Children at risk: City’s child fatality reviews don’t prevent future deaths as intended

The DC Line conducted a six-month investigation, funded by SpotlightDC: Capital City Fund for Investigative Journalism, in pursuit of the answer to that question. This is part of that investigation.



GABRIEL Eason’s name appeared in broadcast media and newspapers for a few weeks following his death in April 2020 and once again after the November arrests of his mother, Ta’Jeanna Eason, and her boyfriend, Antonio Dale Turner, for homicide. The 2-year-old, who was beaten and tortured in the final months of his life, subsequently fell into a hole deeper than any grave. His story and that of his two brothers — also punched and pounded with adult fists — quickly faded from the public’s consciousness. Say their names and puzzled looks appear on more than a few faces.


A similar reaction comes with the mention of Makenzie Anderson. She was only 11 months old on Feb. 6, 2020, when her mother abused her in a hotel that doubled as a temporary DC government shelter for homeless families. She died from blunt force trauma to the head.

No one even knows the whereabouts of 2-month-old Kyon Jones, let alone his name. His mother, Ladonia Boggs, told officers of DC’s Metropolitan Police Department (MPD) in May 2021 that she went to sleep with him one night and the next morning he was dead. She wrapped him in a blanket and threw him in the trash.


The U.S. Attorney’s Office for DC refused to prosecute Boggs for murder. She was charged only with “tampering with physical evidence,” as if Kyon were some piece of paper or file, instead of a human being.



When a child is murdered, people often want to believe the death will force societal change. They want government officials and agencies to rally to ensure no other child will experience a similar demise.


That’s the thinking that led to the creation three decades ago of DC’s Child Fatality Review Committee — which is under the medical examiner’s purview — as well as the subsequent establishment of the DC Child and Family Services Agency’s Internal Child Fatality Review Committee. The two panels are among nearly a dozen entities that make up the District’s child welfare system, with the Child and Family Services Agency (CFSA) as its linchpin. Yet that infrastructure, built over time, has proved incapable of fulfilling its directive to assess child fatalities and reduce preventable deaths.


This is one finding from a six-month investigation by The DC Line — which included an extensive examination of government documents, court cases, and internal and external reports along with dozens of interviews with DC officials, a whistleblower, child welfare experts, lawyers and advocates. It found DC’s child welfare system, which is responsible for preventing, investigating, evaluating and forcing consequences for infant and child deaths, is inadequate at best and allows homicides to proceed without public scrutiny at worst. The DC Line’s probe further found:

  • Delays in evaluating and reporting infant and child deaths keep information and details out of public view for years; some reports never become public.

  • Though the District has two separate review committees — one of which has a subcommittee to evaluate infant deaths — reports are often inconsistent, inconclusive and delayed.

  • Because of the systemic delays as well as undetermined and sometimes questionable causes of death, caregivers and parents sometimes go unpunished for what might have been murder.

“Children who are murdered by caregivers get lost” in the Child Fatality Review Committee’s process, said Stephanie McClellan, deputy director of the DC KinCare Alliance, a nonprofit organization created to support relatives who care for children outside of the traditional foster care system. “There is no way to tell how many children die each year in DC … because there is no current reporting of that information.”


A spokesperson for DC Health, Robert Mayfield, said in an email to The DC Line that the department does not publish an annual list of infants, children and youth who have died in the city. He said the agency instead has “an agreement” with CFRC, “which does publish a report.”


However, the review committee does not publish any listing with the name, age, and cause of death of each child who dies in the city — or even a complete list that omits certain information about the victims.


The structure of the current review system dates back to 1992 when a federal lawsuit helped drive reforms to DC’s child welfare system. While the Child Fatality Review Committee was initially created by mayoral order, U.S. District Court Judge Thomas F. Hogan later demanded its permanent establishment, among various other changes, as part of the class-action lawsuit initially known as LaShawn A. v. Marion Barry Jr.; the class included approximately 2,500 children caught in the city’s child welfare system.


Two years later, frustrated and still unimpressed with the pace of change in the District, the plaintiffs’ attorneys asked Hogan to place CFSA in receivership. He did.


In 2001, then-DC Mayor Anthony Williams sought to regain control of it and five other agencies under court receivership. Working with the DC Council, Williams reconstituted the Child Fatality Review Committee under local law and elevated CFSA to a cabinet-level agency.


He may have rescued the agency from complete court control. But 20 years later, it’s clear that the goal of preventing future deaths of children, particularly abuse or neglect homicides, has been thwarted. Critics also point to the lack of full reviews of every child fatality in the city and the use of privacy concerns to withhold information.


DC Auditor Kathy Patterson, a former Ward 3 DC Council member, was involved in the drafting and passage of the original law. In a recent interview, she recalled the 2000 murder of 23-month-old Brianna Blackmond by her mother’s roommate as an additional impetus for the legislation formalizing the CFRC. “The goal, then, was enhanced accountability when children are in the care of, or known to, the DC government — in part prompted by [that] case,” she said.


