Critical Incident

Rapid Response
Team

Florida Department of Children and Families

September 7, 2017
 Critical Incident Rapid Response Team

Southeast Region
Circuit 15
Palm Beach County, Florida
2017-223074

Table of Contents

Executive Summary 3

Introduction 5

Case Participants 6

Child Welfare Summary 6

System of Care Review 7

Practice Assessment 7
Organizational Assessment 9
Service Array 9

Florida Department of Children and Families

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Executive Summary

On July 31, 2017, the department received a report regarding the death of 8-year-old
. At approximately 11:20 p.m. on July 30, 2017, came out of her bedroom and told her
mothers paramour (who was watching at the time) that she
was having trouble breathing. had a
previous injury that occurred when, on a dare, she drank boiling water from a straw.

The paramour, 29-year-old , went to find

however, when he returned to the childs
room, he observed to be unconscious and unresponsive. immediately called
9-1-1 and emergency responders arrived shortly thereafter. Resuscitation efforts were engaged
and continued for an additional 40 minutes after her arrival at the hospital; however, were
unsuccessful. was subsequently pronounced dead at 12:15 a.m.

Because there was a verified report received within 12 months of death, DCF Secretary
Mike Carroll deployed a Critical Incident Rapid Response Team (CIRRT) to Palm Beach County
to review the prior interventions with the family and to assess for any potential systemic issues
within the local system of care.

The review team consisted of representatives from DCFs Office of Child Welfare, and from the
Southern Region, DCF Office of Administration, Childrens Legal Services from the SunCoast
Region, and the Child Protection Team medical director from the Southern Region (off-site).

The team reviewed the case records involving all key case participants and conducted interviews
with child welfare professionals involved in the most recent prior abuse investigations and
service case. The following agencies were interviewed during the review: Child Protective
Investigations (CPI) from staff from Palm Beach County, case management staff from Childrens
Home Society, independent living staff from Vita Nova, and regional Childrens Legal Services.

Practice Assessment
The process in place to support children care is very robust with
dedicated workers.

From March 2017, through July 2017, there were multiple opportunities to assess the
family functioning and likelihood of future maltreatment; however, investigations were
closed without a thorough assessment being completed in order to determine what, if
any, support services were warranted.

Organizational Assessment
Communication, collaboration, and partnership between the agencies in the county is
viewed as a strength. Additionally, leadership in the Southern and Southeast regions
have demonstrated a commitment to continuous improvement of communication and
collaboration between the tri-county area, consisting of Miami-Dade, Broward and Palm
Beach counties.

The primary CPI was provisionally certified, requiring a higher level of guidance, had an
experienced supervisor and received a manageable number of cases monthly.

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Service Array
The family should have been referred for family support services
however, a referral was not completed, nor were
services implemented. Additionally, the family was placed and remained on a wait list for
additional services.

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Introduction

On July 31, 2017, the department received a report regarding the death of 8-year-old
. At approximately 11:20 p.m. on July 30, 2017, came out of her bedroom and told her
mothers paramour (who was watching at the time) that she
was having trouble breathing. had recently had a
previous injury that occurred when, on a dare, she drank boiling water from a straw.

The paramour, 29-year-old , went to find

; however, when he returned to the childs
room, he observed to be unconscious and unresponsive. immediately called
9-1-1 and emergency responders arrived shortly thereafter. Resuscitation efforts were engaged
and continued for an additional 40 minutes after her arrival at the hospital; however, were
unsuccessful. was subsequently pronounced dead at 12:15 a.m.

Because there was a verified report received within 12 months of death, DCF Secretary
Mike Carroll deployed a Critical Incident Rapid Response Team (CIRRT) to Palm Beach County
on August 2, 2017, to review the prior interventions with the family and to assess for any
potential systemic issues within the local system-of-care.

This report represents the CIRRTs findings, the child welfare history, and a system of care
review including practice assessment, organizational impact and array of available services.

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Case Participants

1988 1994

Child Welfare Summary

There have been multiple reports received between 2009 and 2017, n u ,nntnn
caregiver occurred in
five other reports rec:el\rea ne1rwe!en
2016, involved allegations of between the mother and her respective
paramour (none of which we

Four of the
supervision

In March, a report was received alleging~ad sustained

she drank boiling water out of a straw when she was dared
This report was subsequently verified for inadequate su
the careg iver responsible. She was in the home watching
girls hair, when the incident occurred. She went outside, leaving
approximately five minutes, at which time the incident occurred.
home at the time of the incident, upstairs asleep.

