A new report from the Vermont Citizens Advisory Board says systemic problems with the state’s child protection processes contributed to the deaths of two children this spring.
The 26-page report raises serious questions about communication, quality control, training and investigations at the Vermont Department for Children and Families, as well as within law enforcement and the state court system.
The board was established in 1995 to "examine policies, practices and procedures of the state's child protection agency."
The board, which is also allowed to review the department's performance in specific cases, has been working on the report for months after Gov. Peter Shumlin authorized a review of the deaths of both 2-year-old Dezirae Sheldon in February and 14-month-old Peighton Geraw in April.
The report says that “our current systems, including child welfare, law enforcement, courts and community-based services, failed to protect both children” and that “existing policies and procedures were not followed throughout the system and not just at the Vermont Department for Children and Families.”
Despite these reported failures, DCF Commissioner Ken Schatz said Friday that there was no wrongdoing by DCF staff, and no one was disciplined for the handling of the cases.
"We have not looked at these matters as 'somebody did something wrong.' What we look at it is that we need to make some changes to our policies and practices," Schatz said.
The report, too, said that the policies in place are inadequate to protect Vermont’s at-risk children.
The deaths, in which abuse is suspected, were followed over the summer by at least three others in which parents or other members of the household are suspected of contributing.
- In July, 2-year-old Aiden Haskins died under the care of his mother’s boyfriend, Joshua Blow. Blow was charged with second-degree murder in the case, and entered a not guilty plea.
- Also in July, four-week-old Saunders Gilruth died at the University of Vermont Medical Center (formerly Fletcher Allen Health Care) a week after emergency responders took him, reportedly unresponsive, from a Burlington home. His mother, Rosemary Gile, was charged with involuntary manslaughter in that case earlier this week. She is expected in court Dec. 4.
- In August, 13-year-old Isaac Robitille died after his mother, Melissa Robitille and her boyfriend Walter Richters allegedly injected alcohol into his IV tube. The AP reports that the disabled teen had a blood alcohol content of 0.146 percent at the time of his death, about twice the legal limit for driving.
New Leadership
The string of deaths led to calls for reform within the Department for Children and Families and its parent agency, the Vermont Agency of Human Services. The Secretary of Human Services, Doug Racine, was fired by Shumlin’s staff in August and replaced by former Health Commissioner Harry Chen, who is filling in through the end of 2014. Soon after, DCF Commissioner David Yacovone stepped down from that post. He was replaced by Ken Schatz, who until then served as general counsel for the Agency of Human Services.
Since the high-profile deaths this spring, DCF has been working internally to fix shortcomings, including insufficient numbers of caseworker staff that this week’s report cited as a major – and still unresolved – problem.
Systemic Problems
The new report from the Vermont Citizens Advisory Board made sweeping statements about the quality of Vermont’s ability to protect children, but also got into specifics.
Using confidential reports from inside DCF along with court documents and caseworker notes, VCAB painted a picture of an understaffed department where social workers face unreasonable pressure to close cases quickly and to reunite children with their families.
“An under-funded, under-resourced system has created a culture within the court, the state’s attorney’s offices and DCF that puts an emphasis on bringing resolution to and closing cases as quickly as possible, sometimes without adequate attention or review.”
"An under-funded, under-resourced system has created a culture within the court, the state's attorney's offices and DCF that puts an emphasis on bringing resolution to and closing cases as quickly as possible, sometimes without adequate attention or review." - Vermont Citizens Advisory Board
In each of the cases under review, that closure was brought when the children were returned home to their families, where they later died.
While DCF policy states that “reunification” should only be done when it is in the best interest of the child, it also says that “safe and timely reunification is the first and primary goal for children in [DCF] custody.”
The Vermont Citizens Advisory Board asserts that “[t]he child welfare and family court systems in Vermont reflect a culture which excessively prioritizes reunification as the outcome to pursue, thus influencing practices and decisions.”
Schatz said Friday that the department has become more deliberative in considering returning children to their families.
"We're being more cautious and protective in terms of our practice with respect to substance abuse and young children, in terms of making sure that we look very carefully from the beginning right through case closure," he said.
This pressure toward reunification emerged again and again in the report, with VCAB saying generally that “[t]here was a lack of inquiry by all child protection system players, particularly within the judicial process, on the critical issue of who caused the two abusive injuries to [Dezirae Sheldon in 2013], and how best to ensure her future safety by preventing future abuse.”
That criticism is a reference to a 2013 hospital visit in which Sheldon was treated for two broken legs. Her mother was convicted of abuse-related charges after the incident, but Sheldon was returned home in 2013.
Lacking communication and documentation was another central point of the report, which the board says led officials to make decisions without the benefit of all facts in both cases.
“Because of the lack of documentation, it is reasonable to conclude that important information was not considered or shared with others when making important case planning decisions,” the report said.
One of the problems, officials said Friday, is that the IT system the department uses is 30 years old - predating the world wide web.
"An example of that," Chen said, "is there's a limited ability for DCF and [the Department of] Corrections to view each other's case records and things. And, as you might expect, that's a population that's especially concerning and we want to make sure we have the best communication we can between those two departments on any particular issues that might relate to child safety."
Recommendations
Besides their thorough review and criticism of both cases, the Vermont Citizens Advisory Board also came up with a number of recommendations for improvement in the state’s system for child protection.
These include improving quality control through an annual review process for caseworkers. Managers don’t currently know if their supervisees have done an annual review and don’t have access to review results.
The board also said the documentation of all cases should be improved and communication should be more open among the various agencies and organizations responsible for case work.
“Confidentiality issues and barriers to information sharing should be reviewed to ensure that all parties who need to share information regarding child safety may do so,” the report said.
The board also recommends increased funding from the legislature to allow DCF to comply with national best practices for casework, which calls for a 12-to-1 case to caseworker ratio. Currently, DCF staffing leads caseworkers to have more than 12 cases. A recent hire of 18 new caseworkers will not fix that problem, the report said.
In addition to new caseworkers, the report calls for the hiring of a child abuse pediatrician specifically trained in identifying abuse-related injuries, a “permanency planning manager,” and a “reunification manager.”
Dr. Joseph Hagan, the co-chair of VCAB, emphasized Friday that DCF was very cooperative in the review process, and that the board had an advantage the caseworkers didn't - hindsight.
"When I looked at the work that was done," he said, "I was able to say 'Gee, what if we'd done it this way?' Well, you all know that hindsight is 20/20 ... There were things that we wish had been done differently, but when you look at the decision, as best we can analyze it, as to what was done when, it followed the accepted standard at the time; procedures were followed."
The report, however, said otherwise.
Update 3:49 p.m. This story has been updated to include information from the Friday afternoon news conference with Schatz, Chen and the co-chairs of VCAB.