In 2017, the auditor’s office released the report “Critical Work of the Child Fatality Review Committee Should Build on Recent Reforms, which analyzed the committee’s findings from 2008 to 2015 and raised serious questions about CFRC and its review methods. While Patterson’s report mentioned that the number of city-reported deaths of infants, children and youth dropped significantly during those years — from a high of 182 in 2008 to 124 in 2015 — she was critical of various aspects of the process, including that notwithstanding the large number of government agencies on the committee, their responses to recommendations often were “pro-forma” and did not reflect a “genuine commitment to change policies and procedures.”


Patterson, who worked at the American Public Welfare Association prior to joining the council, said in the report that inclusion of multiple deaths from previous years made it difficult to analyze trends. That was a key function expected to help prevent future fatalities.

Further, the number of reviews conducted by CFRC had dropped dramatically — from 122 in 2010 to 35 in 2015, according to the auditor’s report. That remains a problem today.


Complicating the issues surrounding DC’s fatality reviews is determining what constitutes an accidental death. Experts interviewed for this series assert that changes are urgently needed that would factor in the behaviors of parents and others — including possible neglect — that may have contributed to the child’s death. Even if the redefined cause did not result in more prosecutions by the U.S. Attorney’s Office for the District of Columbia, they say, it would provide a more transparent view of what is happening to DC children.


Additionally, advocates have demanded that all information about children who were murdered be made available to the public. There is no reason for such secrecy, they say, and the information may save the lives of others, including the dead child’s siblings. For instance, it could serve as an early warning signal if ordinary disciplinary action has tipped over into the realm of abuse or maltreatment.




IN THE BEGINNING

Operating as a division of the DC Office of the Chief Medical Examiner (OCME), the Child Fatality Review Committee is the central entity that tracks the deaths of infants, children and youth in the District. It’s statutorily mandated to “identify and characterize the scope and nature of child deaths,” particularly any that are “violent, accidental, unexpected or unexplained.”


By law, the committee must review all deaths of children who were residents of DC, with particular attention to children whose families were “known to the juvenile justice or intellectual disability or developmental disabilities systems” (either at the time of their death or within the two years prior) or were “known to the child welfare system in DC” (at the time of their death or within the four years prior). Additionally, the committee may review the death of a nonresident that occurs in the city if it is deemed accidental or unexpected. The law requires CFRC to prepare statistical reviews as well as to conduct “multidisciplinary, multi-agency review of all individual fatalities within 6 months after the final determination of the cause and manner of death and prioritize fatalities where child abuse, neglect, or another form of child maltreatment is the cause of death or a contributing factor.” The DC Council added the six-month deadline and included maltreatment as a consideration in determining cause of death in an amendment this year.


The fatality review committee must also “examine past events and circumstances surrounding child deaths in the District by reviewing the records, files and other pertinent documents of public and private agencies responsible for serving families and children, investigating deaths, or treating children.” Under DC law, the committee’s stated purpose is to reduce the number of preventable child fatalities and improve their quality of life.


Recent changes to the law mean that two DC Council members — Ward 6’s Charles Allen, as chair of the Committee on the Judiciary and Public Safety, and Ward 1’s Brianne Nadeau, as chair of the Committee on Human Services, sit on the committee as of Oct. 1, 2021.


Other committee members include the directors or representatives from government agencies and government contractors, as well as “community representatives,” who are appointed by the mayor and confirmed by the DC Council. As of 2019, the committee’s government members included the MPD, CFSA, Department of Human Services, Department of Behavioral Health, DC Health Department, Fire and Emergency Medical Services Department, Office of the State Superintendent of Education, Department of Youth Rehabilitation Services, DC Office of the Attorney General, DC Superior Court’s Family Court Operations Division and Department of Health Care Finance. Several of these same entities are also on the subcommittee known as the Infant Mortality Review Team.


Separately, CFSA established its own Internal Child Fatality Review Committee in the early 2000s; its members are agency personnel, the medical examiner and representatives of the Healthy Families/Thriving Communities Collaborative and the Center for the Study of Social Policy, which served as the court-appointed monitor in the LaShawn A. lawsuit until a settlement agreement was reached in June. CFSA’s internal committee reviews the circumstances surrounding the death of any infant, child or youth who had been involved with the agency within five years of their death.


While it may appear that the city is being thorough, the two committees don’t complement each other; they duplicate each other, including their weaknesses. They have both offered only a sampling of the deaths and not a review of every child fatality in the city. They have been late in providing their annual reports. Neither offers recommendations that could ultimately reduce the number of homicides. Officials, meanwhile, stress obstacles to more expansive reporting, such as the time it takes to gather the information to review the circumstances of a child’s death. Advocates and child welfare experts aren’t convinced, saying resources would be better used by creating a more integrated and comprehensive system that provides greater details about each of the child fatalities, including specific information about their home environments, parental histories and interactions with government agencies.


Both fatality review committees began under the promise of prevention and accountability. They have become, however, little more than bureaucratic get-togethers, issuing reports filled with statistical analyses, hand-wringing and toothless recommendations — based on deaths that, in most cases, occurred years earlier. They epitomize the failures of the DC child welfare system.


