Department for Community Based Services

Standards of Practice Online Manual

2.14 Investigations of Child Fatalities and Near Fatalities

Cabinet for Health and Family Services

Department for Community Based Services
Division of Protection and Permanency
Standards of Practice Online Manual
Chapter:
Chapter 2-Child Protective Services (CPS) Intake and Investigation
Effective:
1/15/2016
Section:
2.14 Investigations of Child Fatalities and Near Fatalities
Version:
4

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Legal Authority/Introduction

LEGAL AUTHORITY:

The Division of Protection and Permanency (DPP) investigates all reports of child fatalities or near fatalities that occur due to alleged abuse or neglect by a:

  • Parent;
  • Guardian; or
  • Other person exercising custodial control or supervision of the child; even if there are no remaining children in the home; except if the child is in a facility operated by the Department of Juvenile Justice.  A child fatality or near fatality in a DJJ-operated facility is referred to the Justice Cabinet for investigation under a memorandum of understanding between DJJ and the Cabinet for Health and Family Services.

Near fatality is defined by KRS 600.020(38) as an injury that, as certified by a physician, places a child in serious or critical condition.

DPP also tracks child deaths that are not related to suspected abuse or neglect when (see SOP 2.14.2 for further procedure):

  • There is an active investigation; 
  • There is an active ongoing case and/or received ongoing services in the twelve (12) months preceding the death; or 
  • The child is in out of home care.

DPP is notified of all child fatalities or near fatalities utilizing the Child Fatality/Near Fatality Summary Document. 

In order to assure coordination of appropriate information dissemination, all media inquiries are referred to the Office of Communications at (502) 564-6786.

 

Practice Guidance

  • KRS 72.025 and KRS 72.405 mandate that the coroner require a post-mortem examination, which may include an autopsy, on the death of any child where the cause of the death appears to be violence, child abuse, suicide, drugs, sudden infant death syndrome (SIDS) or a variety of other unexpected or unexplained causes.
  • Information gathered during the course of an investigation, including prior DPP involvement with the family, can be shared with the medical examiner if requested.
  • In cases where abuse or neglect is substantiated and has resulted in a fatality or near fatality and there has been a previous assessment on the child or family, the case is considered to have previous protection and permanency involvement and is required per KRS 620.050(12) to have an internal review. 
  • Prior involvement with the family includes staff that:
    • Have completed a previous assessment involving the family;
    • Have been previously assigned as an ongoing case manager for the family;
    • Are currently assigned as an ongoing case manager for the family;
    • Are currently investigating the child or family; or
    • Have supervised an investigation or ongoing case involving the family.
  • The SSW is encouraged to participate in local child fatality response teams to assist in cross communication and sharing information between different agencies.

Procedure

Receiving the Report

The SSW:

  1. Determine if the referral meets criteria as outlined in SOP 2.3 Acceptance Criteria; 1
  2. Conduct an investigation when the referral meets criteria to: 
    1. Assess whether the fatality or near fatality was the result of abuse or neglect;
    2. Assess risk to any child(ren) in the home (including survivor of a near fatality); and
    3. Protect any children remaining in the home;
  3. Immediately notifies the service region administrator (SRA) or, in the absence of the SRA, the designee for all fatalities or near fatalities that are alleged to be as a result of suspected child abuse or neglect;
  4. Informs the SRA or designee if the case:
    1. Is currently open for open investigation;
    2. Is currently open for ongoing services;
    3. If the child is in the custody of the cabinet;
  5. Provides the SRA or designee with the following information:
    1. Name and age of victim;
    2. Names of parents or caretaker and alleged perpetrator;
    3. Known circumstances around the fatality or near fatality;
    4. Description of physical injuries or medical condition of the child at the time of fatality or near fatality;
    5. Names, ages and location of additional children in the family and any actions taken for their safety;
    6. Description of protection and permanency history with the family or caretaker, if any;
    7. Actions taken by protection and permanency to date and future actions to be taken, including initiation of an investigation; and
    8. Involvement of other professionals in the case;
  6. Notifies law enforcement immediately by telephone (unless law enforcement was the reporting source).2 

