Critical Incident

Rapid Response
Team

Florida Department of Children and Families

February 7, 2019
 Critical Incident Rapid Response Team

Southeast Region
Circuit 15
Palm Beach County, Florida
2018 - 737607

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 10
Service Array 12

Immediate Operational Response 13

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Executive Summary

On November 24, 2018, the department received notification that one-year-old

was pronounced deceased, days after he was admitted to the hospital with
numerous unexplained injuries. Prior to his hospitalization, left in
the care of his mother’s paramour, 28-year-old who was not supposed to
have contact with due to a Chapter 39 injunction filed against
by the department on August 14, 2018.

At the time of the incident resulting in hospitalization, he and his family were open to
in-home non-judicial case management services that stemmed from a previous abuse-related
incident. In June 2018, sustained multiple injuries to include a broken arm, swollen and
bruised lip, and a bite mark on his face.

Because there was a verified prior report within 12 months of death, DCF Interim
Secretary Rebecca Kapusta 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 DCF’s Office of Child Welfare and the
SunCoast Region, Assistant State Attorney responsible for Children’s Legal Services (CLS) from
the SunCoast Region, OurKids (community based-care provider in the Southern region), Gulf
Coast Jewish Family and Community Services (domestic violence provider in the SunCoast
region), and the Child Protection Team (CPT) medical director from the Southern Region.

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 investigation. The
following agencies were interviewed during the review: Child Protective Investigations (CPI) from
Palm Beach County, CLS, CPT, Children’s Home Society (CHS)-case management provider,
Adopt-a-Family (provider for homeless services), Community Partners Parent-Child Center
(targeted case management provider), Center for Child Counseling, and Aide to Victims of
Domestic Abuse and YWCA (co-located domestic violence providers).

Practice Assessment

• Although correctly identified as unsafe , safety

actions and level of intervention taken during the investigation and service case were
insufficient to protect .

• Throughout the life of the case, there was a lack of ongoing assessment and modification
of safety plans during critical case junctures.

Organizational Assessment

• The CPI and case management staff responsible for the most recent interventions with
the family were all experienced child welfare professionals, working in specialized units,
and caseloads were manageable.

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 • Staff from CPI, CLS, CPT, and case management report that they have developed good
working relationships.

Service Array

• was referred to multiple services within the community; however, was

minimally compliant, and services provided were not sufficient
. There was a lack of communication and coordination between agencies
and service providers.

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Introduction

On November 24, 2018, the department received notification that one-year-old

was pronounced deceased,. days after he was admitted to the hospital with
numerous unexplained injuries. Prior to his hospitalization, left in
the care of his mother's paramour, 28-year-old who was not supposed to
have contact with due to a Chapter 39 injunction filed against
by the department on August 14, 2018.

The circumstances surrounding •111111111 injuries are unclear as has provided

multiple and differing accounts, and had yet to be interviewed by law enforcement
officials. The criminal investigation is on-going.

The cause and manner of death are currently unknown, pend ing the autopsy results;
however, on November 24, 2018, he was pronounced deceased due to complications from the
injuries he received• days earlier.

At the time of the incident resulting in hospitalization, he and his family were open to
in-home non-judicial case management services that stemmed from a previous abuse-related
incident. In June 2018, sustained multiple injuries to include a broken arm, swollen and
bruised Ii and a bite mark on his face.

Because there was a verified prior report within 12 months of death, DCF Interim
Secretary Rebecca Kapusta deployed a Critical Incident Rapid Response Team (CIRRT) to Palm
Beach County on November 28, 2018, 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 team's find ings, 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

e at Time of Incident Relationshi

23 months Decedent

3 months

28 years

1991 1993 1990

2012 2013 2016 - 2018 2018

G) l!I a e

Child Welfare Summary

Between 2014 and 2018, there were five reports
involving various household members (including a maternal aunt, the father of
, and a previous girlfriend of wit h - involved in the last
two reports, both of which were received in 2018.

In June 2018, - sustained multiple injuries to include a broken arm, swollen and bruised
Ii and a bite mark on his face.

In-home non-judicial case management services were engaged and provided by

Children's Home Society.

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System of Care Review

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

In this case, both strengths and opportunities for improvement were identified in the following
areas and they provide opportunities for improvement that will benefit the local system of care.

Practice Assessment
PU RPOSE: This practice assessment examines whether the child welfare professionals' actions
and decision making regarding the family were consistent with the department's policies and
protocols.

FINDING A: Although correctly identified as unsafe in the June 2018 report,

safety actions and level of intervention taken during the investigation and service case were
insufficient• • • • • • • •
was named as a parent caregiver in three abuse

any demographic information for

conducted.

