Children at risk: DC’s child welfare system trends toward destruction and death
The final installment of an investigative series by The DC Line supported by SpotlightDC: Capital City Fund for Investigative Journalism
“I’m going to make you two promises in this trial,” DC defense attorney Jonathan Zucker told the jury in his opening statement in the trial of James Embre for the murder of 2-year-old Aceyson Ahmad. “Promise No. 1: A week from now, a month from now, five months from now, a year from now … 10 years from now, occasionally, you will have nightmares.
“Those nightmares will be rooted in the facts of this case and what you learn during this trial,” Zucker continued, noting that prosecutor Cynthia Wright of the U.S. Attorney’s Office “appropriately pointed out parts of them [that] involve the beating and murder of a completely innocent 2-year-old child.”
“What you learn in this case will haunt you, I predict, for the rest of your life. Obviously, not all the time, but it will always be there with you, and you’ll dream about [it],” Zucker added as the murder trial got underway on Sept. 16, 2019.
Jeremy Jones, Adam Benjamin and Bryan Porter, members of the Metropolitan Police Department’s Sixth District, were haunted by the events that occurred the evening of April 17, 2018, when they received a radio call about an unconscious child. They responded immediately. Even before the officers pulled up to the apartment building at 3411 A St. SE, however, a woman wearing only a bra and underwear came running toward them with a bundle in her arms. She opened the rear passenger door of the cruiser and tossed it into Porter’s arms, demanding he save her child.
The police officers were momentarily confused, but Porter and Benjamin quickly began to perform CPR, according to court documents. Meanwhile, Jones took the mother — Ziykillya Thurman Ahmad — aside, guiding her back to her apartment so she could get dressed and explain what had happened.
While performing CPR, Porter bent his index finger into a hook and conducted “mouth sweeps,” trying to see if there was anything obstructing the child’s mouth, MPD Field Training Officer Jeffrey S. Buchanan told the jurors during the trial. Buchanan had “self-initiated” his appearance on the scene after hearing that “officers needed help.”
“All three of us were covered in vomit,” Buchanan told the court. “People were screaming in the background. It was — it was pretty bad — it was a bad scene.
“I asked Porter if he wanted me to take over on the chest compressions because I could tell [he] was visibly shook up,” recalled Buchanan. When the trial started more than a year later, Porter still hadn’t recovered; he was unable to appear in person to give testimony.
Anxious that the ambulance had yet to arrive, officers suggested driving the child to the hospital but eventually abandoned that idea. Upon the arrival of a fire truck, Buchanan grabbed the child and ran to meet the team.
The DC Fire and Emergency Medical Services (FEMS) personnel initiated their department’s protocol: “We did all of our basic skills, which would include opening the airway, started compressions, giving oxygen,” explained Sgt. Christopher Mullen, who was the acting paramedic, according to court documents. The team placed the child on a heart monitor; put an endotracheal tube in his throat; and started an IO, or intraosseous, in which a needle is inserted into the long bone of the leg to administer medications and fluids.
They were working on the 2-year-old from the back of the fire truck parked on A Street on what is called the tailboard, which measures approximately 4 feet by 6 feet. Eventually, the ambulance came and raced Aceyson to Children’s National Hospital, according to court documents.
He was pronounced dead on arrival.
James Embre, the man with whom the child’s mother was romantically involved for eight months, was charged with felony first- and second-degree cruelty to children and first-degree felony murder. Thus came Zucker’s second promise to jurors: “You will have reasons to doubt that the government made the correct decision that this man committed this offense. There will be strong reasons to doubt. The reason is because the bulk of the evidence will point in another direction.”
Ultimately, Embre was acquitted, though members of the jury may still have nightmares about the case. Some jurors told reporters after the trial that they believed Aceyson’s then 6-year-old sister may have beaten him to death.
Inside the story about Aceyson and his family is tangible and indisputable evidence of the generational failures of DC’s child welfare system to protect the city’s children from abuse, neglect and maltreatment — despite a 32-year class-action lawsuit known originally as LaShawn A. v. Marion Barry Jr. After DC and the plaintiffs in that lawsuit decided last summer to end that litigation, The DC Line began examining whether the city’s child welfare system — comprised of at least 10 agencies, with the Child and Family Services Agency (CFSA) as its linchpin — could now ensure the safety and well-being of the District’s most vulnerable children.