The SRA or designee:

  1. Notifies the central office child fatality liaison by completing parts I and II of the DPP-126 Child Fatality/Near Fatality Summary Document emailing it to DPP.childfatality@ky.gov, within twenty-four (24) hours, exclusive of weekends and holidays; 3 
  2. Follows procedures SOP 2.14.2 Notification and Funeral Preparation During a Child Fatality or Near Fatality Investigation for notification of the birth family and committing court in cases where the fatality or near fatality is abuse or neglect related and the child is in out of home care;
  3. Preferably assigns staff that have had no prior involvement with the family to investigate the child fatality or near fatality.

The central office child fatality liaison:

  1. Reviews the Child Fatality/Near Fatality Summary Document for accuracy and completeness;
  2. Assigns the case a fatality or near fatality number;
  3. Re-distributes the numbered notice to the SRA or designee for use throughout the investigation;
  4. Distributes the initial document to designated central office staff;
  5. Tracks the investigation through completion;
  6. Offers consultation and assistance as needed; and
  7. Reviews the assessment and provides feedback to the region.
Fatality/Near Fatality in an Open Case or Pending Investigation

Upon receipt of a fatality or near fatality on a pending investigation the intake SSW:

  1. Immediately notifies the SRA or designee of the fatality or near fatality investigation; and
  2. Marks the case as controlled access.

The SRA or designee:

  1. Immediately reviews the status of the pending investigation;
  2. Obtains the following information:
    1. Length of time between referrals;
    2. The amount of work remaining to be completed on the investigation; and
    3. The quality of the work conducted;
  3. Consults with the central office fatality liaison regarding:
    1. How to assign and complete the investigation; and
    2. The finding of the pending investigation;
  4. Directs the intake SSW on how to proceed with the intake;
  5. Directs the investigative SSW on how to proceed with the investigation; and
  6. Determines if the control access designation remains.

Upon receipt of the fatality or near fatality investigation on an open ongoing case the SSW:

  1. Immediately stops all ongoing contact with the family in an in home or out of home ongoing case for a period of at least fourteen (14) days;
  2. Documents all efforts and information in TWIST (ADT, case plan evaluations, contacts), within three (3) working days of the report date of the child fatality or near fatality; and
  3. Coordinates services for the child(ren), as necessary, in an in home or out of home ongoing case;
  4. Resumes work with the family after the initial fourteen (14) day period, at the discretion of the SRA or designee;
  5. For child victims who are in out of home care the following procedures are followed:
    1. Procedures for DCBS foster homes:
      1. The R&C worker follows the procedures outlined above; and
      2. The provide case is assigned for review in central office;
    2. Procedures for PCCs:
      1. The investigating SSW and/or FSOS follows the procedures outlined in SOP 2.15 Specialized Investigations and SOP 2.15.1 Investigations of Foster or Adoptive Homes (DCBS or Private Child Placing (PCP) Agencies);
      2. Collects the PCC records relating to the child by the SSW; and
      3. The SSW provides the records to the central office fatality liaison and they are assigned for review in central office.

The SRA or designee:

  1. Notifies in writing the judge of the court of jurisdiction and the guardian ad litem for active court cases when a child fatality or near fatality occurs, as soon as practical, but no later than five (5) working days after receipt of the report;
  2. Notifies the Department of Public Advocacy, Protection and Advocacy Division, in the Justice and Public Safety Cabinet if:
    1. A child identified as a protection and advocacy client dies as a result of alleged abuse or neglect by a caregiver; or
    2. If the child fatality occurred as a result of:
      1. Placement in a seclusion room pursuant to 922 KAR 1:390; or
      2. Therapeutic hold applied pursuant to 922 KAR 1:300;
  3. Provides support to staff to assist them in managing the trauma experienced through their involvement with the fatality/near fatality (refer to SOP 1.13 Debriefing of Protection and Permanency Staff-Reaction and Emotional Responses to Trauma).

