Child Fatalities and Critical Incidents. Headlines Accused of Neglect in the Past, Mother is Charged in Childs Injuries Cited for neglect on three prior.

Child Fatalities and Critical Incidents

Headlines “Accused of Neglect in the

Past, Mother is Charged in Child’s Injuries”

Cited for neglect on three prior occasions

“Abuse Allegations Made Before Child’s Death”

Headlines “Case Raises questions

about Child Protection in State”

“Mother in Child Death Case Lost Custody Twice” Child was beaten to death on her birthday

What Happens after the Headlines?

Four Outcomes Critical to Success

Safety Assurance and Response to Family

Usually handled at local office level.

Should have designated person to advise, consult and provide oversight.

Assignments should be made based on ability to perform certain tasks.

Safety Assurance and Response to Family May need to do some re-assignments

for current situation.

CPS safety assessment should occur simultaneously with the agency review process.

Develop a support plan for the family.

Public Accountability/Media Response Gather case record information using a

specific protocol.

Designate a media point person.

Within 24 hours, at least, provide media response with information on the critical incident review procedures.

Public Accountability/Media Response Acknowledge the tragedy within the

confines of confidentiality restrictions–

Whenever a child dies or is severely injured, it impacts all of us significantly.

Our staff works hard everyday to address the safety of children.

Public Accountability/Media Response Provide any initial info that can be

provided to the media and give a timeframe for when additional information will be released.

Keep providing updated information as more is known about the case.

Identify and Address Systems Issues Separate reviews of personnel actions

from case reviews for the purpose of systems improvement.

For purposes of systems issue focus the case review on CPS agency involvement with the family that occurred within the last three years.

Identify and Address Systems Issues Conduct case reviews according to set

format and in a designated timeframe usually 30-45 days to assure that all known information has been collected.

Timeframe examples from Washington State and Oregon:

Activity Due

Child fatalities or near-fatalities resulting from alleged CA/N on open cases or on families receiving services within 12 months of fatality

Report to Office of Risk Management (ORM) by telephone within 1 hour of receiving information.

All Administrative Incident Reports Report in AIRS within 24 hours of receiving information. When automated transmission in AIRS is not possible, report by phone to ORM or DLR as appropriate.

Regional Administrator (RA) or designee reviews administrative incident report

Review within 48 hours of receipt of AIRS email notification.

Completed Initial Administrative Incident Report, including follow-up in AIRS

Completed in AIRS within 10 working days.

Child Fatality The Regional CPS Program Manager or designee reviews the case record within 14 calendar days of receiving notification of the child fatality.

5160. Administrative Incident Reporting Timelines

Child Fatality The Regional CPS Program Manager or designee provides the RA with a summary of the case within 45 days.

Child Fatality Review (CFR) Final report is completed and documented in AIRS within 180 days of report of fatality.

Executive Child Fatality Review (ECFR) Completion of the final report and documentation in AIRS within 180 days of the report of fatality.

CFR Work Plans Work plans are completed and documented in AIRS within 30 days of the Child Fatality Review or Executive Child Fatality Review.

Quarterly reviews of all administrative incidents documented in AIRS

Reviews occur quarterly*:

Statewide program managers with responsibility for management of administrative incidents conduct an internal review to evaluate occurrences, potential trends and summarize findings, with recommendations. Regions and each local office review administrative incidents occurring in their jurisdictions *January-March; April-June; July-September; October-December

Identify and Address Systems Issues Timely knowledge transfer is critical

once issues about practice have been identified.

Set up a system of routine staff alerts. Example: New York Child Safety Alerts are provided routinely, numbered and included in all training for existing and current staff.

Identify and Address Systems Issues

Identify and Address Systems Issues

Document findings of case review in a report with recommendations for next steps listed with timelines.

Make changes as quickly as possible and regularly review progress on implementation of changes.

State Examples of Review Processes Georgia-

Example of Child Death/Serious Injury Report:http://www.dfcs.dhr.georgia.gov

Oregon-Example of Child Fatality Report:http://www.oregon.gov/DHS/abuse/publications/children/md-cirt-final.pdf

Examples of Review Protocol:http://www.dhs.state.or.us/policy/childwelfare/

manual_1/critical_incident_protocol.pdf

State Examples of Review Processes Washington State-

Administrative Incident Reporting Procedures(AIRS):

http://www.dshs.wa.gov/ca/pubs/mnl_Ops/Chapter5.asp

New York-Agency Reporting Form:http://www.ocfs.state.ny.us/main/forms/cps/

Stabilize Work Environment and Respond to Staff Needs

Critical incident or child fatality can have a devastating effect on the office environment.

This is particularly an issue when the child is known to the CPS agency.

Stabilize Work Environment and Respond to Staff Needs Not only does the event impact the

direct worker and supervisor, it can impact:

Stabilize Work Environment and Respond to Staff Needs

“Negative media leaving workers feeling disheartened and devalued leads to low organizational commitment”

“Investigative workers are more apt to be fired or dismissed”

Burstain, J. (2009)

Stabilize Work Environment and Respond to Staff Needs

“Emotional exhaustion consistently predicts an intention to leave in caseworkers”

Journal of Public Child Welfare (2006)

Stabilize Work Environment and Respond to Staff Needs Constant media reports can keep the

strain on the office active.

Sometimes personnel action is related to need to show accountability rather than malfeasance on the part of staff.

Stabilize Work Environment and Respond to Staff Needs Supervisors and managers as well as

caseworkers need regular training updates on the impact of secondary trauma.

Any critical incident stress debriefings should be provided by uninvolved parties.

Stabilize Work Environment and Respond to Staff Needs Keep in mind that just like the grief

process, staff may be in shock and denial in the early stages of the event.

The effectiveness of immediate critical incidents debriefings will be impacted by the stage of grief.

Stabilize Work Environment and Respond to Staff Needs Critical incident stress debriefing

should be offered again at key points such as:

Stabilize Work Environment and Respond to Staff Needs Display attitude that we are in this together.

“ A professional organization culture characterized by supportive adaptive leaders strengthens Child Welfare staff member intent to remain employed”

Children and Youth Services Review (2009)

Conclusions

Be timely in response, reviews and information dissemination.

Commit to:

For Technical Assistance

925 #4 Sixth Street NWAlbuquerque, New Mexico 87102Phone: 505-345-2444Fax: 505-345-2626www.nrccps.org

References1. Burstain, J., “A Better Understanding of Caseworker Turnover Within

Child Protective Services,” Policy Page 9 (364) (Texas: Center for Public Policy Priorities, February 4, 2009).http://www.cppp.org/

2. Strolin, JJ., McCarthy, M. and Caringi, J., “Cause and Effects of Child Welfare Worker Turnover: Current State of Knowledge and Future Directions,” Journal of Public Child Welfare1(2)(2006): 29-52.

3. Ellett, A., “Intention to Remain Employed in Child Welfare”

Children and Youth Services Review v. 31 (2009): 78-88.