FRANKFORT, Ky. (July 16, 2012) – In order to ensure that state agencies meet the policies and standards expected in cases of child abuse and neglect, Governor Steve Beshear today issued an executive order to establish the Child Fatality and Near Fatality External Review Panel. The independent, multi-disciplinary panel will conduct comprehensive reviews of child fatalities and near fatalities that are determined to be the result of child abuse or neglect.
“The death of any child for any reason is devastating to families and communities. But when a child dies or is critically injured because of abuse or neglect, we must carefully review the practices of all government entities involved to make sure that our system performed as it was supposed to – and if not, that review allows us to take disciplinary action,” said Gov. Beshear. “Just as important, these reviews allow us to see if policies and practices in the entire system need to be altered to better protect Kentucky’s children.”
The independent 17-member panel will be attached to the Justice and Public Safety Cabinet for staff and administrative purposes, and will be composed of a wide range of experts and stakeholders including those of law enforcement and social services, and representatives of all three branches of state government. Those members who are not serving by virtue of their office are selected for service by external peer committees or by the Attorney General.
Members will meet quarterly to review official records, case files, or information relating to child fatalities or near fatalities and analyze the medical, psychosocial and legal circumstances of the child to identify conditions that contributed to the death or serious injury. The panel will recommend improvements to the Cabinet for Health and Family Services (CHFS), the Department for Community Based Services (DCBS) and to any other public or private agencies involved with the family relating to protocols, practice, training or other protections to keep children safe.
The panel will also publish an annual report of case reviews, findings and recommendations that will be submitted to the Governor, the CHFS Secretary, the Chief Justice of the Supreme Court and the General Assembly and will be available to the public on the websites of both the Justice and Public Safety Cabinet and CHFS.
“I appreciate Gov. Beshear’s leadership in establishing this independent review panel to examine child fatalities in our Commonwealth,” said Attorney General Jack Conway. “The panel provides accountability and will help establish protocols of what can be done in the future to protect Kentucky kids.”
“The Cabinet welcomes a review of these cases by this professional panel and looks forward to the recommendations it will make that can guide improvements in our investigative process. Those recommendations will also be useful to to all agencies and stakeholders involved with these tragedies,” said CHFS Secretary Audrey Tayse Haynes.
“Despite our best efforts, tragedies sometimes happen in families. When our agencies have been involved with the families before a fatality or near fatality, we investigate to ensure our workers followed the proper procedures,” said Teresa James, acting commissioner of the Department for Community Based Services. “The Cabinet is continually working to improve protocols and increase training to provide a safer environment for the children and families we serve. The external review panel will be a tremendous help in this effort.”
Advocates call panel ‘tremendous step forward’
Child and family health advocates hailed the Governor’s order as an important step in enhancing protections for children.
"We applaud Governor Beshear for taking this very important first step in recognizing the need to involve the agencies, departments and professions who impact the lives of Kentucky children,” said Jill Seyfred, Executive Director of Prevent Child Abuse Kentucky. “This is the first step, but not the only step we need to take in order to enhance our child abuse prevention efforts. One child fatality as a result of child maltreatment is one too many, but the work of this Panel will enable all agencies impacting children to learn from mistakes and prevent similar tragedies from happening in the future."
“Child fatality review is one of the most important learning opportunities we have in our efforts to protect our most vulnerable citizens from preventable causes of death,” said Melissa L. Currie, MD, Chief and Medical Director, University of Louisville Pediatrics - Forensic Medicine. “This action by the Governor is to be commended, as it establishes a panel that will ensure that no child’s death in the Commonwealth of Kentucky will go unexamined by objective and knowledgeable eyes. The lessons we learn by reviewing child deaths have come at an enormous price -- the life of a child. It is our responsibility as citizens to make sure we identify those lessons and put them to good use by effecting necessary changes across all systems that interact with children. This is a tremendous step forward for Kentucky’s children.”
Fatality, near fatality records to be released; all CHFS names and actions included
Gov. Beshear also announced today that he has directed CHFS to provide to the Courier-Journal and Lexington Herald-Leader the remaining child fatality and near fatality records that have been the subject of ongoing litigation between the newspapers and the Cabinet.
Those records include the case files for all child fatalities and near fatalities that occurred during calendar years 2009-2010 in which criminal charges are not pending or findings of abuse are not on appeal.
The Cabinet has already released about 76 of the approximately 140 case records from that time period. An estimated 43 case files will be released to the newspapers today. Other cases still have pending court action and will be released after they have been adjudicated.
Despite reports to the contrary, these records and those released prior to today have never redacted or excluded any information about CHFS employees. All names and actions by the employees involved in these cases have been available to the media and the general public, and they will remain open to public review. This information must be open to the public, says CHFS Secretary Audrey Tayse Haynes, so the Cabinet as well as the public can evaluate the actions taken by the state.
"There remain many misconceptions among the general public as to why the Cabinet and the newspapers are in court. Simply stated, we disagree on how much personal information about the children and private individuals included in caseworker files should be made public," said Sec. Haynes. "The Cabinet has sought to protect the innocent parties involved in these cases—some of whom are still grieving the loss of a child, sibling or grandchild.”
“We have also protected the identities of those who step forward to report abuse or neglect, as the law requires, a safeguard essential to ensuring that reports will continue to be made,” Sec. Haynes continued. “At no time since the Cabinet began releasing these case files last year, has the Cabinet attempted to protect the identity of our staff who worked these cases nor has the Cabinet concealed the actions of our workers. That information has consistently been provided in full to the public.”
Training, education efforts continue
Since 2007, DCBS has implemented many training and educational opportunities for DCBS staff and community partners to reduce the number of children experiencing maltreatment-related fatalities and near fatalities, including:
- Identifying risk factors and the assessment of child protective service training for frontline staff and supervisors in all nine service regions;
- Providing education on substance abuse and child maltreatment including training for nearly 800 DCBS staff on substance use disorders and specific drugs and their effects;
- Training for approximately 8,500 DCBS staff and community partners in the non-medical community in the recognition of medical indicators of abuse and neglect;
- Training for approximately 2,000 community partners about the statutory requirements for mandatory reporting of suspected child maltreatment;
- Training for 150 community professionals on recognizing and documenting child maltreatment.
- Training for 150 medical and legal professionals on recognizing abusive injuries;
- Mandatory training on pediatric abusive head trauma for various professionals in child welfare, as well as the legal and medical communities; and
- Training of 25 Protection and Permanency supervisors in all nine service regions to increase coaching and mentoring of staff in clinic decision making and implementing best practices.
Additionally, DCBS has implemented several initiatives designed to strengthen practices including:
- Partnering with the Casey Family Programs to implement and evaluate a high-risk case consultation model;
- Contracting with the Division of Forensic Medicine at the University of Louisville to provide medical evaluations and clinical consultation of approximately 1,100 child abuse victims;
- Continuing work with the Sobriety Treatment and Recovery Teams (START) program to help DCBS families gain quick access to substance abuse treatment and improve child welfare outcomes, including parental sobriety. As a result, 320 families involving 550 parents and 635 children have received services to improve parental capacity and increase parental sobriety.