On May 31, 2018, the CPI completed an unannounced home visit and reported seeing male
clothing items in the laundry. The CPI addressed the male clothing with and she
re orted that he "comes and oes·" however he lives with his mother not with her.

on e m orma ion 1n e case recor

lack of cooperation , the "safe"
appeared to be more protective of her
paramour than she was of . Conflicting information (including how often the paramour
was in the home and the male clothing observed in the residence, as well as
refusal to provide the full name of her paramour so that required background checks could be
completed), was not fully reconciled or considered prior to closing the investigation .

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She further stated that she was afraid of him. Despite her expressed fear, she allowed him to
wa t c h -while she went to work on more than one occasion.

correct! identified as unsafe and a present danger safety plan was developed
as the safety manager. The tasks included instruction that.
not allowed to be around the paramour and not to return to the home until the locks
are changed ." A supervisory consult was completed on June 15, 2018, and it was determined
that the present danger plan was not sufficient as the identified safety manager had a prior
abuse history and was not approved to be a safety manager. The supervisor documented that
the "use of the Safety Management Action Response Team (SMART), which provides intensive
in-home services, is strongly advised as a monitoring system." Instead of using the SMART
team, the CPI talked with the mother and she identified a non-relative as a safety manager. After
running background checks, the CPI and supervisor approved the non-relative as a safety
manager and indicated that, although the SMART team is used in most present danger cases, it
was not utilized in this case as they determined the informal safety managers were sufficient to
monitor child safety.

The mother and moved in with the safety managers and they were to "ensure the
mother was not alone with at any time and to contact the CPI if the mother is
suspected to be communicating with ." Children and Families Operating Procedure
(CFOP) 170-7, Chapter 1 addresses safety actions to consider when developing an in-home
safety plan. The CFOP states, in part, that an in-home safety plan may not be used when 24/7
supervision is needed. This level of intrusiveness constitutes a shelter or out-of-home safety plan
and , in this case, the safety plan restricted from being alone with
requiring a shelter hearing, which was not done. Although the non-relative agreed to be the
safety manager, the plan lacked specific tasks to ensure would be protected.

On July 9, 2018, the CPI saw the mother in her apartment and had not changed
the locks on the doors, or moved to a new residence, and stated that she wanted to
be a art of life

The CPI completed the referral for in-home non-judicial case management services, identifying
the risk as high. When staffing the case for services, it was noted that visits to the home should
be unannounced. The CPI and direct case manager (DCM) completed a joint home visit, family
team meeting on July 20, 2018, and discussed the Chapter 39 petition for an injunction that
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The safety manager was not present. On July 25, 2018 , on behalf of all
, the CPI completed a Case Opening Document (COD) to request a Chapter 39
injunction, which would require to refrain from committing further acts of child abuse
or domestic violence, refrain from coming within 500 feet of the children's home, school or where
ever they were located , and to vacate the home. Children and Families Operating Procedure
(CFOP) 170-7, Chapter 4 addresses Chapter 39 injunctions, and in part states:

Inj unctions.
a. To protect the non-offending parent/legal guardian and their children from further
perpetrator-focused victim blaming and potentially, often lethal, acts of violence, child
welfare professionals can seek issuance of an injunction under s. 39.504, F.S. An
injunction is a valuable safety action that child welfare professionals should routinely
consider to help provide protection for the survivor and children in cases involving
intimate partner violence. However, as there is no guarantee that a perpetrator will
adhere to the terms of an injunction, an injunction should never be the sole or primary
safety action in a plan.

In this case, the CPI identified that had diminished protective capacities in the
areas of taking action, history of protecting, recognizing threats, understanding protective role
and plans, and articulates protection plans. Additionally, she had a history of not being
forthcoming regarding information about , was still having contact with him , and had
not taken steps to protect , to include chang ing the l o c k s . • • • • • • • • •
The Chapter 39 injunction and non-
dan er threats.

After the joint home visit, the case was transferred to case management. The DCM completed a
total of seven home visits, approximately every two weeks, with each visit lasting an average of
20 minutes. Although the CPI requested that visits be unannounced, six of the seven visits were
scheduled visits. Visits focused on service referrals and asking the mother and if they
had seen

On August 8, 2018, the DCM updated the family assessment and did not identify any areas of
diminished protective capacity for , which conflicted with the assessment
completed less than a month earlier by the CPI. There was no documented behavior change
noted with and it was noted that she was w illing to be "monitored" moving forward .
The case plan focused on compliance-based tasks includ ing participating in counseling and play
therapy; however, did not address behavioral changes needed to improve her diminished
protective capacities. Although in daycare, never seen or
interviewed in a neutral location regarding contact-. or their mother, may have been having
w ith . Ongoing contact with providers was not occurring and information was self-
reported by

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The identified safety manager was seen on August 1, 2018, and signed the safety plan; however,
did not respond to any other calls from the DCM after that date. There was no direct information
from the safety manager regarding the mother’s compliance, or lack of compliance, with the
tasks. The safety plan was not sufficient to ensure child safety.