Agency directors and government officials may praise the city’s work creating what they call a “system of care” and a “system for prevention.” The evidence, however, points to a system that lacks the capacity to proactively prevent harm to children — a view shared by critics with expertise in the subject. Even after being alerted to dangers and risks, DC’s child welfare system managers and staffers have often failed to make the tough decisions necessary to shield children, including removing them from homes where their parents lack the skills or ability to care for them — in many cases because the parents suffer from substance abuse or mental health disorders, and sometimes from both.


As for the medical examiner’s and CFSA’s fatality units, neither effectively reviews the deaths or homicides of children during the year in which they occur, as noted in the auditor’s 2017 report. The former is years behind in its assessments. The latter has at times skewed the number of child deaths that occur in DC by burying those that happened years earlier but weren’t previously acknowledged, a review of government documents shows. Given that the chief mission of the review committees is to prevent future deaths or murders, the growing number of fatalities and the fact that many of them are similar to those that occurred in previous years represent failure on two counts.


The Child Fatality Review Committee didn’t publicly release its 2019 report until March 2021. The panel reviewed 51 deaths of infants, children and youth. Not one of those deaths occurred in 2019. They happened in 2015, 2016, 2017 and 2018.


Children who were murdered in 2019 and 2020, whether by gun violence or at the hands of their mothers, fathers, parental paramours or relatives, have yet to receive attention in a publicly available report from the CFRC, as of this writing. Most of those children were Black or brown.


There is also no reporting on near fatalities like D.J., a 5-year-old girl whose brutal beating by her father landed her in a permanent vegetative state, and L.D., a 2-year-old girl whose father broke her left and right jaws requiring emergency surgery. Because the two children are alive, there is no mandate that any reviews be conducted about the circumstances surrounding the extreme abuse they suffered.


Equally disturbing is this: In 2019, in a departure from past practice, CFSA decided not to provide detailed information on the deaths of 20 children because they occurred prior to 2019. Their erasure appeared in a footnote in the agency’s internal fatality report.


Child welfare expert Marie Cohen found the shift unconscionable. “For every dead child, several more may be suffering from abuse and neglect that will poison their future,” she said.


“Leaving out more than half of the children whose deaths were reviewed in 2019 just because they died in previous years is an unnecessary loss of information that could be crucial in saving lives in the future,” added Cohen, a former CFSA social worker and a current community member of the chief medical examiner’s Child Fatality Review Committee. She is also the author of the Child Welfare Monitor DC blog, which examines local and national government policies and practices.


CFSA did not publish its internal 2020 fatalities review until late October 2021; even then, it buried the report on its website, without the legally required notice of its availability to the public. The agency’s team reviewed 42 deaths; 27 of those actually occurred in 2020, while the other 15 were from 2018 (nine) and 2019 (six). Information is provided in some depth on 40 deaths of infants, children and youth in the District: Nine were from natural causes, five were deemed accidental, 20 were gun-related homicides, and three were abuse or neglect homicides. One was classified as undetermined, and another — which occurred outside the District — was listed as unknown; there is no explanation of what happened in the other two cases.


Almost all of the children and their families had at least some contact with CFSA, including nine who were involved “with the District’s child welfare system at the time of the decedent’s death.” Two families had open Child Protective Services (CPS) investigations; one family had an open in-home foster care case and an open investigation; five families had open traditional foster care cases; and one had an open foster care case and CPS investigation.


Of the 40 fatalities, as many as 17 had CFSA involvement within 12 months of the death: 11 of those had at least one investigation opened, two families had a new or reopened foster care case, and four had an open CPS investigation and a foster care case, according to the agency’s report.


Additionally, virtually all of the families were mentioned in calls to the District’s 24-hour Child Abuse and Neglect Hotline that had been screened out. At least 38 of the 40 children whose deaths were reviewed in 2020 were the subject of screened-out calls within five years of the fatality — 10 families had one screened-out referral, seven had two, five had three, and 16 had four or more. There is no explanation provided for why that happened. It’s reasonable to wonder whether those children might be alive had those calls not been dismissed.


In advocating for more transparency in the overall fatality review process, whether at the OCME or the CFSA, Cohen said, “I think it should be ombudsperson, or a lot of states have child advocates. It should be one of those people. Illinois has an inspector general for child and family services. It needs to be an independent agency.” Such an office would review the deaths to answer a key question: “What was done wrong?”


DC KinCare Alliance’s McClellan echoed the call for transparency and accountability, saying both considerations outweigh privacy concerns: “That’s what they hide behind. The kid is already dead. If I’m a dead kid, the best thing you can do is tell everyone what happened to me.”


In the original law creating the Child Fatality Review Committee, a public hearing focused specifically on the annual report was required. Patterson said the council has defaulted on demanding adherence to that provision. Surprisingly, two sections that had mandated greater public disclosure were repealed in the 2022 Budget Support Act.


Council member Allen, as chair of the public safety committee, initiated those changes, among others, to CFRC as well as the Office of the Chief Medical Examiner earlier this year. In an email to The DC Line, he argued that his amendments mandate more thorough reviews for all child fatalities, bolster public access to findings and recommendations and expand what he called the current “skeletal” reviews. He did not, however, repeal confidentiality now provided for “an alleged or suspected perpetrator of abuse or neglect upon the child,” which was among the changes sought by many advocates.