Fatality/Near Fatality Investigation and Documentation


The SSW:

  1. Follows investigative guidelines set forth in SOP Chapter 2 Intake and Investigation as well as the following procedures when completing a fatality or near fatality investigation;
  2. Determines the safety of any surviving children, including other foster children and natural children, through immediate assessment to assure their safety if child abuse or neglect is suspected;
  3. Includes the following in the assessment:
    1. Arranging for physical examinations to check for any current injuries to the surviving children, if indicated;
    2. Determining whether there has been any history of prior abuse or neglect to the children or other family members by the alleged perpetrator;
    3. Interviewing the children separately and in a safe environment to assess present emotional condition, and to determine to what extent they may have witnessed family violence;
    4. Observing interaction between parent or caretaker and children;
    5. Discussing parent or caretaker’s own family history;
    6. Making collateral contacts with neighbors, schools, and extended family;
    7. Determining whether the surviving children were present during the time frame of the deceased child’s injuries and therefore may have witnessed what occurred;
    8. Referring immediately to mental health counseling, if appropriate;
    9. Developing immediately a prevention plan for siblings, pending the completion of the investigation, if they remain in the home; and
    10. Checking TWIST records for a history of child abuse/neglect, court records for a history of domestic violence and criminal records for alleged perpetrator and other adults in the home;
  4. Consults with the central office child fatality liaison regarding how to proceed if a coroner refuses to request an autopsy, and the SSW asserts the need for an exam; 4
  5. Interviews first responders to the fatality or near fatality including, but not limited to, law enforcement and emergency medical staff as collaterals in the fatality or near fatality investigation;
  6. Obtains all medical records for the child, and seeks consultation from the fatality nurse administrator regarding the injuries to the child fatality or near fatality both chronic and acute as well as siblings when indicated;
  7. Makes every effort to interview the alleged perpetrator, but does not interfere with the investigation by law enforcement;
  8. Clearly documents if the perpetrator refuses to be interviewed and reasons for delays in the investigation or interview with the perpetrator;
  9. Enters a date of death for the child, if applicable;
  10. Consults with regional office upon completion of a fatality or near fatality investigation and approval of findings;
  11. Documents regional consultation in the assessment; and
  12. Submits the ADT to the central office fatality liaisons for review prior to finalization of the assessment in TWIST.   
  13. Never utilizes an abbreviated assessment in a child fatality or near fatality investigation.

The Internal Review Process

The SRA or designee: 

  1. Contacts the central office child fatality liaison to schedule an internal child fatality or near fatality review meeting, within sixty (60) calendar days of receipt of the report of child fatality or near fatality when the Cabinet has substantiated abuse or neglect and had prior involvement with the child and/or family to discuss:
    1. Previous protection and permanency (DPP) involvement;
    2. The current investigation;
    3. Existing practice to identify areas for improvement; and
    4. Opportunities for staff training and development; and
    5. The region's plan to track and monitor improvement outcomes.
  2. Invites other DCBS staff to participate at their discretion;
  3. May invite the regional continuous quality improvement (CQI) specialist to assist in tracking and monitoring regional improvement areas; and
  4. Completes sections III and IV of the Child Fatality/Near Fatality Summary Document and submits to the central office child fatality liaison within ten (10) working days of the internal review meeting.
  5. The following people are required to participate in the internal child fatality or near fatality review meeting:
    1. SRA or designee;
    2. SRAA or SRCA;
    3. FSOS supervising the fatality/near fatality investigation;
    4. SSW investigating the child fatality or near fatality;
    5. SSW and FSOS who were assigned cases in the previous twenty-four (24) months; and
    6. The central office child fatality or near fatality liaison.