Based on a six-month investigation that drew on public documents, Freedom of Information Act requests and scores of interviews with DC officials, experts and advocates, the answer to that question is no. The DC Line found serious problems, documented through this series “Still Broken: DC’s Child Welfare System”:
The abuse and neglect hotline managed by CFSA is a haphazard operation: Calls are casually and recklessly screened out, repeatedly enabling the continued maltreatment of children or, worse, their death.
Abuse and neglect investigations often are poorly executed — closed too quickly with flawed results.
Some child deaths are determined by the medical examiner’s office to be accidental without sufficient review of evidence that points to the role of parental or caregiver neglect.
Reviews of child fatalities continue to be incomplete and years behind despite a report released four years ago by the DC auditor that raised significant questions about the process.
Some children are required to remain at home, in a nebulous status of in-home foster care placement, despite determinations that parents and others in those homes were engaged in child abuse, neglect or maltreatment.
Other children are removed from their homes and sent to live with people who may or may not be relatives, without the government conducting required monitoring of their placement or providing necessary resources to their caregivers.
Robert Matthews, CFSA’s acting director, has no qualms about keeping children in homes where they have been subjected to abuse and neglect, and he wants to reduce current mandatory reporting requirements — positions that worry some advocates. Ward 1 DC Council member Brianne Nadeau, who chairs the committee that oversees the agency, nonetheless recently called Matthews “eminently qualified” and is allowing his nomination to take effect while skirting a vote by the full legislature.
In two years, at least 11 DC children died in foster care placement.
Those findings have shocked and raised concerns among many people, including elected officials, child welfare experts and advocates, and individuals who were connected directly to the LaShawn A. case, which was intended to reform the system.
“Some of the issues addressed in the series [“Still Broken”] are beyond the reach of the [LaShawn A.] lawsuit, but are still real problems,” Marcia Robinson Lowry, founder and executive director of the national watchdog organization A Better Childhood, told The DC Line in a recent interview. She was a lead attorney with the American Civil Liberties Union in New York when she and several other lawyers there and in its DC office filed the LaShawn A. lawsuit in 1989.
“I will say that your series is helping me learn about the agency. … I think what’s difficult here is that lives are at stake and the cases are heart-wrenching and horrifying,” at-large DC Council member Elissa Silverman told The DC Line during a recent interview exploring what the city could do to improve conditions for children. There are more than 130,000 children who call the nation’s capital home; about half of those with CFSA involvement live east of the Anacostia River.
“Standing up for the District’s children and doing all we can to put them in the best position to become independent contributing adults is the objective of every engagement our office has with children,” DC Attorney General Karl Racine said in a statement sent via email. He has pledged to push harder for DC Council passage of the “Protecting Children and Vulnerable Adults Through Mandatory Reporting Amendment Act of 2021,” which would expand the list of individuals and institutions mandated by law to report abuse, neglect or maltreatment of children.
Asked whether the city should establish a list of individuals who have committed crimes against children comparable to those for pedophiles and whether there should be consideration for mandatory minimum penalties, a spokesperson for the office told The DC Line, “The OAG agrees that prosecuting adults who commit crimes against children should be the highest priority.”
The agency, however, does not prosecute adults for those offenses. That is handled by the U.S. Attorney’s Office for the District of Columbia. “The truth is that there have been cases where OAG has expressed concern about the manner in which those cases were prosecuted,” continued the spokesperson, noting that having statehood would give DC’s elected AG more authority in this area.
Additionally, determining the usefulness of mandatory minimum sentences would require evaluation of whether they are a deterrent and how they affect recidivism rates. “AG Racine has asked the team” to conduct an analysis, said the spokesperson.
Child welfare experts and advocates have called for a major transformation of DC’s system to include stronger public disclosure laws regarding release of information about children who die in the District, especially those who were the victims of abuse, neglect or maltreatment.
“The case histories reviewed by the Child Fatality and Infant Mortality Review Committees should be made available to the public. They do not contain names, so there is no reason they should not be public,” argued Marie Cohen, a policy analyst and former CFSA social worker who reports on the local and national child welfare system via her blog, Child Welfare Monitor DC.
