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:
10/1/2019
Section:
2.14 Investigations of Child Fatalities and Near Fatalities
Version:
5

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Legal Authority/Introduction

LEGAL AUTHORITY:

 

Introduction 

The Department for Community Based Services (DCBS/Department) 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;

KRS 620.050 requires that the Cabinet for Health and Family Services (CHFS/Cabinet) conduct an internal review of any case where child abuse and neglect has resulted in a fatality or near fatality and the cabinet had prior involvement with the child or family. This statute also requires that the cabinet submit a report by September 1 of each year to the governor, the General Assembly, and the state child fatality review team that includes a summary of the internal reviews and an analysis of historical trends.


All media inquiries are referred to the CHFS Office of Public Affairs at (502) 564-7042. 
 

Procedure for Receiving and Accepting the Report

The Central Intake Staff:

  1. Determines if the referral meets criteria as outlined in SOP 2.3 Acceptance Criteria by consultation and approval with the FSOS and Central Intake Branch Manager;
  2. Screens the allegation to determine acceptance criteria for the alleged maltreatment and then identify a link that the alleged maltreatment directly contributed to the child’s fatal or near fatal condition. When this occurs the centralized intake staff will designate the intake in TWIST as a fatality/near fatality.
    1. The fatality designation is used in the intake when a child’s death has occurred.
    2. The near fatality designation is used in the intake when the child has a near death condition as defined in KRS 600.020 (40) as an injury that, as certified by a physician, places a child in serious or critical condition.  Staff shall use the “determining a near fatality tip sheet” to decide if the child’s condition meets criteria for the near fatality designation.
    3. The regional after hour protocol shall be used for screening, designation, determination, and assigning reports that are made outside of regular business hours. SOP 1.12 defines on-call activities. 
  3. Determines the initiation timeframes as defined in SOP 2.10.
  4. Immediately notifies the Service Region Administrator (SRA) or, in the absence of the SRA, the designee when the intake meets acceptance criteria and has been designated as a fatality/near fatality.  

Practice Guidance for Receiving and Accepting the Report  

  • Reports of improper use of vehicle (child) restraints and sudden unexpected infant death (SUID) do not meet acceptance criteria unless there are other allegations of maltreatment documented.
  • Notifications to the SRA and/or to the Division of Protection and Permanency (DPP) are not required for resource links or law enforcement assist referral.
  • Intake staff should request that the reporting source provide information regarding the contributing link between the maltreatment and the child’s fatal or near fatal condition.
  • A fatality/near fatality designation cannot be used with a risk of harm (neglect) or dependency sub-program.
  • Centralized intake branch manager can consult with system safety analyst as needed.
  • The region should assign staff that have had no prior involvement with the family to investigate the fatality/near fatality referral.


Procedure for Notifications
 

  1. The SSW or other regional staff immediately notifies the SRA (or in the absence of the SRA, a designee) when an investigation is accepted and has a fatality/near fatality designation and when a child fatality occurs in an active case.
  2. The SRA or designee completes sections I and II of the System Analysis Report (SAR) form and emails DPP.childfatality@ky.gov within forty eight (48) business hours.
  3. The SRA or designee notifies, in writing, the judge of the court of jurisdiction and the guardian ad litem for active court cases within five (5) business days when:
    1. Any child fatality occurs in an active court case; and
    2. A near fatality investigation is accepted in an active court case.
  4. The central office system safety analyst assigns the case a fatality or near fatality number and re-distributes the numbered form to the SRA or designee for use throughout the investigation.
  5. The system safety analyst distributes the numbered SAR to the director of service regions, office of legal services, and records management. 
  6. The SRA or designee notifies the Division of Protection and Advocacy at 5 Mill Creek Park Frankfort, KY 40601 when:
    1. The child is identified as a client of Kentucky’s Protection and Advocacy Division and DCBS has accepted an investigation designated as a fatality;
    2. The child fatality occurs as a result of placement in a seclusion room pursuant to 922 KAR 1:390; or
    3. The child fatality occurs as a result of a therapeutic hold pursuant to 922 KAR 1:300.
  7. The SRA or designee notifies the child’s legal parent(s) of the fatality or near fatality when:
    1. The child is in the custody of the cabinet and placed outside of the birth parent’s home.

Practice Guidance for Notifications 

  • The System Analysis Report (SAR) is an internal document and is not included in the case file and is not distributed to outside entities.
  • The notification to the court and to Protection and Advocacy will be a written letter drafted by regional staff.
  • Notification to parents should be face to face or by phone.

Procedure for Investigative Process 

SRA or designee will ensure the case record is changed to controlled access immediately when there is an active case.  

Active Ongoing Cases:

  1. All ongoing contact (to include R&C case management) with the family immediately stops in an in home or out of home ongoing case for a period of at least fourteen (14) days. The SSW should not have any face to face contact with the family within the fourteen (14) day period:
    1. Documentation for home visits, contacts, case plans, etc. that was completed prior to the fatal/near fatal incident, will be updated within three (3) working days.  
    2. Ongoing work may resume with the family after the initial fourteen (14) day period at the discretion of the SRA or designee.  

Active Pending Investigations:

  1. The SRA or designee shall:
    1. Immediately review the status of any pending investigation;
    2. Determine the amount of work needed to complete and develop a plan for completion; 
    3. Email the plan of completion to the central office system safety analyst within three (3) business days; 
    4. Ensure that all pending investigations are completed, entered into TWIST, and approved within fifteen (15) calendar days of the fatal/near fatal incident; and
    5. Ensure that support to staff is available to assist them in managing trauma experienced through their involvement with the fatality/near fatality as set forth in SOP 1.13 in accordance with their regional protocol.

