Watchdog Report: Reviews of child abuse deaths not always completed

Cabinet did not do required evaluation in some abuse cases

bmusgrave@herald-leader.com, bestep@herald-leader.comJuly 22, 2012 

FRANKFORT — Derek Cooper was just 2 years old when his father, Brandon Fraley, put his hands over the crying toddler's mouth "until the child was silent," according to a state file on the case.

"The love and laughter that once surrounded our family has disappeared and in its place a heavy fog of despair has settled," Jessica Wall, the boy's mother, wrote in a victim impact statement when Fraley was sentenced to 10 years in prison.

According to the social services case file on Derek, which the Lexington Herald-Leader obtained through a court order, there was a previous allegation of domestic violence by Fraley in 2006 that was unsubstantiated by social workers. There also were other previous reports involving Fraley when he was a child.

Still, state child-protection workers did not conduct an internal review of Derek's death, even though state law mandates such a review by the Cabinet for Health and Family Services in every case in which a child dies, or nearly dies, because of abuse or neglect and the cabinet "had prior involvement with the child or family."

A Herald-Leader analysis of 41 child fatalities in 2009 and 2010 found at least six cases where the cabinet did not do an internal review even though there were previous reports involving the family before the child died. The reviews are supposed to examine the cabinet's actions in a case to see if there were missteps, and to identify needed improvements and training that could prevent future deaths.

In some of those six instances, the cabinet's prior contact with adults in the cases occurred when they were children themselves, and the cabinet does not do internal reviews in such cases, said Jill Midkiff, a cabinet spokeswoman. She cited that reason in Derek's death, but provided no explanation about why the 2006 domestic violence investigation of Fraley didn't trigger an internal review of Derek's death.

Terry Brooks, executive director of Kentucky Youth Advocates, said if the cabinet is not doing internal reviews as required, officials may miss an opportunity to fix problems in the child-protection system.

"One of the reasons why they are so important is for systems change," Brooks said of the internal reviews. "It's like a coach looking at a game tape — you have to figure out what went right and what went wrong."

A lack of confidence in the cabinet's internal reviews was one reason Brooks and other advocates applauded a move last week by Gov. Steve Beshear to create a new panel outside the cabinet to review child deaths and critical injuries caused by abuse and neglect in Kentucky.

The 17-member panel will meet quarterly, review the cases and make recommendations. The review panel will be housed in the Department of Justice and Public Safety, and the people on the review panel will not be cabinet staff.

Brooks said the external reviews can serve as a check to make sure the cabinet is following its protocols consistently, backing up its promises with actions. Brooks said he hopes outside reviews also will examine the adequacy of the cabinet's internal reviews.

There were wide inconsistencies in how different child-protection offices around the state conducted internal reviews in 2009 and 2010, and in the scope of recommendations they produced. Some of the reviews appeared to be thorough, but in others, child-protection workers produced only one-page reports with little detail on what happened to the children and no assessment of potential improvements, a Herald-Leader review found.

State Rep. Susan Westrom, D-Lexington, who sponsored an unsuccessful measure to create an external child-fatality review panel earlier this year, said she was encouraged Beshear moved to create such a body. But the cabinet also needs to do good internal reviews, Westrom said.

"The cabinet for so long has hidden everything it could," she said.

Angel Tucker

The death of 5-month-old Angel Tucker also did not spur an internal review by the cabinet, even though there was a prior report involving Brittany Felty Garcia, Angel's mother, a month before Angel's death.

The Medical Center at Bowling Green called cabinet officials after Garcia brought Angel to the hospital in November 2009 after reportedly falling down stairs with the baby.

Hospital staff contacted the cabinet because Garcia had delayed bringing the baby in for treatment, but child-protection workers did not accept the report. Instead, the cabinet made a "resource linkage," meaning a link to other services or information.

Angel, who lived in Morgantown, died Dec. 4, 2009, as a result of blunt-force injuries to her head and spine.