Christian Greene, a former CFSA employee, told The DC Line she learned during her tenure as ombudsperson from 2015 through 2017 that the agency wanted to withhold certain information about child fatalities from the citywide CFRC. The result would have been, she said in an interview earlier this year, “a summary of a summary of a summary.”

Greene was fired after demanding the agency comply with legal mandates to notify children of their rights and to issue certain reports publicly. A judge ruled against her resulting 2018 whistleblower lawsuit; Greene’s appeal in the DC Court of Appeals is pending.


While the community’s goal for the fatality reviews might be to hold abusers, neglecters and even government officials accountable, Greene said the statute doesn’t mandate that type of scrutiny. Instead, she said, the “language in the legislation and the purpose of CFRC is to [conduct a nonjudgmental] look at the case superficially and say, ‘What could we have done differently?’ or ‘What themes are we seeing to prevent a future death?’ They’re not looking at holding anyone accountable with a family. It is purely what recommendations can we make so that another child doesn’t die.”


Judith Meltzer, president of the Center for the Study of Social Policy and the former LaShawn A. court monitor, has tracked the District’s child welfare reforms for more than two decades. She offered that some states have been rewriting their laws to help ensure accountability. “So, if a child dies, you’re essentially able to release more information,” she said of these model laws.


“The [CFRC] was an absolute disaster and a mess for the first 15 or 20 years that I was doing this work,” Meltzer said. In contrast, she added, its “infant mortality subcommittee, which doesn’t just look at child abuse and neglect death [but instead] at all infant deaths, [is] very functional. They make good recommendations. They actually got some traction on them.”


As for the CFRC itself, Meltzer said procedural barriers hinder its potential effectiveness, although she has seen improvement. “Sometimes there’s a police investigation and the police won’t release information. Secondly, sometimes it takes a long time for the medical examiner to release a report about whether the death is from natural causes, homicide, or undetermined. Then, the process has been slowed.


“So, there’s been a backlog of cases. Sometimes they’re reviewing cases that are old. However, the review process itself of the cases, internally and in the citywide committee, has gotten stronger,” Meltzer continued, asserting that the task at hand is inherently “a little more complicated than any of us would think.”


It’s difficult to hold anyone accountable or even to know with certainty that reviews were conducted competently or with fidelity since CFRC destroys records after it publishes its annual report — a practice called for in the original statute. Toya Byrd, a spokesperson for the medical examiner, could not provide details on how promptly the records are destroyed, but she confirmed the practice, offering that “a lot of the records are not ours,” including medical records and other documents from private sources.




HOW COMPLICATED IS THE REVIEW PROCESS?

To compile the case files that are presented for review to the citywide CFRC, the staff of the medical examiner’s child fatality review unit selects a sampling from the list provided by DC Health of child deaths that have occurred in the city. Supplemented by autopsies and full access to other public and private records, those files include relevant information like the child’s age, the cause of death, the status of the family — income, parental health, relationship of parents — and any interaction the family may have had with DC agencies, particularly CFSA. Names are not used. Each child is simply referred to as “decedent,” and the resulting reports rely heavily on statistics — an approach that for many comes across as inhumane.


If a 5-year-old child died, “at some point we need to contact other states to see if there was any interaction with hospitals, with child welfare systems in other states to try to put that picture together. That retrospective review is time-consuming,” explained Dr. Francisco J. Diaz, who became the city’s medical examiner in January 2021 after serving as deputy ME since 2017.


“We have a few children that died with asthma. … Is asthma a death sentence?” asked Diaz. “If you have a 10- or 11-year-old that’s been suffering from asthma, let’s say, six or seven years, the length of the medical records, the different hospitals and urgent care centers that that family visited, all that will be reviewed.”


Additionally, “In every instance there is an infant death, we do what is called a scene reenactment,” he noted.


That kind of rigorous review, Diaz said, accounts for holdups that have resulted in CFRC still looking at case files from 2015 without yet examining in many cases what happened to children who died in 2021, 2020 or even 2019.


Developing the files may take a long time, but staff presentations and accompanying discussions by committee members often do not last any longer than “an hour or 45 minutes” per case, said Cohen, who added, “There’s just not enough time.” Nonetheless, she praised the work of the ME’s fatality unit, adding that it would be impossible for committee members to read entire case files.


“But there are many times when I’ll read what the staff wrote and I’ll say, ‘Wait a second, I don’t get this.’ It’ll be unclear,” added Cohen.


When there are questions, the staffer or agency representative in attendance may respond. “They’re supposed to bring their own records, too. So that if there are questions, they can look it up right then,” Cohen explained during one of a series of interviews.


“It’s really short. There’s just not enough time. And that’s one reason I don’t think Child Fatality Review can really do what needs to be done,” said Cohen.


After a discussion of a case, presented mostly in summary by the medical examiner’s review staff, the committee members “come up with findings,” Cohen said. “A finding might be that there [aren’t] enough mental health services for moms in the District.”