“It is unacceptable that the public is not able to see these records, which show families that have been reported over and over to CFSA, with no meaningful intervention to save the children, until a child finally dies,” added Cohen, a community member of the chief medical examiner’s Child Fatality Review Committee.
Marla Spindel and Stephanie McClellan — executive director and deputy director, respectively, of DC KinCare Alliance, a nonprofit organization they co-founded to support relatives who care for children outside of the traditional foster care system — have called for the city to “stop leaving children in homes where they are being severely and repeatedly abused or neglected.”
DC’s history makes child welfare advocates less than sanguine about the prospect of any true transformation of the system. Lowry explained that the LaShawn A. case was “very heavily litigated,” involving multiple “en banc” reviews in which all of the judges on the DC Court of Appeals considered the case. The plaintiffs and their lawyers hoped the city would comply independently with the court’s 1993 initial order, which laid out benchmarks the DC child welfare system had to meet. When, the following year, that still didn’t happen, it prompted a partial and then complete receivership that continued for a total of six years.
Over the years, several “exit standards” and strategies were created to facilitate a conclusion to the litigation. Lowry said the District is “largely in compliance with the court order, which is why we’ve decided that it is the right time” to end the lawsuit.
However, Lowry said that the findings highlighted in “Still Broken” raise separate concerns, among which she mentioned problems with the fatality review committees. “[But] that’s not what the lawsuit was about.
“The court doesn’t really have jurisdiction over those issues. And so, you can’t really do anything about it in the context of LaShawn,” continued Lowry.
“Were there a court order, for example, to deal with the problems of inadequate investigations or screening out, that’s a whole different case really,” which could be brought separately from the LaShawn A. case, she added.
Lowry cited New Jersey, where she litigated a case similar to LaShawn A., as a state that has “gone ahead and developed so many programs that are beyond what’s required by the court. And it is really a good system.”
The state’s reforms have “gone far beyond the decree, which is right because lawyers and the court, federal court, can’t tell a system all the details of how they should operate,” said Lowry. “They’ve got to set up the standards, and then one hopes the system can then move forward in a really progressive way and figure out what the details of the needs are [and] how to best meet the needs.
“The District has not done that as fully as it could,” continued Lowry, noting that part of the problem is that there “hasn’t been an even trajectory. It hasn’t constantly gotten better. It’s gotten better, it’s gotten worse, it’s gotten better. So, there have been lots of fits and starts.”
TWEAKING vs. TRANSFORMING
Thus far, there is little indication that key District officials, particularly those on the DC Council, fully understand the massive failure of the city’s child welfare system in meeting its prime mission. That disconnect may be partially attributable to the fact that for the past three decades the federal court assumed responsibility for and oversight of the system’s policies and programs.
For example, the judge’s orders in the LaShawn A. case effectively established how often children in foster care can be moved and how quickly the city is supposed to begin investigations emanating from an abuse or neglect hotline call. Additionally, the appropriate caseload for social workers at the Child and Family Services Agency was set at a maximum 1:15 ratio through a federal court order.
Legislators may have gone through the motions of conducting annual performance and budget hearings. However, the heavy lifting of overseeing and directing changes at CFSA, the centerpiece of the city’s welfare system, was performed by the court, using its appointed monitor, the Center for the Study of Social Policy. Consequently, critics say, elected officials have opted for tweaking or making high-profile media announcements that ultimately do not lead to the tangible and measurable transformation of a system that each day fails thousands of children.
On Jan. 13, Mayor Muriel Bowser announced a pilot program that provides cash payments to lower-income new or expectant mothers, drawing praise from many in the nonprofit community. The initiative doesn’t do anything, however, to address issues raised repeatedly by advocates, such as the need for city action to prevent the use of drugs during pregnancy or improving the care children receive after they leave the hospital.
Child welfare advocates, joined by some DC officials, like the city auditor, believe more — much more — must be done. Citing the original laws that set up the Child Fatality Review Committee, DC Auditor and former Ward 3 Council member Kathy Patterson said the attempt to “combat the deaths of children from abuse and neglect” relied on sunshine and public pressure to ensure that those entities were “doing the right things.”
“The whole disclosure movement was to improve services,” added Patterson, who has raised concerns about the council’s repeal via the Fiscal Year 2022 Budget Support Act of two disclosure measures that were included in the child welfare laws adopted in the early 2000s. The recent changes were triggered by Ward 6 Council member Charles Allen, chair of the Committee on the Judiciary and Public Safety.