In May, two reports were r&>.r&>. n .r&>.n one was a reiteration of the March occurrence, in
addition to concerns that not being properly supervised. Both were
closed with no indicators

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In June, a report was received after accidentally ingested that she found while
she was in the care of another relative (different from the March report). The report was closed
as not substantiated.

System of Care Review

This review is designed to provide an assessment of the child welfare systems interactions with
the family and to identify issues that may have influenced the systems response
and decision making.

In this case, both strengths and opportunities for improvement were identified in the following
areas. Although the following findings were not a contributing factor in death, they
provide opportunities for improvement that will benefit to the local system of care.

Practice Assessment
PURPOSE: This practice assessment examines whether the child welfare professionals actions
and decision making regarding the family were consistent with the departments policies and
protocols.

FINDING A: The process in place to support children care is very robust with
dedicated workers.

, the mother was assigned a mentor

through United Way. That mentor is the executive director of the local case management
agency, who had been involved with the family throughout ongoing case management and she
continued to have a relationship with the over the years.

The mother was participating in the Independent Living program, continuing to go to school, and
the program continued to provide day care referrals and the mother was continuing to attend life
skills meetings, occasionally bringing , most recently approximately
six weeks before passed away.

Overall, the time that the mother and were involved with ongoing case management,
connections were created that provided support to the family over the past several years.

FINDING B: From March 2017, through July 2017, there were multiple opportunities to assess
the family functioning and likelihood of future maltreatment; however, investigations were closed
without a thorough assessment being completed in order to determine what, if any, support
services were warranted.

Over a period of four months, there were a total of three investigations concerning allegations of
abuse or neglect made . This provided multiple opportunities to
assess how the family functioned to determine if safe and, if so, if at
risk of future maltreatment.
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The March 2017 report alleged sustained burns to her mouth and throat after she drank
boiling water out of a straw when she was dared by to do so.

Given the nature of the initial incident, Florida Statute requires a

mandatory referral to the Child Protection Team (CPT); however, there is no documentation,
from either the CPI or CPT, to reflect that a referral and consultation occurred.

Also, a determination was made that the investigation did not warrant a family functioning
assessment be completed, ;
however, the mothers paramour was at the home upstairs sleeping when the incident occurred.
The investigation focused solely on outlining what occurred during the incident and had no
analysis to support the investigative findings or to determine safety in the home. It
is noted that the investigative sub-type of Other can be used in non-institutional settings in
which the alleged perpetrator is an adult sitter or relative not residing in the household. While not
required for investigations closed with a sub-type of Other, CPIs have the option of completing
the full assessment to assist in decision making. Completion of the full assessment would have
been beneficial in helping understand and assess the dynamics of the family.

during the report received

in March 2017, , a referral was made for a
psychological/psychiatric evaluation. Despite the referral being made early in the investigation,
there was no follow up in this investigation, or the next as to the status and results of this referral.
Finally, there was an abundance of information available from child welfare partners that had
worked with the over many years. However, they were never contacted
by the investigator. Prior to closure, the risk assessment indicated that safe but
at high risk of future maltreatment; however, the report was closed without further assessment or
referrals to family support services. The report was subsequently verified for inadequate
supervision with the relative identified as the caregiver responsible.

In May, two reports were received, however, one was a reiteration of the March occurrence with
added concerns
that the mother was not meeting medical needs from the burn. This investigation was
correctly identified as an in-home case and was referred to CPT; however, the referral occurred
a month after the report was received. CPT completed a medical evaluation and specialized
interview and found that all of medical needs were being met. The investigation revealed
that there was a glitch with the pediatricians computer system and the mother had not missed
any appointments. While the incident that was originally reported was correctly unfounded, the
mother reported that she was having a hard time
balancing now complex medical needs and the basic needs of

The CPI promptly referred the mother for an assessment and any follow up services needed
through Legacy Behavioral Health Center, however upon follow up by the CPI at the conclusion
of the investigation, an intake had been completed but services had not been initiated. The CPI
did not document the recommendations from the intake and closed the investigation before
services had begun. Just prior to closure, the risk assessment was completed and indicated that
at moderate risk of future maltreatment. However, the risk assessment was
inaccurate and at high risk of future maltreatment. This would have required a
mandatory referral to family support services, which are prevention-based services that provide
support and education to the family.