Assistant U.S. Attorney Cynthia Wright praised the fatality review process as designed. A former CFRC co-chair, she said the “benefit and the beauty” is having all the people in one room. “We sit down and work as a team.


“That group is one of the most important things for me personally, in my career, because you get information and insight about how to change things. Keep in mind, it’s always developing,” continued Wright, who for the past 20 years has prosecuted most of the abuse and neglect cases in the District. She has been handling those related to the murders of Gabriel Eason, Makenzie Anderson, Kyon Jones and others.


Wright said she does see at least incremental improvement because of the CFRC’s work.

“We’re making a little difference. You can’t change everything overnight and certainly these are, you know, systemic, big issues that have been around for a long time, but things are getting better,” added Wright.


DC KinCare Alliance’s McClellan doesn’t necessarily see it that way. Essentially, she said, the process is mostly a “hodgepodge. There is no one place to look to see what’s going on.”



The greatest complication in the fatality review process may be how the deaths are classified. By statute, “we have to classify the manner of death,” Diaz explained in describing his role as chief medical examiner. Among the options are natural death; suicide; homicide; and accidental death, which could be caused by a variety of things, including an automobile crash or an unintended drug overdose.


“Sometimes we’re not able to determine and therefore the manner of death is ‘undetermined,’” said Diaz. “That means that we don’t have all the elements [and] we’re not comfortable in calling it an accident, but we don’t have the certitude that it’s a homicide.”


A child’s death is classified as a homicide when it is “a result of the actions of others,” he continued, adding that the review in such a case would examine the interactions between the child and the family. For instance, “Was the child taken to hospitals or urgent care centers in the previous years or months?”


Sometimes, children become the victims of abuse because someone “snapped,” said Diaz. That’s not always the case, however. “In a significant proportion, they are victims of chronic abuse and neglect … and the final constellation of injuries is an event, but that event is preceded by multiple smaller events.”


The CFRC’s 2019 report covers 51 fatalities that occurred from 2015 through 2018. Those do not include all the deaths in that period, however. The committee “does not conduct surveillance of all child deaths,” explained the ME’s spokesperson. “Cases are prepared for review once the deaths have been certified and all of the agency information has been received for review.”


Of the deaths that were reviewed by the CFRC in the 2019 report, 28 were from natural causes; five were classified as homicides; nine were undetermined; and the other nine were deemed accidents.


Diaz said no medical examiner classification is ever really final: “If more information arises even with the passing of time, the manner of death could be revised and amended.” He didn’t discuss how that would be affected by the destruction of records once CFRC’s report is complete.


Knowing how and why people die can help with developing public health policies, Diaz explained. For example, during his tenure as a medical examiner in Wayne County, Michigan, he and his staff prepared a study related to an “unsafe sleeping environment.” Infants were dying because they were placed in bed with adults who sometimes rolled over them or pushed them between the bed and the wall. A public education campaign as well as the distribution of cribs helped decrease those deaths in the county.


The District also has an “unsafe sleep environment” problem, said Diaz. “It is not only [when there are] three, four, five or six people sleeping in a bed. Sometimes it’s the environment itself where children are found in compromising positions, which will prevent them from properly breathing.


“We see infants or children that [have] been found wedged between the wall and the bed. Or in some instances where the infant is placed in a car seat that is doubling up as a bed.” They’re also placing a lot of blankets on the car seat, which can compromise the child’s breathing, he said.


Compounding that issue, said Diaz, is the fact that people who are “supposed to be taking care of those children, unfortunately, are under the influence of substances.”


Almost invariably, DC officials classify deaths resulting from unsafe environments as accidents. Should they instead be considered homicide by neglect, especially when the adults involved were under the influence of drugs or alcohol? That question is asked by many local child welfare advocates.


CFSA’s 2020 Internal Child Fatality Report stated that 16 children ages 2 and younger who had some contact with the agency died that year — a substantial increase over the seven during 2019. Of the 16, five involved unsafe sleep environments; CFSA did not provide specific details, however.


“What we don’t know are the facts surrounding the unsafe sleep,” DC KinCare Alliance’s McClellan said of what actually happened in these five fatalities. “We need to have more detailed reporting.”


Consider the case of Ladonia Boggs as reason for concern about the use of “unsafe sleep environment” as an accidental cause of death: Early in May 2021, according to court documents, she was having arguments with her boyfriend — the father of her 2-month-old son, Kyon. At one point she called him on the telephone, asserting, in colorful language, that she regretted having the baby.


When Boggs was pregnant, she used PCP, a mind-altering drug that can lead to hallucinations. In 2020, CFSA received notifications that 271 infants were born in DC with some type of drug in their system, including cocaine, THC (the compound that gives marijuana its high) and phencyclidine (commonly known as PCP).


Boggs continued to use PCP after the birth of her child. Her description of the problems Kyon exhibited — including digestive issues and excessive crying — suggests he may have been a drug-addicted infant. Boggs had other children, but apparently wanted and needed help with Kyon. On May 4, she told her boyfriend to come get the child, according to court documents.


