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Abandoned in Hell
The majority of Kentucky children who die or nearly die in abuse and neglect cases had previous contact with social workers, five years after the state committed itself to being a better protector.
Kentucky continues to fail children five years after it pledged to better protect them.
In response to several embarrassing stories and legal challenges by the Herald-Leader and The Courier-Journal of Louisville, then-Gov. Steve Beshear established in 2012 an independent panel of medical, legal and social work experts to review cases of children who are killed or severely injured by abuse or neglect. The panel gives special attention to cases in which the Kentucky Department for Community Based Services had previous involvement with a family but failed to prevent a tragic outcome.
“When a child dies or is critically injured because of abuse or neglect, we must carefully review the practices of all government entities involved to make sure that our system performed as it was supposed to,” Beshear said at the time. “If not, that review allows us to take disciplinary action.”
The panel has met dozens of times. It has carefully read the files from several hundred cases, and it issues annual reports to state leaders with its conclusions about what went wrong for each child and what could be done better in the future.
However, the number of substantiated child abuse and neglect findings in Kentucky has steadily risen from 9,934 in fiscal 2012 to 15,378 in fiscal 2016, according to Community Based Services. At least 334 children in those cases died or nearly died from mistreatment.
And the heightened scrutiny has not significantly reduced how often children die or are severely injured despite the presence of state social workers. In its 2014 report, the panel said 66 percent of the 116 cases it reviewed had previous involvement by Community Based Services. In its 2016 report, issued at the start of January, that number was 59 percent of 116 cases — still more than half. Among the cases with state involvement, there was an average of 4.25 previous contacts, the report said.
The state’s court system proved no more effective at preventing tragedy. Fifty-seven percent of the cases the panel reviewed in 2016 had a history that could be tracked either through criminal proceedings or behind closed doors in dependency, abuse and neglect hearings. Each of those cases averaged 6.2 court contacts before the child fatality or near-fatality occurred.
Nearly half of the children’s deaths reviewed in 2016 were “potentially preventable,” the panel concluded. It cited many problems it found along the way, from bystanders who failed to report suspected abuse to social workers sometimes “screening out,” or rejecting, substantive tips that are called in, leaving children in danger. When the state does act to remove a child from a chaotic home, there might not be enough stable relatives or foster parents available to accept them.
Dr. Christina Howard, a panel member and chief of pediatric forensic medicine at UK HealthCare, said in a recent interview that she has been forced to call child sexual abuse reports in to Community Based Services three or four times before the reports were accepted. Howard said she always insists that social workers call her back to let her know whether a case was opened concerning her report and, if so, to whom it was assigned. Otherwise, she said, she never would know what happened after she passed along her information.
Kentucky isn’t making anywhere near the progress it should to keep children safe, panel members said in interviews. DCBS is struggling to monitor too many cases even as more families collapse every year into drug addiction, they said.
“We need a systemic, a top-to-bottom tightening of the safety net in this state, because too many children are continuing to fall through even when we’re aware of a bad situation,” said Ed Staats, a panel member who oversees more than 700 volunteers statewide through the Citizen Foster Care Review Board.
“I think if the public understood the system better, they would be a lot more concerned about it,” Staats said. “These cases — every single one of them is serious to somebody. And some of them are truly godawful.”
The Kentucky Cabinet for Health and Family Services, which oversees DCBS, says it received 105,527 allegations of child abuse or neglect in fiscal 2016, of which 52,424 met the criteria necessary to start an investigation. Of those, 15,378 were substantiated.
The cases reviewed by the independent panel are a small sample of the total.
“Hindsight is 20/20,” said Tim Feeley, the cabinet’s deputy secretary and a former family court judge. “You never know how it’s going to come out, but you have to make the best call when you’re seeing a case. On the fatality review board, it’s a wonderful review to point out where we might have made mistakes. But they don’t — they see those cases that did turn out badly for a child. They don’t see the overwhelming number of cases where we do the right thing.”
The cabinet’s primary mission, Feeley said, is to reunify children with their biological parents.
“When we know that there’s a safety issue, we step in and do the best we can,” he said. “If we suspect there’s a safety issue, it’s not so easy to just say we’re taking children away from a parent.”
An overwhelmed system
Some of the panel’s recommendations over the past five years have proven slow to implement, including opening up family court proceedings involving abused and neglected children so the system can be scrutinized by the public.
The General Assembly passed a law a year ago to launch that effort. But no courts have opened these hearings yet. Instead, judicial circuits encompassing Jefferson, Hopkins, Harrison, Nicholas, Pendleton and Robertson counties have agreed to be part of a future pilot project to experiment with public hearings, although the court system is working with an outside consultant on the details.
As written, the law would not allow courtroom observers to make audio or visual records of the abuse and neglect hearings, or publicly report the names of people involved, and that would make news coverage difficult if not impossible. When the panel recommended opening abuse and neglect hearings, it called for full transparency “to increase public awareness.” The legislation that ultimately passed was a compromise measure, panel members said.
“The worst part of my first year as a judge in these cases was that none of the horrible things I was seeing in my courtroom every day — the horrible things happening to children — none of that was reported in the newspaper, because nobody from outside was allowed to watch. And I wish they were!” said Jefferson Family Court Chief Judge Paula Sherlock, a longtime advocate for opening court proceedings. “Instead of stories about a puppy being thrown from a truck window, as bad as that is, we should be reading about the dozen children who are being killed or nearly killed by their own families.”
Other recommendations from the panel carry hefty price tags, including its call for “necessary funding” for the “grossly underfunded” DCBS, which has lost tens of millions of dollars because of state budget cuts from 2009 through this year.