The third and final report prior to death was received in June. The report was received
after accidentally ingested that she found while she was in the care of another

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relative, a different one from the prior investigation. The report was closed as not substantiated.
While the appropriate determination was made by the CPI handling this report, the CPI did not
follow up with the providers to ensure services from the prior investigations had been initiated.

Organizational Assessment

PURPOSE: This section examines the level of staffing, experience, caseload, training, and
performance as potential factors in the management of this case.

FINDING A: Communication, collaboration, and partnership between the agencies in the county
is viewed as a strength. Additionally, leadership in the Southern and Southeast regions have
demonstrated a commitment to continuous improvement of communication and collaboration
between the tri-county area, consisting of Miami-Dade, Broward and Palm Beach counties.

Interviews indicated that there is good communication and partnership between investigations,
case management, children's legal services, and the child protection team. There are regularly
scheduled legal staffings twice a week, as well as regular meetings between all parties to
facilitate communication. A conflict resolution process is utilized when needed.

The Southeast and Southern regions utilize their tri-county protocol to guide CPis on
requirements for communication and collaboration during joint investigations. The tri-county
protocol was created years ago, under the guidance of regional leadership. It is continually
updated to address new issues that arise and any changes in requirements and outlines
expectations for any circumstance when multiple CPis are involved in a case.

FINDING B: The primary CPI was provisionally certified, requiring a higher level of guidance,
had an experienced supervisor, and received a manageable number of cases monthly.

All three investigations received since March 28, 2017, were investigated by the same CPl. The
CPI holds a Master's degree in social work and had previous work experience providing targeted
case management to children; however, was new to child protective investigations, had only
completed training four months earlier, and was still provisionally certified. The supervisor holds
a social work degree, has five years of experience as a CPI and seven years as a supervisor.
The unit had a CPI to supervisor ration of 5:1, which is within the recommended range outlined
by the Child Welfare League of America.

The CPI, who was provisionally certified, required a higher level of supervisory guidance. The
severity of the injuries to the child , the frequency with which reports were received , and the
significant prior history made this an extremely complex case. Additional supervisory guidance
would have helped ensure all relevant information was gathered and utilized in completing a
thorough assessment of the family, assessing the sufficiency of the information gathered, and
providing guidance on the collaterals to be contacted, as well as ensuring the risk level was
correctly identified .

Month CPI Unit 29 County

(Total) (Average) (Average)
March 2017 11 11.6 10.2
Apri12017 13 14.6 11
May 2017 19 15.2 11.8
June 2017 10 10.8 7.7
July 2017 9 10.2 8.3

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The number of reports received by the CPI, the average number received monthly for the unit
and the county and the number of reports received during the time these reports came in, was
reviewed by the team and determined to be manageable. In every month reviewed, the CPI
received fewer cases than the average for the unit and county, except for May 2017.

Service Intervention/Array

PURPOSE: This section assesses the inventory of services within the child welfare system of
care.

FINDING A: The family should have been referred for family support services as
determined to be safe but at high risk, however, a referral was not completed, nor were
services implemented. Additionally, the family was placed and remained on a wait list for
additional services.

As outlined in operating procedure, CFOP170-5, Chapter 21, Assessing and Responding to Risk,
every family whose children are determined to be safe but at high or very high risk of future
maltreatment be referred to a family support service program. The majority of these voluntary
programs utilize evidence-based or evidence-informed practices aimed at increasing protective
factors in families.

In this case, during the March 2017 investigation, the CPI initially determined that
safe but at high risk; however, the investigation was closed as an investigative sub-type of
Other prior to completing the assessment, with verified findings for inadequate supervision,
identifying a babysitter as the caregiver responsible for the maltreatment. The family was not
referred to family support services, which are handled by Boys Town in Palm Beach County. In
the May 2017 investigation, risk was incorrectly identified as moderate risk, thus not requiring a
referral to family support services.

The family received multiple referrals during the time they were involved with the department,

. was initially referred to the Legacy program for

evaluation and counseling on April 24, 2017, and a referral was made on June 28, 2017, for
family counseling; however, services were never initiated. There was a wait list for some of the
referred services.

Florida Department of Children and Families

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