He never came to collect the child. Instead, on May 5, she called to tell him that the child would be gone for a long time. She said a staffer at the Child Protective Services division of CFSA took Kyon.


The next day, the child’s father called his case worker at the National Center for Children and Families, who later told him that Kyon had not been removed from Boggs’ Benning Road NE apartment. At some point, the case worker called the CFSA hotline, reporting a missing child and a mother with a history of PCP use, according to court documents.

That prompted an MPD officer to conduct a “welfare check” that day. Boggs told him no young children lived there. He left.


A CFSA social worker arrived on May 7. Boggs offered the same story about the child being removed. The social worker knew better. The police returned.


Finally, over the course of several days of interviews, Boggs revealed that she had gone to sleep with the infant in the same bed. When she woke up the next morning, the child was dead.


She never called an ambulance or the police. Instead, she wrapped Kyon in a blanket and dumped him in a nearby trash can. Then, she removed all of his clothing and any other trace of him from the apartment. Boggs admitted that a day or two before the child’s death, she had smoked PCP.


The police officer investigating the case noted in his affidavit that a “pediatrician at Children’s National Medical Center advised that co-sleeping may result in death, the risk of which may be increased when a parent is under the influence.”


Without referring to any specific case, Diaz seemed sympathetic in a recent interview with The DC Line to concerns about classifying every unsafe sleeping environment as an accident. “You are not wrong in the sense … if five people [were] in a bed — plus an infant — and four of them were on drugs,” there is a danger to the child.


He added, however, that as a medical examiner he can’t assume the “role of editorializing” or “opining.” The “autopsy report should speak of itself.” It’s up to other agencies to determine neglect and what should be done, Diaz said.


Boggs’ case is pending in DC Superior Court; a preliminary hearing is scheduled for Jan. 12, according to the court docket. The police originally arrested her on charges of felony murder. The U.S. Attorney’s Office reduced it to tampering with evidence.


“The office has no comment on charging decisions and has no comment on this particular matter,” the U.S. attorney’s spokesperson said about Boggs via email.

Kyon’s body has yet to be found.


A FAILING SYSTEM BY THE NUMBERS

The review conducted by the medical examiner’s office may be considered a macro portrait of the failures of the frayed, wholly inadequate safety and protective system for DC’s children. The one prepared by the CFSA’s Internal Child Fatality Review Committee is a microscopic view that offers disturbing details about the system and the plight of children in DC; the information in the report leaves many people — and even some government insiders — wondering why a federal judge signed off on the settlement of the LaShawn A. lawsuit.


In effect, the details provided in the “Child and Family Services Agency Internal Child Fatality Report: Statistics, Observations and Recommendations, 2020” — as well as the previous 2019 report — offer an admission sotto voce that DC is failing to protect its young and most vulnerable citizens.


CFSA reviewed the deaths of 33 children in its 2019 report, but 20 of them did not meet the standard set by the agency of occurring within the target year of 2019, according to the report and the agency spokesperson. That meant CFSA’s review unit performed a full examination of “demographic information, as well as child welfare histories and receipt of services documented” for only 13 of the 33, who ranged in age from 2 months to 20 years old.


Most of those 13 children, including several who were killed by abuse or neglect, were living with their families; four of the 13 families were involved with CFSA at the time of the fatalities. At least one-third of the children had siblings in the household who were believed to be in danger, as signaled by the fact they were removed from their homes after the deaths occurred.


According to the report, three of the 13 deaths were from natural causes and three were accidental. The cause of death was undetermined in one case. The other six were homicides — three of them from gun violence not involving a parent or guardian, and three from abuse or neglect. Among those in the latter category, all three children were under 3 years old; one of them died from ingesting fentanyl.


While African Americans represented only 45% of DC’s population in 2019, they accounted for 100% of the 13 fatalities covered by the report. Seven of the children lived in Ward 8; four in Ward 7; and one in Ward 5. Another child lived in Maryland but was under CFSA’s oversight.


Of the 13 fatality reports to CFSA’s hotline, 11 came from MPD, one was from a decedent’s family member, and one was reported by a local hospital.


In terms of prior contact with the agency, four were “involved with CFSA at the time of the child’s death”; the agency’s foster care division also “managed all four cases.”


The report cited “complicating factors” for the three accidental fatalities — all infants — but specified only one such factor: “unsafe sleeping arrangements.”


Of the 20 remaining deaths referenced but not officially covered in the 2019 report, 10 fatalities occurred during 2018; seven were in 2017; one was from 2016; and two were from 2015. That information, included in the report’s footnotes, represents a new CFSA policy that limited cases for review to only those that occurred within the targeted calendar year, in this instance 2019.


“The purpose of an annual fatality report is to report on the fatalities that occurred within a particular calendar year. For the 2019 annual CFR, this was a measured pivot from previous reports,” agency spokesperson Kera Tyler said, adding that the analysis of those 20 families appears in Appendix A. The reference there, however, consists of a footnote that indicates those cases were included “for the purpose of data integrity,” without further analysis.