FINDING B: Throughout the life of the case, there was a lack of ongoing assessment and
modification of safety plans during critical case junctures.

There were several opportunities where additional assessment should have occurred.

Based on the seriousness of the injury to , the previous history of

not being forthcoming or willing to provide information as to , this was
a critical juncture in which the case should have been staffed to determine if additional actions
were needed to ensure child safety.

At the time the case was transferred to services, the mother was pregnant
was dishonest with the
DCM regarding who was watching while she
was in the hospital. Despite being told could not go to the ,
due to prior abuse history, had them care for . In accordance with
CFOP 170-1, Chapter 9, Florida Administrative Code, and statute, as well as internal ChildNet
policies, children born into open service cases, regardless of legal status are required to be
assessed. The case should be staffed prior to the birth, the child to be added to the case, and
the safety plan updated. There was no updated assessment or modification of safety plans at
this critical juncture.

CFOP 170-7, Chapter 11 addresses the requirements for managing safety plans. Shortly after
the present danger plan was implemented, the safety manager was changed due to the initial
safety manager’s prior abuse history. There was minimal ongoing contact with the new safety
manger, by either the CPI or DCM and she did not return any calls after August 1, 2018. The
DCM relied on self-reported information from and was not able to verify or ensure
that the safety plan was sufficient to ensure child safety. The plan should have been reassessed
and modified when the safety manager stopped communicating or monitoring the safety plan.

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: The CPI and case management staff responsible for the most recent interventions
with the family were all experienced child welfare professionals, working in specialized units, and
caseloads were manageable.

The June investigation was initially assigned to the CPI who had investigated the prior report
which had closed two weeks earlier; however, it was transferred three days later to the Special
Victims Unit (SVU). The SVU takes investigations county-wide and cases assigned to the unit
are typically complex cases, with victims under four, multiple priors, and serious injuries,
including broken bones. The unit is also on call to receive rapid response cases which require
immediate response and involve allegations of death or near death or serious injury to a child, or
sexual molestation of a child under the age of five. The SVU works closely with CPT, with each
CPI in the unit assigned to work with a specific case coordinator.
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The CPI from the SVU, assigned to the June investigation, had two years of child welfare
experience and held a bachelor’s degree in communication. The investigator was carrying an
average caseload of nine open investigations. The CPI supervisor had a total of 17 years of child
welfare experience, including five years as a supervisor. She held a bachelor’s degree in
psychology and has successfully completed the CPI supervisor proficiency process. The
proficiency process is designed to ensure that each CPI supervisor has the knowledge, skill, and
ability necessary for case analysis and consultation.

The DCM had three years of child welfare experience and held a bachelor’s degree of social
work. She was responsible for an average caseload of 23 children. The DCM supervisor had
nine years of child welfare experience and held a master’s degree in social work. The service
case was assigned to a unit that was responsible for a specialized caseload of in-home non-
judicial cases.

FINDING B: Staff from CPI, CLS, CPT, and case management report that they have developed
good working relationships.

Staff across all agencies in Palm Beach County report they have developed positive working
relationships. For example, DCF has a CPI co-located at CPT available to sit in on medical
staffings and ensure critical information is shared with the assigned CPI. Additionally, each CPI
in the SVU is linked with a specific CPT case coordinator. In this case, the CPI contacted the
CPT case coordinator on June 12, 2018, the same day the abuse report was received, and
scheduled an appointment for . Due to the severity of the injuries,
also examined, and specialized interviews were conducted. The CPT medical
reports and findings were shared with the CPI on the day of the examinations and the final report
was sent to them two weeks later.

CLS is co-located with the CPIs and an attorney is always available via phone. Staffings between
CLS and CPIs involving requests for legal actions, including Chapter 39 injunctions, petitions to
direct file for court ordered supervision, and legal consults for cases involving impending danger
where legal action is needed, are routinely scheduled on Tuesdays and Fridays. Prior to the
staffing, the CPI fills out a Case Opening Document (COD) which includes information on the
family and the type of legal action being requested. It is noted that CPIs are not required to
contact CLS prior to removing a child; they complete the COD after removal and, after hours,
documents can be sent to a dedicated CLS email address, ensuring information is shared timely.
In this case, the CPI completed a COD requesting a Chapter 39 Injunction on behalf of
.