Allen, who has oversight of the Child Fatality Review Committee, helped secure an extra $228,532 for its budget. The money is for two additional staff reviewers in an effort to expedite CFRC’s work. His legislation also mandated that CFRC, which operates under the auspices of the Office of the Chief Medical Examiner, complete its fatality reviews no later than six months “after the final determination of the cause and manner of death.”
Three new members also were added to CFRC as of Oct. 1, 2021: the director of the Mayor’s Office of Gun Violence Prevention and two council members — Allen, as chair of the Committee on the Judiciary and Public Safety, and Nadeau, as chair of the Committee on Human Services. Allen has had a representative attend at least two of the past three meetings.
Speaking recently to The DC Line, he called CFRC’s work and data “stale — it’s already two or three years old.” He complained that each year he has added money for new specialists but “the mayor keeps zeroing out” those dollars.
Ward 2’s Brooke Pinto, who was elected to the council in 2020 and is a member of the Judiciary Committee, praised Allen’s actions as “critical improvements.” In an email to The DC Line, she said she hopes they will “make an impact in providing greater protection of our kids in DC. I’ll be working closely with my colleagues and the Committee to track the progress of these improvements.”
“Keeping our children safe is a fundamentally important responsibility of our government,” added Pinto.
Committee members Anita Bonds and Mary Cheh did not respond to multiple requests for comment. Ward 7 Council member Vincent Gray, who suffered a minor stroke in early December, did not respond to an email sent last week after he participated in his first legislative meeting since being released from the hospital.
Not everyone is satisfied with Allen’s legislative moves. Patterson met with him earlier this month to discuss, among other things, restoring the repealed section of CFRC law related to disclosure. Spindel and McClellan have continued to push for more accurate and timely reporting of details of each child fatality and near fatality where child abuse or neglect is a cause or a contributing factor. They said 16 states, including California, Texas, Ohio and Massachusetts, require reporting on near fatalities.
Responding to advocates and the failures highlighted in the “Still Broken” series shouldn’t be difficult given that the appropriate building blocks are in place, said Patterson. “When you look at the pieces [DC] has put together … we have a child welfare system; we have a major child welfare agency.
“We have a Child Fatality Review Committee. We have another child fatality review committee, the internal one to CFSA. We have a citizen’s review panel that’s supposed to do oversight and make recommendations,” continued Patterson, who helped set up some of those entities while in the council.
“We have so many different parts, but there are some things that you just don’t see happening,” said Patterson. “There’s a significant absence of coordination and collaboration and leadership to make sure that some of the things that we know [are problems] get addressed.”
She also noted that the city lacks a “fatality prevention plan” — a practice recommended in the March 2016 final report of the congressionally established Commission to Eliminate Child Abuse and Neglect Fatalities. “That’s something that the national commission that looked at child abuse and neglect fatalities a couple of years ago talked about — that you don’t analyze child fatalities for the sake of analyzing child fatalities,” she said.
“You do that so you can see what could have been done better in each case. And what could have, if anything, been done to prevent that death,” she said, asserting that in 2007 she and then-Mayor Adrian Fenty pushed through legislation establishing an “interagency collaboration group” modeled on a program in Auburn, New York, “that was very successful in reducing neglect and abuse.”
“That entity was codified in the Public Education Reform Act,” the same law that put DC Public Schools under mayoral control, continued Patterson. It lasted two years before morphing into “another public-private partnership place where people come to meet and talk.”
Notwithstanding Allen’s tweaks to the fatality review process, it’s clear that many legislators aren’t fully informed about conditions in the city’s child welfare agency; one reason is that the DC Council generally follows a territorial approach that discourages getting too deeply involved in work that is believed to be the domain of a committee chair. Silverman may have been in the legislature for several years, but this is her first council period as a member of the Committee on Human Services, which has direct oversight of key elements of the child welfare system, including the Department of Human Services and CFSA.
“I’ve weighed in on certain issues in [DHS] that sync up with the labor committee. But CFSA, I will admit to you, is an area that I haven’t invested much of my time and council resources,” said Silverman, referencing the work of the Committee on Labor and Workforce Development, which she chairs.