The agency conducted what appears to be a more complete review for its recently released 2020 report than it did the prior year. However, the deaths of two children are omitted without explanation, and the full assessment of the 15 deaths from 2018 and 2019 is mostly relegated to an appendix. Then, there is the fact that the report was not easily accessible to the public.


DC KinCare Alliance co-founder and executive director Marla Spindel complained about the latter issue, noting that broad dissemination of such critical information is necessary for the public to ascertain whether the city is taking appropriate steps to reduce child deaths from maltreatment. She said CFSA continues to provide reports that are opaque, obscuring how many deaths occurred in any given year by failing to review child deaths in a timely fashion and then relegating information on fatalities from prior years to sparse appendices of subsequent reports.


“If the DC Council and CFSA seek to try to prevent child maltreatment deaths in the future, every child’s death must be reported on in the same way, regardless of when the child died,” added Spindel.


It’s difficult to understand why CFSA would not do everything possible to determine whether children under its purview were — and are — in danger. Data collection and analysis are intended to serve as early warning signals, instigating preventive and protective government action, according to the fatality review law.


The annual fatality reports and similar documents critical for developing a robust, proactive child welfare system have been sent year after year to the mayor, senior executive branch officials and the DC Council. Based on CFSA’s own 2019 report, seven of the 13 decedents’ families were involved with CFSA within 12 months of the fatality; five of those seven families were the subject of a Child Protective Services investigation within 12 months of the child’s fatality. One of the families had received a family assessment referral. Four families had open foster care cases, and one family had an open case with CFSA’s In-Home Administration.


“Two of the four children were in foster care at the time of their deaths; both children were placed with relatives,” explained the CFSA spokesperson. “The remaining two children were not in foster care; however, at least one of their siblings who lived in another household was in foster care at the time of the child’s death.”


Further, said the spokesperson, “It is important to note that prior allegations and substantiations within the 12 months prior to a child’s death may not be related to a child’s cause or manner of death. For 2019, two of the 13 children who died in 2019 were in foster care at the time of their death, and one of the two children was in abscondence at the time of their death,” added the spokesperson.


After the fatalities, CFSA removed eight siblings in all from the homes of their biological parents. “Three were formally removed by CPS and five were informally placed with relatives,” according to the report.


The latter practice of informally placing children with relatives has raised concerns among child welfare advocates, lawyers and elected officials, who have described the results as “hidden foster care.” DC KinCare Alliance has filed six federal lawsuits seeking to protect the rights of children and relatives in those situations.


“I strongly suspect that because of CFSA’s hands-off policy, kids are being abused and neglected to death, with the relevant data being hidden or skewed,” said McClellan, the group’s deputy director.


In CFSA’s 2019 fatality report, eight of the 13 families being reviewed had prior CPS investigations, and all eight had at least one allegation substantiated within five years of the fatality. “Most substantiations were for neglect,” according to the report.


In that category, the top two issues were inadequate supervision and parent or caregiver incapacity; taken together they portend the rise in youth crime and violence, according to sources for this series. Other areas of neglect included positive toxicology in newborns, medical neglect, mental abuse, physical abuse, exposure to unsafe living conditions, and substance abuse by parents or caregivers.


Six of the eight families that had been investigated had more than one charge substantiated, while three families had three substantiations, and three other families had four or more charges confirmed during the past five years.


The substantiations open the door to ponder how many children are being abused and neglected on a daily basis in circumstances similar to those who died — cases like D.J., L.D. or S.C. — but are still alive. Even if the children have been brutally beaten, these near fatalities are not being tracked in any agency reports, a concern of many child welfare experts and advocates.


“The difference between near fatality and a fatality is how quickly the child got to the hospital,” said McClellan. “There are lots of near fatalities that don’t get reviewed at all.”


The CFSA’s 2020 Internal Child Fatality Report exposes a devastating trendline in the District. Consider the fact that the circumstances were similar in many of the deaths, including those in the accidental category, where four of the five involved children less than a year old who had unsafe sleeping environments, as Kyon Jones allegedly did.


Further, most of the children who lived with their families at the time of their deaths had been the subject of hotline calls where allegations of neglect or abuse were substantiated. More specifically, 34 of the children covered in the 2020 report were living at home at the time of their deaths; two were living with relatives in a “kinship foster care placement”; two children resided at the Hospital for Sick Children while waiting for foster care placement; one was in a government-managed shelter; and one “had been committed to a youth services center but had run away.”


According to the 2020 report, the families of nine of the 40 deceased children were involved with the city’s child welfare system at the time of their deaths. That number may be deceptive, however. After all, by the agency’s own admission, 38 of the decedents’ families had at least one referral screened out within five years of the fatality.


Equally important, 33 of the families had at least one investigation within five years of their child’s death, according to the report. Five families had two investigations, six had three investigations, and 10 had four or more investigations.


Many of those investigations uncovered abuse and neglect. For 19 of the children who died, their families had at least one substantiated allegation from a CPS investigation within five years of their fatality. Of those, eight families had one substantiation; four had two; three had three; two had four; and two others had five. The proven allegations included physical abuse, parental substance use; failure to protect the child or children; failure to provide adequate supervision; exposure to domestic violence; sexual abuse; medical neglect; inadequate food or clothing; mental abuse; and exposure to illegal drug activity.