Apart from the cuts, Gov. Matt Bevin put $3.3 million in the current two-year state budget to provide pay raises for social workers and family support employees. Still, some of Kentucky’s social workers juggle 60 to 80 cases at once, a load that is several times heavier than recommended and that leads to high rates of staff burnout and turnover.
In 2013, DCBS suspended for five days a social worker in Madison County, Robert Wayne Baldwin, who skipped home visits with two dozen of his assigned families for as long as half a year. Before he agreed to accept his punishment, Baldwin briefly appealed to the state Personnel Board, arguing that the caseload he inherited from his exiting colleagues was unmanageable.
“I was unfairly suspended for my being overwhelmed by swollen case numbers,” Baldwin wrote in his appeal. “With the numbers and intensity of cases, it was impractical and near impossible for me to give quality services to between 50 and 60 families in a given month.”
In November, social workers warned a legislative committee in Frankfort that the state is sweeping abused and neglected children “under the rug” by not adequately funding DCBS. Social workers who remain at the agency are overworked, underpaid and horrified by what they witness every day, they said.
“It’s about the exposure to children being beaten until they are dead, or neglected so badly that they eat their own feces because that’s how they survived, and having a supervisor who doesn’t understand why your investigation is past due,” said Rachel Blanford, a DCBS social worker who quit for a job in the private sector. “It’s about dealing with mental illness and substance abuse and domestic violence and not having adequate training. It’s about walking into a home where a mother is lying lifeless with a needle in her arm, and the baby is soaked in urine with a bottle of spoiled milk and cheeks that should be chunky are sunken in, and you have no place to put that baby, no home to place that baby.”
Hiring more social workers around the state — there are about 1,800 who work in the division that protects children — would cost millions. But the legislature won’t revisit the state budget until next year.
“I think the average legislator would tell you they’re concerned about this. But I can’t tell you what they’d be willing to actually do to make the system more responsive for the children,” said state Rep. Tom Burch, D-Louisville, who until December was chairman of the House Health and Welfare Committee and a member of the independent panel that reviewed cases.
“I do predict there won’t be any tax increases to raise money to take care of these babies,” Burch said. “You can take that prediction to the bank right now. We’ll pass legislation against abortion all day long, but once the babies are born, they’re on their own.”
State Rep. Russell Webber, R-Shepherdsville, who leads the House budget subcommittee that controls DCBS funding, said, “Right now, we’re still a year away from the next budget session.” Nobody has shown him what DCBS will request or how much state money will be available in 2018, Webber said.
“As the new chairman of this budget subcommittee, I can tell you that certainly children are a priority for me, and I think they’re a priority for the leadership in the House,” he said.
Catching the errors
The Cabinet for Health and Family Services will spend most of 2017 assembling a list of what it needs from the state budget in 2018 to better serve families, DCBS commissioner Adria Johnson said.
That’s likely to go beyond money to hire more social workers, important as that is, Johnson said. For example, she said, the cabinet hopes to restore the Kinship Care program that provided a $300 monthly stipend to relatives who agree to accept children removed from a troubled home. State budget cuts forced the program to stop accepting new people in 2013.
Johnson not only runs DCBS, she also sits on the panel that meets to examine — and often criticize — her agency’s work. It has been an educational experience, she said.
“Each case is unique in some respects, so it’s hard for me to make a sweeping statement as to ‘Here are certain deficiencies,’” she said. “I do think I have a workforce that works extremely hard at doing their job each and every day they come here to do that. I’m also not too naïve to know that when caseloads are high, when the work is overwhelming, that that by and of itself can lead to certain things that we see in certain cases.”
Over the past five years, DCBS has tried to improve its practices in several ways, Johnson said. The agency has created a stronger, standardized internal review process to determine what went wrong after a child fatality or near-fatality in which social workers had previous involvement, she said.
In one such case, in January 2016, a 4-year-old Lexington boy was pulled down the stairs and knocked unconscious by his mother’s boyfriend, Carl Jason Carpenter, a 6-foot, 3-inch, 220-pound heroin addict. The boy was rushed to University of Kentucky Chandler Hospital, where he stayed for more than a week with brain bleeding, retinal hemorrhages and severe bruising. Carpenter pleaded guilty six months later to criminal abuse. Fayette Circuit Judge Ernesto Scorsone agreed to let Carpenter serve his five-year sentence on probation instead of prison after Carpenter told the judge he wanted to be free to spend time with his own four children.
Social workers had been involved with the Lexington boy’s family because of past child abuse and neglect reports, including one filed two days earlier. The cabinet’s internal review uncovered a lengthy list of errors, including failure to properly investigate past abuse, failure to document a history of domestic violence in the home, failure to determine why two other children no longer lived in the home and failure to address the mother’s poor mental health and drug use. Also, some case plans looked as if they were “copied and pasted” and not newly prepared based on family members’ individual needs, the internal review stated.
DCBS records released to the Herald-Leader under the Kentucky Open Records Act do not reveal what steps, if any, were taken after the internal review, such as disciplinary action or policy changes.
Johnson said she is always concerned when DCBS is warned of problems in a home, and yet a child is nonetheless killed or badly hurt. Based on what it has learned from its internal reviews, the agency is working to be more sensitive during the intake process so legitimate abuse and neglect reports aren’t screened out, she said. Once an investigation is opened, social workers are communicating more closely with their supervisors. When children at risk are 4 or younger, the county-level offices initiate a “high-risk consult that gets elevated to here (in Frankfort) at central office,” she said.
“I do think that we have done a good job of putting into place appropriate supports and higher-level reviews to ensure that a front-line worker isn’t making a decision in isolation and has the support that they need, (and is also) looking comprehensively at what has happened with that case and with the prior history,” the commissioner said. “It’s just continuous quality improvement over our work.”