Report: 14 Montana kids died within a year of abuse reports

In this 2015 file photo, April Hall, seated at left, whose granddaughter was killed by the mother's boyfriend in June 2011, and Robin Castle, second from left, a licensed clinical professional counselor, meet with Gov. Steve Bullock, seated third from left, to demand improvements in the state Division of Child and Family Services, in Helena. A review of 14 child deaths in Montana from July 2015 to November 2016 concluded that most died of abuse or neglect, with several common factors that should have raised red flags with child protection workers.

AP photo

HELENA -- A state panel that's been given unprecedented access to dig deep into the deaths of children in Montana's child protective services system met for the first time last week to develop a road map for its work.

The first two hours of Thursday’s session were open to the public and provided a glimpse into possible paths the commission will take to do its work: how it will pick the deaths it reviews, how it will interact with the communities where the death took place, and how it can make the most of its annual reports recommending how to reduce child deaths.

The commission includes doctors, a tribal representative, advocates for children who have been abused or neglected, a foster parent, a lawmaker, representatives from the state Departments of Justice and Public Health and Human Services, a former judge, a deputy county attorney and an adult who was abused and neglected as a child.

Called the Child Abuse and Neglect Review Commission, it is believed to be the first of its kind in the country given these powers.

Members, who work under the auspices of the state health department, have until August to develop a plan to reduce child abuse and neglect over a five-year period.

The commission was created out of frustration in the last legislative session over the lack of information about how 28 children had died after coming to the attention of the state's Child and Family Services Division since July 2015 — and how those deaths could be prevented in the future.

Several efforts have been made in recent years to look at troubles in child protective services after increasingly vocal and frustrated parents, grandparents and others involved in the system began showing up in large numbers at legislative hearings to voice their concerns.

In addition to high turnover of case workers because of large workloads in the division, the number of children in foster care has dramatically increased in recent years, jumping more than 12 percent from 2015 to 2016 and reaching about 3,300 last year. In a recent legislative audit, the health department attributed some of that increase to turnover among caseworkers.

In 2013, the Legislature passed a bill to create the Child and Family Ombudsman Office, which produces an annual report listing the number of fatalities for children who have come into contact with child protective services. But the ombudsman does not review specific cases in detail for its report.

In 2015, Gov. Steve Bullock formed the Protect Montana Kids Commission to review problems with the state’s child protective system and foster care network and to make recommendations to the Legislature. However, it doesn't look specifically at child deaths.

Matthew Dale, team coordinator for the Domestic Violence Fatality Review Commission, which does work similar to what the new commission will do, said he believes the new team is the first of its kind in the nation and has a great ability to access and use information others don't have to form recommendations for change.

Because of its newness and uniqueness, Dale cautioned that the group will see a heightened amount of attention.

“Your team is the only team that has the opportunity to review these cases at a depth that you have,” Dale said. “You will have lots of attention paid to you both in the state, but lots of other places as well.”

Dale’s own team has been reviewing domestic fatalities since 2003 and was created in a similar way as the child fatality review team.

He drew upon that experience Thursday to provide the child fatality review commission with suggestions and insight on how it could approach its work.

Dale’s team reviews two cases a year, in October and May, and makes biennial reports at the start of each legislative session that include the examination of four deaths. There are about 10-12 intimate partner homicides a year, Dale said. That’s just slightly less than child abuse and neglect deaths, 14 in each of the years since the state has tracked them.

When deciding how many deaths to review, Dale said the team should do at least two and spend a large amount of time on each.

Montana also has a suicide mortality review team that can examine hundreds of cases a year, Dale said, but the nature of their reviews is different than the work his team does and what he suggested the child fatality review team pursue.

The domestic fatality review commission travels to the community where the death took place to do its work. Once, Dale said, it went to a community about a year after killings took place and it was too early because the fatalities were still too raw.

He said by going to the communities, it gave the commission a chance to understand just how rural Montana can be and how that can affect deaths.

“There are parts of this state where it’s going to be 30 to 45 minutes before an ambulance gets there,” he said, saying that one stabbing death his team reviewed would probably not have ended in a fatality if an ambulance had been able to reach the scene earlier.

He also suggested the team make an effort to ensure the cases they review are geographically diverse.

“You would be able to fill your quota of cases per year without ever going beyond Great Falls, Missoula, Billings, Bozeman,” he said. “You want to acknowledge that these killings can happen anywhere in the state.”

Dale stressed that when it picks the cases it reviews, the commission must take into account that part of its review will include discussing the fact that resources for families may be different from Scobey to Missoula. But the commission also needs to show that child deaths do not just happen to poor families or single parents or in urban areas or on reservations.

When in a community for a review, Dale said his team meets in a central location and reaches out to invite residents who may have important information, such as prosecutors, law enforcement officers, clergy members, doctors or others, as long as participants sign a confidentiality agreement.

Dale suggested that the child fatality review team may also benefit from the same approach.

“The more people that know about the work, the more people that can flesh out this case for us, the better,” he said. “Every police officer knows something about a case they’re not willing to write down in a report.” 

It’s critical that the people who agree to share information with the commission know what they say is confidential and won’t end up in the newspaper the next day. The more work the commission does properly, he says, the more the people they work with spread the word about their experience with others in their field around the state.

“You build goodwill, you build credibility,” he said.

Caroline Warne, with the health department’s Office of Legal Affairs, walked the commission members through the confidentiality agreement each signed and the rules that govern their work.

Among the key elements:

• All of the panel's review work is confidential and cannot be disclosed.

• Meetings are exempt from open meetings laws and records are exempt from public records requests.

• Committee members must return all documents at the end of each meeting and members cannot divulge their views of the review or work to the public or media.

• Commission members who violate the confidentiality agreement can be removed from the commission and face a civil penalty of up to $500.

• The work of the commission is not subject to a subpoena or discovery in a court case and can only be reviewed by a judge behind closed doors. The judge would rule on whether information could be released.

Without an airtight confidentiality agreement, Dale said, the work of the group could be rendered useless.

“You’re talking about the most intimate elements of people’s lives. Medical records, mental health records, substance abuse. You can’t talk about it with your kids, your spouse, your coworker. You can’t forget and leave your binder at the restaurant on the way to the review.”

Dale said his team has had very little turnover and that no one has ever broken the confidentiality agreement in 15 years.

“That’s the glue that holds it together,” Dale said. “Without that, nothing works.”

Warne said the committee will present the part of its work that can be made public in an annual report required by law that also includes recommendations.

Dale cautioned that the report produced by the team must be user-friendly and easy to read, otherwise the information and the team won’t be taken seriously.

“I see (the report) as the calling card of the commission,” he said.

Dale said that in his mind, the recommendations the committee makes are among its most important duties. “It’s what we are learning, the trends, and what we are going to do about it as a state,” he said.

The reports released by the committee must contain the cause and circumstance of each fatality and near fatality attributable to child abuse or neglect reviewed by the commission. They must also include the age and gender of each child involved, as well as information describing any previous reports of child abuse or neglect and the results of any investigations into those reports.

The committee must also include in its report what services were provided by or actions taken by DPHHS on behalf of the child that are pertinent to the abuse or neglect that led to the death or near death.

Dale said the team is in a never-before-seen position to create great change.

“Your team is the only team that has the opportunity to review these cases at a depth that you have” Dale said. “You will have lots of attention paid to you both in the state but lots of other places as well.”

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