Twenty-three decedent families had at least one in-home or traditional foster care case opened within five years of the fatality. That included 11 families with one in-home case during that time period and six families with two in-home cases opened. Twelve of the 40 decedent families had one traditional foster care case opened within the five years before the child’s death, and one family had two.


Meanwhile, seven decedent families had at least one in-home and one traditional foster care case opened within five years of the fatality. That means CFSA had tried its normal approach of keeping abused, neglected or maltreated children in homes when protective services had determined a low-risk danger. Ultimately, the agency removed the children from those homes.


CFSA is quick to note that fatalities often were children no longer actively involved with the agency, but that may be all about timing — as in how quickly cases were closed. While the review indicated that 30 of the decedent’s families were not involved with CFSA at the time of the fatality, 18 of them did have contact with the agency either through an investigation, family assessment or case closure within 13 months of the child’s death.


Four of the 18 had an investigation within three months of the fatality; one family had a case or investigation closed within four to six months; three families had their case closed within seven to nine months; and four families had a closure within 10 to 12 months. Those numbers suggest that CFSA may have prematurely ended its involvement with several families, even though there continued to be dangers for the child in that home, as evidenced by the deaths so soon after the agency closed the case.


Based on data in the report, the problems of abuse and neglect not only had a generational impact but were often marked by CFSA’s involvement over multiple generations, underscoring concerns held by many sources in this series that the District is creating the environment for future child murders. For example, eight of the 40 children whose deaths were reviewed in 2020 had birth mothers “with prior CFSA history as children”; four of the mothers had been in foster care, one of whom was placed there because of parental substance abuse but aged out at 21.


Another decedent’s mother had been “born with a positive toxicology for marijuana.” One mother had been removed from her home as a child because of a “history of sexual abuse by her stepfather when she was 13”; another had suffered neglect and exposure to domestic violence. Two birth fathers also had CFSA history as children, although there is no additional information about that involvement; there is scant detail on all accounts regarding birth fathers in the report.


In its 2020 report, the agency’s Internal Child Fatality Review Committee recommended providing support to child welfare professionals who experience client-related traumatic stress; setting up more information-sharing agreements among agencies; and using comprehensive medical information platforms to track patients’ medical histories and providers. “It has been observed that families may use different doctors in an attempt to hide patterns of abuse and neglect,” the report says.


The committee did not make recommendations related directly to the problems outlined in its report.


Can the cycle of abuse, neglect and killing be broken? If the suggestions presented in the 2020 CFSA report are any indication, the answer is no.


SHOULD ANYONE BE HELD ACCOUNTABLE?

Former CFSA ombudsman Christian Greene asserted during an interview that not many abuse and neglect cases actually get prosecuted.


In other cases, prosecutors have sought strong charges — at least initially. There have been subsequent plea deals for the killers of babies. A couple of trials remain distant events, leaving it uncertain whether anyone will be held accountable for the deaths of children.

What about government managers? Despite data in the 2019 and 2020 reports that raise questions about the quantity and quality of services provided, neither CFSA nor the other agencies that comprise the child welfare system have accepted responsibility for failing to prevent the seemingly preventable deaths of dozens of children.


As in 2020, the various recommendations in CFSA’s 2019 report seem weakly connected to the fatalities and don’t appear to offer a comprehensive plan of action. One CFSA review staffer recommended developing a process to obtain consistent and reliable information from DC Health on fatalities in the District to more quickly review cases of decedents whose families have prior history with CFSA. The staffer’s recommendation also requests more timely notification of child fatalities from the Office of the Chief Medical Examiner, including information about victims whose families did not have “active CFSA involvement at the time of the child’s death.”


Currently, CFSA has a memorandum of understanding with DC Health to provide birth and death certificates for children whose families were involved with CFSA.

Developing and acting on a more comprehensive action plan is essential, said former court monitor Meltzer.


“Some of the recommendations are too weak,” she said. “Then they issue a report, but there really is no teeth or no mechanism to get consistent follow-up on all of the recommendations.”


Advocates and child welfare lawyers like McClellan want the processes reformed. This year they successfully persuaded Council member Allen to add a requirement that the deaths of all children be reviewed within six months after the medical examiner determines the final cause and manner of death. Further, at Allen’s behest, the council added the city’s director of gun violence prevention — as well as the two DC Council committee chairs with jurisdiction over the child welfare system — to the CFRC.


However, the council did not take action around concerns about use of the “accidental” determination when a caregiver’s reckless decisions or inattentiveness may have contributed directly to a child’s death. The council also made no change as to whether that caregiver can be criminally charged in such instances.


While some experts and advocates commend the preliminary improvements that Allen has made, they assert that stronger reforms to the fatality review process and a full transformation of the child welfare system remain critical. Not the least of their requests is determining when the city ought to remove a child from a dangerous family environment if it intends to prevent future deaths.





A version of this article was first published in TheDCLine.org


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