Moreover, Silverman acknowledged that the council has been focused on the pandemic and budgetary matters. “There really hasn’t been a lot of ability to delve deeply in programmatic areas that are not related to COVID.” She said she will “look to” Nadeau, as the Human Services Committee chair, for guidance and leadership.
Nadeau, who is running for reelection, has not responded to five requests from The DC Line to participate in an interview for this series; two of the requests were made after articles in the series were published.
Ward 4’s Janeese Lewis George, another member of the Human Services Committee, did not respond to The DC Line’s email request for an interview. The communications manager for at-large member Robert White, who is also on the committee, promised to send a statement but didn’t. The communications director for Ward 8’s Trayon White, the other committee member, said The DC Line would need to submit an interview form but did not respond to a question as to whether completing that document meant that the council member was prepared to comment, although the highest percentage of the child abuse and neglect cases documented through investigations occurred in the communities he represents.
With Nadeau holding the basic responsibility for overseeing the failing child welfare system, many people interviewed for this series are pessimistic about the prospects for the necessary overhaul. They complained about the absence of consistent, aggressive oversight. All the deaths or severe maltreatment captured in this series happened during Nadeau’s tenure as chair of the Committee on Human Services, which began in January 2017. There are no records of any oversight hearing or roundtable being held that focused specifically on any of the deaths. There is also no indication that Nadeau ever held a separate public hearing on CFSA’s annual internal fatality review report.
A recent flashpoint involves concerns about the DC Council’s delays in setting up the Office of the Ombudsperson for Children, which was codified in April 2021, to be headed by a council appointee with a five-year term and independence from the executive branch. Advocates pushed for its creation, worried that after the LaShawn A. lawsuit ended and the court monitor was eliminated there wouldn’t be any credible individual serving as a watchdog or scrutinizing the veracity of information being distributed by CFSA.
By law, the ombudsperson is responsible for “improving outcomes for children involved with, previously involved with, or otherwise known to the [CFSA].” Further, the office will have “access [to] information contained in the Child Protection Register and from staff of [CFSA] that identifies individual children reported as or found to be abused or neglected or which identifies other members of their families or other persons otherwise considered confidential.” The office would also have subpoena powers enforceable in DC Superior Court.
Nadeau and the council didn’t provide funding for the office until FY 2022 and have delayed recruiting candidates. On Nov. 12, 2021, a group of child welfare leaders and advocates sent letters to council Chairman Phil Mendelson and Nadeau, asking them to “expeditiously identify” and appoint the first DC ombudsperson for children.
“Filling this position promptly is particularly critical now, as the LaShawn class action litigation is coming to a close along with the Court Monitor’s oversight of CFSA’s operations. The sooner the Ombudsperson is appointed, the sooner the benefits of the Office to DC’s children and families can be realized,” the ad hoc group wrote. Among the signatories were Cohen and Spindel, as well as Sara Tennen with the DC Volunteer Lawyers Project; Susan Punnett, executive director of the Family & Youth Initiative; and Judith Sandalow, head of the Children’s Law Center. The authors also sent the names of three recruitment firms that could help with ferreting candidates for the job.
During a recent interview, Mendelson said he approved funding to hire a search firm after Nadeau sent a letter in December making the request.
Christian Greene, who was among those who lobbied for the creation of an independent ombudsperson, emphasized that the appointee should be a seasoned and licensed social worker. She believes that with that kind of expertise, the city might provide better services and protection for children and families. Failing to make that kind of hire, she predicted, could eventually mean another protracted legal fight. “This time it will involve not only two branches of government — it will consume all three: executive, judicial, and legislative,” she said.
“Now is the time to embrace systemic change, not only for our families but for our government,” added Greene, a former CFSA ombudsperson who filed a whistleblower lawsuit after being removed from her position. A judge dismissed her case; her appeal is pending.
More recently, members of the child welfare community took issue with Nadeau’s decision to allow CFSA’s acting director, Robert Matthews, to become the permanent director without a full council vote. The deadline for his confirmation is Jan. 27, and if the council doesn’t take action on it by then, his nomination will be deemed approved.
The Community Board of DC KinCare Alliance wrote a letter dated Jan. 12 indicating its dissatisfaction with that move. “We are disappointed that the DC Council is not holding a vote of all councilmembers on the new Director of CFSA,” the members wrote. “We believe the DC Council should vote on the proposed new Director of CFSA and not just let his nomination become approved through inaction. We believe this is an important part of the DC Council’s oversight role.”