The central office child fatality liaison:

  1. Reviews the summary document and finalizes it by removing the "Draft" watermark;
  2. Provides copies of the summary document to the SRA or designee; and
  3. Distributes the summary document to:
    1. Cabinet’s general counsel;
    2. Assistant Director of Protection and Permanency; and
    3. Director of Service Regions; and
The Regional Review Process

If the fatality or near fatality investigation is unsubstantiated but the agency has had contact with the family in the twenty-four (24) months preceding the death, the following procedure is followed by the SRA or designee:

  1. Completes a review of the agency’s interactions with the family leading up to the fatality or near fatality investigation;
  2. Identifies areas of strength in the case work as well as areas for improvement; 5
  3. Meets with staff about the strengths and areas for improvement;
  4. Develops a plan of action around the improvement areas;
  5. Identifies a plan to monitor improvement outcomes;
  6. Completes sections III & V of the Child Fatality/Near Fatality Summary Document; and
  7. Submits the summary document to the central office fatality liaison once the investigative assessment has been finalized.

The child fatality liaison:

  1. Reviews the document for accuracy and ensures it is completed appropriately;
  2. Removes the draft watermark to finalize the document;
  3. Provides a copy of the document to the SRA or designee; and
  4. Files the final document in the child’s file in central office.

Preparation of case files for the child fatality and near fatality external review panel

Upon request from the division of service regions or division of protection and permanency, the SRA or designee:

  1. Makes a copy of the child fatality or near fatality investigation;
  2. Gathers all prior case work, assessments and investigations from the field;
  3. Makes copies of the prior case work;
  4. Ensures all copies:
    1. Are single sided;
    2. Do not have staples/paperclips/binder clips/rubber bands;
    3. Have not been hole punched;
    4. Are complete with any and all prior investigations, assessments, and ongoing work (all documentation contained in the agency case file–prevention plans, after care plans, notification letters, etc.);
    5. Provides the intake summary, DPP-115 and CQA/ADT printed from TWIST for archived cases;
  5. Completes the DPP-127 Checklist for Fatality/Near Fatality Cases; and
  6. Delivers the copies to the central office child fatality liaison.

The central office child fatality liaison:

  1. Ensures all appropriate cases are provided to the external panel;
  2. Adds the Child Fatality/Near Fatality Summary Document to the file prior to release; and
  3. Prepares and organizes the cases for release to the external panel.

Notification of Family and Court When a Fatality/Near Fatality Occurs in an OOHC Case

The service region administrator (SRA) or designee: 

  1. Appoints a SSW or supervisor to immediately notify the child’s parents of the fatality or near fatality when:
    1. The child is in the custody of the cabinet and placed out of the birth parent’s home in a:
      1. Foster home;
      2. Cabinet facility; 
      3. Psychiatric unit/hospital; or
      4. Private child-caring facility; and
    2. Parent’s parental rights are intact;
  2. Notifies a child's biological or legal parents of the child's fatality or near fatality if parental rights have been terminated, there are special circumstances including ongoing contact with the child, and a finalized adoption has not occurred. 
 

Footnotes

  1. If referral does not meet acceptance criteria but the deceased child is named in an active investigation, open case and/or is placed in out of home care, refer to Section 2.14.1 Child Fatality in an Open Case or Investigation with no Allegations of Abuse or Neglect.
  2. Law enforcement, the commonwealth attorney and/or the county attorney are notified of all child fatalities allegedly due to abuse or neglect in writing using the DPP-115-Confidential Suspected Abuse, Neglect, Dependency or Exploitation Reporting Form.
  3. The Child Fatality/Near Fatality Summary document is not placed in the official case record.  It is filed in the child's fatality or near fatality file, located in central office.
  4. The SRA and the director of service regions are responsible for following up on action plans and monitoring for completion.
  5. The SRA or designee is responsible for reporting to the central office fatality liaison the improvement outcomes tracked from the internal review at the end of the state fiscal year (SFY). 

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