be as high as 3,000 annually.
Montana’s Child and Family Services Division has been heavily criticized in recent years over the deaths of children after workers failed to remove them from dangerous situations, as well as allegations that other children were wrongly removed from homes and poor communication with families.
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“We know there is more to accomplish and we’re determined to continue down the current path of comprehensive system improvement,” said Jon Ebelt, spokesman for the Department of Public Health and Human Services, which includes the child welfare division.
The agency has established and recently began using a critical incident review process, which analyzes deaths and near-deaths to determine the factors involved and what the division can do to improve its practices, Ebelt said.
An update to its antiquated computer system is expected this fall after numerous delays. Employees are receiving increased training, he said.
Maurita Johnson, who began work in November as administrator of the Child and Family Services Division, said she supports legislation calling for the creation of a child fatality review committee.
April Hall of Great Falls will also support the bill, as she has for other legislation to improve the state’s child protective services. Her 2-year-old granddaughter, October Perez, was killed by her mother’s boyfriend in June 2011.
Hall has said she made several reports to Child and Family Services about abuse including broken bones, missing teeth, missing hair and other injuries. But caseworkers left the girl in her mother’s custody.
“The pain that child went through – that’s what haunts you,” she said. “And nobody would listen.”