Those views were ignored when the Human Services Committee, with only three of five members in attendance, voted on Jan. 20 to approve Matthews’ nomination. Nadeau referred to “several community stakeholders” who testified at his Dec. 9 confirmation hearing. The individuals who spoke on his behalf were either former CFSA employees or current contractors, including a representative of the court monitor.
At last week’s committee markup, neither Nadeau nor Lewis George nor Silverman raised any concerns about the number of children who had died while Matthews worked at the agency or the series of botched investigations under his watch or the disturbing statistics from the recent internal fatality review report.
The committee vote is ordinarily only a first step. There will not be a second one, however, as the full council will not have the opportunity to vote on Matthews’ nomination.
Mendelson, the council chairman, told The DC Line earlier this month that Nadeau could have requested consideration at a special legislative session on Jan. 18 to facilitate a full vote on the Matthews nomination.
While there was a special session on that date, Nadeau did not hold her committee vote in time. She scheduled it for two days later.
Matthews is poised to become the permanent director of a multi-million agency with only three legislators weighing in.
Matthews’ views around foster care placements, mandatory reporting and child protective services investigations, among other things, have come under scrutiny, especially after he told The DC Line during an interview for this series that “I believe the public sees CFSA as the child welfare system, [but] we’re just the agency.”
Lowry, whose work at A Better Childhood has included examining systems across the country, saw the comment as undermining any sense of accountability. “One of the things that troubled me in the series was that the CFSA [director] does not seem to take responsibility for the system and talks about how it’s one of other parts,” said Lowry. “When you have dispersed responsibility, you have no accountability. And in our view, and I think the law supports us on this, the public agency that is responsible for the well-being of kids, for the protection of kids in the District, and in other child welfare systems, is the public agency, CFSA.
“It’s supposed to work with the other agencies to bring in additional services because it doesn’t provide all of the services, but ultimately the buck stops with CFSA.
“And so they need services from the mental health agency. They need to get medical services from other agencies. It is CFSA that’s responsible for pulling all this together.
“I am disappointed that the current acting administrator of CFSA does not seem to accept that notion,” added Lowry.
WHOSE LAW IS THE LAW?
The absence of an integrated and comprehensive child welfare architecture and Matthews’ perceived unwillingness to fully embrace CFSA’s leadership role exacerbate the worries of advocates, experts and others about the safety and well-being of the city’s most vulnerable children in the coming years. Their concerns are also magnified by the fact that many standards and policies adopted by the District during the LaShawn A. case never became local law. With the end of the lawsuit, there are questions about what will be continued and what will be dumped in the trash.
The Office of the Attorney General, as is its statutory mandate, represented the District in the litigation. It’s also required to “use the law in the public interest,” which the spokesperson said OAG interprets as protecting the “District’s most vulnerable residents.”
Still, as CFSA’s legal representative in court, “ethical rules require that OAG do so zealously.”
The spokesperson noted that the OAG has “withdrawn from serving as counsel to the Department of Forensic Services (DFS) and, more recently, the Department of Corrections (DOC) in matters related to the U.S. Marshals Service’s investigation into the conditions and treatment of detainees at DOC.” There’s no indication that it is prepared to do the same for CFSA, despite the findings presented in The DC Line series.
The OAG insisted that CFSA — as part of the city’s child welfare system to prevent abuse and neglect — must protect the civil rights of children and is “required to satisfy its constitutional obligations, albeit now without a court-imposed monitor. Going forward, OAG is responsible for advising CFSA of its constitutional responsibilities,” the spokesperson added, disregarding that the judge in the LaShawn A. case ruled that the District had violated various local and federal laws in its treatment of children in foster care.
Unclear is what happens to the standards that are not codified by DC law. Consider for example, that the court, plaintiffs and the District together set the standard that an abuse or neglect investigation must start within 48 hours of receiving a hotline call. However, the current law indicates that such an investigation is required to begin within 24 hours.
Is CFSA to follow the local law or is it to maintain the 48-hour policy that it has attempted, albeit with mixed results, to follow for the past two decades? Should the council pass legislation making clear that existing child welfare laws take precedence over any conflicting sta