Conducting the Investigation

 

The SSW shall:

  1. Follow procedures and practice guidelines set forth in SOP 2.10 and SOP 2.11 and follow any initiation timeframes set forth by central intake staff or the on-call FSOS. Investigative services shall also include:
    1. Engagement with law enforcement for joint investigation;
    2. Collaboration and consultation with first responders, coroners, medical examiners, and medical professionals; and
    3. Collection of all available medical records and review of all records relevant to fatality/near fatality.
  2. Determine the alleged perpetrator’s access to other children of which they may exercise a caretaking role and address any safety issues with those children to determine what safety response is necessary.

The service region shall:

  1. Provide the system safety analyst an update of the status of the investigation within thirty (30) calendar days of the fatality/near fatality investigation being received. The update shall include:
    1. Anticipated finding and rationale for the finding;
    2. Information regarding the cause of death or mechanism of injuries as determined by the autopsy or pediatric forensic medical consult; and
    3. Summary of tasks to be completed.

Making a Finding and Completion of the Investigative Assessment

 

  1. The designation of fatality/near fatality shall only be applied to a substantiated finding of maltreatment when the maltreatment has been found to directly contributed to the child’s fatal/near fatal condition.
  2. The fatality/near fatality designation shall only be applied to the subprogram most closely related to the child’s fatal/near fatal condition. Only one subprogram can have a fatality/near fatality designation.
  3. The investigation shall not be finalized until the receipt of finalized reports from medical examiner, pediatric forensic medicine, or other solicited experts collaborating or reviewing child’s injuries or conditions.
  4. The regional SRCA or AA shall review the completed investigative assessment prior to FSOS approval.
  5. The regional SRCA or designee shall provide notification of the completion of investigative assessment to central office system safety analyst upon approval by completion of section III of the SAR.
  6. The region may consult with the system safety review team or the child protection branch at any time during the investigation as needed. 

Practice Guidance for Investigative Process 

 

  • Records collected should include:
    • Birth records;

    • Pediatric records;

    • Hospital records;

    • Immunization records; and/or 

    • Any other records related to the specific health needs of the child.

  • SSW should consult with the system safety analyst regarding how to proceed if a coroner refuses to request an autopsy, and the SSW asserts the need for an exam. 
  • 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.
  • The SSW should participate in local child fatality response teams to assist in cross communication and sharing information between different agencies.
  • The SSW shall determine in consultation with the FSOS if filing court petitions is necessary for the safety of any surviving children when a substantiated finding is made with the fatality/near fatality designation.  The SSW should assess the frequency of the perpetrator’s contact and access to the surviving children and other protective capacity issues within the family.
  • The SSW should assess for sudden unexpected infant death (SUID/SIDS) and safe sleep in all investigations.  See the Sudden Unexpected Infant Death information sheet.

Procedure for System Safety Review (DCBS Internal Review Process) 


All cases where a child fatality has occurred in an active case and/or accepted as an investigation with the fatality/near fatality designation will have an initial review by the system safety analyst and will be presented to the multi disciplinary team (MDT)  for consideration of a comprehensive analysis.


The system safety review team will complete an initial case review, which will include a review of the circumstances of the fatal/near fatal incident, allegations and details of prior investigations, and the provision of ongoing services. The goal of this initial review is to identify features that may be recommended for a more in-depth analysis. Particular attention will be given to history occurring within the twenty four (24) months prior to the fatal/near fatal incident. The details of this process can be found in the System Safety Review Process Manual.

The process focuses on understanding the complex nature of child welfare work and the factors that influence decision-making and practice in real-time. It moves away from the simplistic approach, which has a tendency to assess blame and results in the application of quick fixes that fail to address the underlying issues. The system safety analyst assigned will complete an initial case review within thirty (30) days of fatality/near fatality notification, identifying potential features for further consideration.

  • A multi disciplinary team (MDT) will review the case to make a determination on whether further analysis of the case is recommended. 
  • Cases selected by MDT for further analysis will be given to the system safety analyst for human factors debriefing.
  • Cases not selected for further analysis will be documented in the SAR and will be scored by the system safety analyst in the System Analysis Scoring Tool after the completion of a pending fatality/near fatality investigation.
  • Information gathered in the human factors debriefings will be presented by the system safety analyst to regional mapping teams:
    • Regional mapping teams will consist of various frontline staff, regional staff, and local community partners;
    • The mapping teams will work to identify systemic issues influencing practice.  
  • Influences revealed in the mapping process will be scored to identify factors impacting practice.  
  • Factors identified will be presented to DCBS leadership for consideration of systematic program improvements.

Procedure for External Fatality and Near Fatality Review Panel 

    KRS 620.055 establishes an external child fatality near fatality review panel for the purpose of conducting comprehensive reviews of child fatalities and near fatalities reported to the Cabinet for Health and Family Services, suspected to be a result of abuse or neglect. The panel shall be attached to the Justice and Public Safety Cabinet for staff and administrative purposes.
     

    The external review panel is composed of governmental appointees and various professionals from other entities related to child welfare. The external panel meetings are open to the public and to media outlets. This panel has the authority to review and analyze all DCBS records and any other records related to fatality/near fatality cases. 
     
     
    The region(s) shall provide all agency records to the system safety review team for submission to the external review panel within thirty (30) days of the fatality/near fatality investigative assessment approval.
     
    The system safety review team is responsible for providing all records to the external review panel.
    The file is to be divided and scanned in sections in chronological order:
     
      1. F/NF investigation (DPP-115, investigative assessment, Notification of findings, AOC records and prevention plans);
      2. Prior investigations;
      3. Court records;
      4. Medical records;
      5. EMS records;
      6. Autopsy records;
      7. Law enforcement records;
      8. Case plans and evaluations;
      9. Service recordings; and
      10. Any other pertinent professional documents.
     
     

     

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