Kentucky overhauls procedure for investigating deaths of abused children

bmusgrave@herald-leader.comAugust 3, 2012 

FRANKFORT — Kentucky's child-protection agency has overhauled in recent months the way it conducts internal reviews of cases involving children who died of abuse or neglect, a move that follows intense scrutiny from the state's two largest newspapers.

The Cabinet for Health and Family Services is required to examine its own actions after an abused or neglected child is critically injured or dies if state social workers had "prior involvement with the child or the family." The reviews are aimed at highlighting missteps and recommending policy changes to prevent more deaths.

A December analysis by the Lexington Herald-Leader of 84 internal reviews from 2009 and 2010, which were obtained through a court order, showed vast discrepancies in the way internal reviews were conducted.

In some geographic areas, child-protection workers routinely did extensive reviews of the cabinet's prior contact with a family and made detailed recommendations for policy changes. In other areas, internal reviews sometimes consisted of one page that failed to include basic facts about a child's death.

Since December, the cabinet has overhauled and streamlined how it conducts internal reviews, said Teresa James, acting commissioner of the Department for Community Based Services. James said that the agency now has a standard form which must be used for all internal reviews and that staff are given key topics on which to focus.

She said the template would result in "a greater amount of consistency." Any recommendations generated from internal reviews will require action plans to help ensure that recommendations are followed, she said.

"We will have more information both on the statewide and the countywide level to show what we have done to be accountable to those recommendations," James said.

A new person is overseeing the internal review process, she said.

Terry Brooks, executive director of Kentucky Youth Advocates, a Louisville non-profit, applauded the cabinet's changes.

"This is a critical and significant step forward in terms of accountability, transparency and quality assurance," Brooks said.

"The cabinet's commitment will ensure that whether a youngster lives in Pikeville or Paducah, he will have guarantees around consistent best practices. That consistency can lead to systems change that is deep and needed."

On July 22, the Herald-Leader reported that an analysis of 41 child-abuse deaths from 2009 and 2010 found at least six instances in which the cabinet never conducted an internal review even though it had prior contact with the family.

The cabinet discovered last week that it had completed an internal review in one of those cases — the death of Derek Cooper, a 2-year-old Lexington boy who was suffocated by his father, Brandon Fraley, in August 2010.

The cabinet failed to release its review of Derek's death in December 2011, as Franklin Circuit Judge Phillip Shepherd had ordered. (The Herald-Leader and The Courier-Journal of Louisville had sued the cabinet to get access to the state's records on children who died of abuse or neglect.)

Derek's case was unique because it took several months to determine his cause of death, said Tina Webb, the cabinet's assistant director of protection and permanency.

A second case file was opened after it was determined Fraley suffocated the child, Webb said. The two case files — which were labeled with two different names — created confusion that caused cabinet officials to overlook the internal review of Derek's death, she said.

"There was confusion in the merging of those two cases," Webb said. "It was a process problem."

Webb said she was confident there are no other internal reviews from 2009 and 2010 that haven't been made public.

The internal review conducted by child-protection workers after Derek's death was eight pages long. It included details about a 2005 domestic violence investigation that involved Fraley and a woman who was not Derek's mother.

The woman said Fraley choked her and hit her. No children where in the room at the time of the incident, so it was not accepted as a child-abuse investigation, according to the case file.

The sole recommendation of the internal review was to consistently label case files using a mother's name to make it easier to track families.

Earlier this month, Gov. Steve Beshear appointed a 17-person outside panel to review all deaths and near-deaths of abused or neglected children. The first meeting of that panel has not been scheduled.

Beth Musgrave: (502) 875-3793. Twitter: @BGPolitics. Blog: Bluegrasspolitics.bloginky.com.

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