A review of the 2022 death of a baby who ingested fentanyl and an animal tranquilizer raised several concerns regarding the state Department of Children and Families’ safety planning for families and transparency in its work.
Baby Kaylee S. died in February 2022. DCF had been working with her family since August 2021 because of concerns about neglect after her father left Kaylee and two other children alone in a vehicle in a public parking lot. He was later found to be in possession of 20 bags of fentanyl, according to the report from the Connecticut Office of the Child Advocate.
The accusation of neglect was found to be true, and the state offered services to the family and a plan for ensuring the children’s safety, including steps to get substance abuse treatment for the father.
But the plan wasn’t adequate; DCF didn’t do enough to ensure the steps were being followed, even though workers had evidence the family wasn’t adhering to the plan, according to the report.
Kaylee’s parents were arrested late last year on charges of second-degree manslaughter, risk of injury to a minor and drug charges.
Several children have died or nearly died since 2021 in circumstances that “raised concerns for OCA regarding the lack of consistency in DCF’s assessment and management of family risk and child safety concerns, including timely connection of caregivers to appropriate services,” the report states.
The problems broadly fall under three categories: ensuring families consistently have the supports and services they need, providing quality assurance for case work, and transparency around concerns or problems within DCF so that the agency can get the support it needs to correct issues, said child advocate Sarah Eagan, the state’s child advocate.
“Ostensibly, what it’s about is what monitoring and services are really needed to support our highest-risk, most vulnerable infants and toddlers,” Eagan said.
DCF Deputy Commissioner of Operations Michael Williams said the report came too late to be helpful, that it disregarded changes the state was already making to improve systems and distracted from the important issue of the lethality of fentanyl.
“We’re just shocked that they would try to offer this into the field a year later, after the field has moved so far down the road, that we have an evolution as it relates to fentanyl,” Williams said. “I’m really concerned that this can be confusing by way of timing, that they [OCA] want to contribute to this issue one year after an event has occurred.”
State statutes sets out mandates for OCA, including to “evaluate the delivery of services to children by state agencies” and recommend ways to make them better.
The OCA is working on a wide review of deaths of infants and toddlers over a three-year period. An initial review of 99 showed that 24% of preventable infant and toddler deaths in Connecticut either had open DCF cases or had an open case within the year before the child’s death, according to the report.
After its review of Kaylee’s death, OCA recommended several measures to improve the system.
The recommendations included:
- DCF should implement quality assurance regarding its assessment, safety planning and service delivery for families.
- The state should ensure there’s transparency and accountability within the child welfare system, including reviving the now-dormant Children’s Report Card, a policy tool that legislators use to better understand outcomes for kids in the state. Eagan said it hasn’t been produced in a couple of years.
- The legislature should hold an informational hearing to review the report’s findings and services for families when a caregiver has an opioid use disorder.
- The state’s Opioid Settlement Committee should include people with expertise and lived experience supporting children affected by the opioid epidemic.
- OCA should receive some federal funding allocated by the state for more independent child fatality reviews.
Eagan emphasized that her office still wants to see children remain with their biological families if possible.
“We are not advocating for all of these children to come into foster care,” she said. “We need surgical precision, not amputation.”
Transparency
The agency has distributed training and guidance related to fentanyl use since Kaylee’s death. In August, it issued updated interim safety practice guidance and in October issued interim fentanyl guidance, said Ken Mysogland, DCF chief of external affairs.
DCF has made strides in recent years and last year exited a court settlement known as Juan F. The decades-old case mandated federal court oversight of the state’s child welfare system and required officials to report certain measures related to the system.
The goal of the oversight was to encourage the state to provide services to families instead of taking children away from their parents.
But in lieu of Juan F., the state still needs to provide transparency and ensure best practices are consistently followed within cases, the report states.
“The exit from involuntary federal court supervision cannot mean the end of structured monitoring,” the report states.
Williams said some of the agency’s review procedures, including a long-term review of practices that occurred after Kaylee’s death, are meant to be “internally instructive” and that the agency tries to be as transparent as possible while respecting privacy rules and any criminal proceedings.
“This process that we have — the special review process — isn’t a ‘gotcha’ kind of blaming process,” he said.
DCF reviews a number of things after a child’s death, including evaluating whether there was negligence on the part of any workers. In Kaylee’s case, they didn’t find any, he said.
Although DCF identified some concerns with case practices after Kaylee’s death, it didn’t publicly disclose their specific concerns, according to the report.
Those concerns included some issues similar to those listed in the OCA report — inadequate safety plans for children, inadequate documentation for safety plans in the case file and lack of enough documentation about safety plan monitoring.
Instead, a statement to the media briefly mentioned DCF’s involvement and investigation, the lethality of fentanyl, and efforts to review the case. The statement said DCF couldn’t comment further in part because of pending criminal charges. The OCA report suggests a few measures for public disclosure of findings related to child death cases.
Mysogland said the statement to the media doesn’t represent the breadth of what DCF disclosed publicly, including interviews with print media and radio.
Eagan said she believes more transparency is needed so that any additional support systems DCF needs or changes that should be made can be addressed on a policy level.
“How are you evaluating that work internally, and what are you telling the public and policy makers about that work?” Eagan said. “We need a framework, a mandate, a structure around transparency and accountability. What should the department be required to tell the public about this work?”
Monitoring
Agency monitoring of Kaylee’s family’s safety plan was one of the issues OCA mentioned in its report. It also found that DCF should have more effectively ensured the family had access to services so Kaylee’s father could get help for substance misuse.
Some of those supportive measures could have included education for the mother on supporting a partner with substance abuse problems, additional therapeutic services or housing, Eagan said.
Opioid use is a growing problem nationally and within the child welfare system. In Connecticut, eight infants and toddlers have died because of fentanyl intoxication over the past few years, according to the OCA report.
“While state agencies are working to help adults with opiate use disorder, support gaps remain,” the report states.
Children whose family members have opioid use disorders are more likely to experience maltreatment and neglect. And young children, like Kaylee, are at heightened risk of severe injury or death from abuse or neglect, research shows.
The department has been working with national groups, including the federal Substance Abuse and Mental Health Services Administration, to develop better ways to help families dealing with addiction, Williams said.
DCF caseworkers also hadn’t visited the family in person for about two months before Kaylee’s death, even though the agency has policies that require visits. And workers conducted only announced visits, reflective of a new procedure change in the state agency, Williams said.
The program supervisor also didn’t review or approve the family’s safety plan, the report states.
The report also included information about cases that included problems with safety planning of an infant who died from an infection soon after DCF closed his family’s case and a 1-year-old who almost died from a fentanyl overdose.
“Multiple critical incident reviews from 2021 to the present, including the death of Kaylee S. raised concerns regarding DCF’s assessment and management of family risk and child safety concerns, including timely connection of caregivers to appropriate services,” an email from OCA reads.
Safety planning has been a “weak spot” with DCF in past years, Eagan said.
Williams said the department is implementing a new safety practice model, a process that began before Kaylee’s death. The ABCD Practice Model includes several strategies related to family engagement, visitation and individualized services.
“In real time, our workers and our staff did exactly what they should have done,” Williams said Wednesday. “In retrospect, there’s a lot of things we could look at and learn from and do differently, but in real time, we stand behind our work.”