When transferring a case from investigations to ongoing services, a preparatory meeting is held
to discuss the case and the CPI and case manager participate in a joint home visit or family team
meeting in the home with all case participants. The joint visit helps facilitate the exchange of
critical information between the CPI, the case manager, and the family and, in this case, a joint
home visit/family team meeting was completed.

Domestic violence advocates from two different agencies, Aid to Domestic Violence Abuse
(ADVA) and YWCA are co-located with the CPIs and positive working relationships are evident.
When a case involving allegations of domestic violence is received, the CPI provides a referral to
the DV advocate to contact the family. The advocate also serves as a consultant to the CPIs. In
addition, they attend and/or participate in staffings, family team meetings, court hearings, and
mediation. A referral to the ADVA advocate was made by the CPI and the advocate contacted
to offer services.

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Service Intervention/Array

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

FINDING A: While was referred to multiple services within the community, she
was only receptive to those that provided monetary assistance. There was a lack of
communication and coordination between agencies and services providers with multiple referrals
being provided to different programs by different entities.

In November 2017, through a community referral, was initially linked with the
Youth 100 program which provides services to clients ages 18-24 and includes assistance in
securing and maintain housing. She was later linked with the Adopt-a-Family program which
rovided similar in-home services and assistance with housin .

If services offered provided monetary assistance,

Services were being offered to ; however, she was not participating or engaged; and
there was an increasing level of violent incidents, with multiple partners in her life, impacting her
ability to protect•••• • • • • • • • • • • • • • • • • • • • • • •
. As continued to be
discharged from services that were being provided through community partners, due to non-
compliance, a higher level of service provision to include court ordered services, either in-home
or out-of-home, was not considered or implemented. There was a lack of coordination between
the services that were being offered and/or provided through community referrals and through
case management.

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Immediate Operational Response
Operational meetings

1. Prior to the CIRRT team’s arrival, Southeast Region (SER) leadership convened a
meeting on Monday November 26, 2018 with leadership staff from ChildNet, Children’s
Home Society, Children’s Legal Service (CLS), CPI Operations and program office staff
to review the case and prepare the team for the CIRRT.
2. Following the CIRRT, the same team met on December 13, 2018 to discuss and prepare
a CIRRT Strategic Plan pertinent to the initial findings at the debriefing and discussions
held within our agencies.
3. The CIRRT Strategic Plan is being review monthly at joint operations meetings for
monitoring.

Systemic reform - CPI/CLS

1. Updated local protocol for program administrator (PA) consultations and 2nd tiers. A PA
consultation is now required for all investigations where the alleged perpetrator is not
located. A 2nd tier review is now required in all cases where impending danger is
identified, and the case is not being referred for judicial action. The PA will conduct the
consultation to discuss impending danger determination, safety analysis sufficiency, and
sufficiency of impending danger safety plan.
2. Developed criteria for mandatory notifications of hospital cases that will be escalated to
the Operations Manager. The PA will notify the Operations Manager for all cases
involving children presenting to the hospital with concerns of abuse of neglect.
3. The local domestic violence agencies will provide mandatory domestic violence
training/refresher course and training on the Safe and Together model for staff hired since
the time the last time the training was held.
4. Develop a local protocol for requesting Chapter 39 injunctions.

Systemic reform - Case Management

1. CHS will create and hire two specialist positions, a Dependency Case Management
Specialist (DCMS) to review cases sent to ChildNet/CHS for transfer to ensure necessary
case related items are present and reviewed for content at transfer. In addition, a Quality
Management Specialist will be hired and report to CHS leadership to respond to local
review needs identified by CHS.
2. Pending the above, following the hiring of the DCMS, the Circuit 15 Case Transfer
Protocol will be updated and CHS will add non-judicial cases to the formal staffing
schedule.
3. In-home non-judicial case policies will be thoroughly revamped to include formal team
meetings and required visits.
4. Safety planning workshops will be scheduled and jointly offered to CPI and DCM staff to
discuss current cases and safety plans. A formal calendar with training dates will be
provided, with the first two workshops scheduled and held in January 2019.
5. Formal escalation protocol will be developed regarding non-judicial cases and
implemented between ChildNet, CHS, and DCF/CPI.
6. Create a policy implementation workgroup to address CFOP/law changes.

Personnel actions were taken in both Case Management and CPI divisions

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