Midkiff, the cabinet spokeswoman, said the commissioner who oversees child-protection workers would review Angel's case on Monday to explain why an internal review was not conducted.

Other examples in which the cabinet did not do an internal review include:

■ Kayla Mosley, 2, who died of an acute drug overdose in March 2010 in Bell County. Authorities believe her parents were not watching her when she swallowed their pills. According to the case file, there was at least one prior report involving her parents in 2008.

Details about the prior report were removed from the file provided to the newspaper, as they were in many other case files. The newspaper, along with The Courier-Journal of Louisville, is in an ongoing legal battle with the cabinet over how much information from the case files the state must release.

Midkiff said the state would review Kayla's case on Monday to determine why an internal review was not conducted.

■ Kiara Smith, who was 12 months old and lived in Grant County when she died as a result of blunt force trauma in January 2009. Her mother's boyfriend, Brandon Barnhill, was convicted of beating her to death. The case file indicates that there were no reports against Kiara's mother, who was 17 at the time of Kiara's death. However, there were numerous reports regarding Kiara's grandmother.

Barnhill's conviction was overturned on appeal, but the prosecutor, Jim Crawford, said he will retry Barnhill on the murder charge.

Midkiff said no internal review was conducted because the state does not do them in cases where the cabinet's prior involvement with an adult came when the person was a child.

■ Cole Frazier, 21 months, who was shot and killed by his father in May 2009 in Nelson County. The cabinet had received multiple reports of domestic violence between Cole's parents while the child was present, including one days before Cole's death. The cabinet did not investigate the last claim of domestic violence because Cole's parents did not live together at the time, according to the case file.

When the Herald-Leader first reported about Cole's death in January, Midkiff said no review was required because there was no ongoing case involving the family, and the prior reports involved domestic violence among adults in the home, not allegations of abuse or neglect to the little boy.

■ Kayden Branham, also known as Kayden Daniels, who died in May 2009. The 20-month-old Wayne County toddler drank a caustic drain cleaner that had allegedly been used in making methamphetamine at the mobile home where Kayden and his 14-year-old mother were staying.

Kayden's mother had been removed from her parents' home and placed in foster care earlier, but she and the baby had been returned to her mother's home before Kayden's death. All three — the grandmother, the 14-year-old mother and Kayden — were still being supervised by the cabinet at the time he died.

The cabinet said it did not do an internal review because there was a court order in place for a short time that barred anyone other than mental-health professionals and defense attorneys from talking to Kayden's mother about his death.

However, that order would not have prevented an internal review. Also, it was later dissolved.

An attorney involved in the criminal case related to Kayden's death said a review would show that the cabinet didn't do enough to protect the boy.

Amy Dye

In another high-profile case, the cabinet acknowledged it did not do an internal review after the death of Amy Dye, a 9-year-old who was killed in February 2011 by her adopted brother in Todd County.

The cabinet had prior involvement with the family, facilitating Amy's adoption by her great-aunt and later checking into reports from school officials about concerns that the vivacious girl was being abused at home, according to records.

The cabinet said it had no jurisdiction to pursue those reports because a sibling, not a parent, was allegedly hurting Amy, but Franklin Circuit Judge Phillip Shepherd flatly rejected that assertion in a ruling last November.

It is clear under state law that abuse includes situations in which a parent or guardian ignores physical abuse of one child by another, or fails to take action, Shepherd said.

"This case presents a tragic example of the potentially deadly consequences of a child welfare system that has completely insulated itself from meaningful public scrutiny," Shepherd wrote last November.

Cabinet officials said the agency did not do an internal review because Amy died at the hands of a sibling, not a parent or guardian.

Bill Estep: (606) 678-4655. Twitter: @billestep1; Beth Musgrave: (502) 875-3793. Twitter: @BGPolitics. Blog: bluegrasspolitics.bloginky.com

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