4.3.8  Fatality, Near-Fatality Abuse/Neglect or Other Critical Event

Staff will receive notification of a child fatality through alert by CANHU of a Fatal Child Abuse/Neglect Report and/or a Non-CA/N fatality referral (F-referral).

If staff becomes informed of the death of a child through any source other than receiving a CA/N-1, staff should immediately advise the supervisor that a fatality has been reported.  The supervisor shall verify in the CA/N automated system that either a CA/N report or an F-referral has been made.  Allegations of child abuse/neglect must be reported to CANHU pursuant to Missouri Revised Statutes Chapter 210.115.  Additionally, Missouri law requires the Medical Examiner to report the death of any child in Missouri.

Related Subject:  Section 1, Chapter 4.7, Roles and Responsibilities of the Medical Examiner/Coroner

The CA/N investigation shall be completed according to Section 2, Chapter 4, Investigation Response, and with the following additional actions to be taken by the Children’s Service Worker (CSW) assigned to the investigation.

NOTE: Pursuant to Section 210.145,  Children's Division may not close pending child abuse or neglect investigation if a child involved in the investigation dies during the course of the investigation, until such time as any separate investigation by the Division regarding the death is completed.

Related Subject: 4.3.8.2 Child Fatalities During a Pending Investigation

Thoroughly check automated system for all current or prior Children’s Division history on all persons listed on the CA/N report.  Be sure to check the following screens for all persons listed with any available DCN, date of birth, social security number, or name: S024, ANUM, ANME, SNME, KDCN, KCAS, ZCAS, ZPLA, ZCRT.  Document findings in the investigation record, and include on the CS-23 and Fatality/Critical Event Summary as required.

Assess the safety of any surviving children.  A safety assessment must be completed on any child who will remain in the home.  Staff will also determine if the alleged perpetrator has been residing in the same home.  Staff must document in the investigation record how safety was assured of any other household children.  If safety was not assured, staff shall immediately contact law enforcement when any child is in immediate danger to notify them of the imminent safety concern and request their assistance in assuring for the child(ren)’s safety; and additionally request in writing that the juvenile officer file a petition with the juvenile court for removal of other children remaining in the home with the alleged perpetrator at any time that their safety cannot otherwise be assured.

NOTE:  If either law enforcement or the juvenile officer is unwilling, or otherwise unable to assist, including the failure to take protective custody when recommended by the Division, staff shall immediately inform the supervisor.  The supervisor shall assure that all relevant information has been shared with the law and juvenile officials.  The supervisor shall determine if a referral to the Division of Legal Services is warranted, and take appropriate action as necessary.  Staff shall document the refusal and, if known, the reasons for the lack of assistance from the law or juvenile officials in the investigation record.

Field staff will notify Central Office through supervisory channels, within specified timeframes, of the fatality by completion of a CS-23 and Fatality/Critical Events Summary as indicated in Section 2, Chapter 4.3.8.1, Fatality/Critical Events Reporting and Review Protocol.

NOTE: The requirement to notify Central Office will depend on the particular incident.  All CA/N fatality reports and any non-CA/N fatality referrals (except for those solely due to premature birth) in which the family has current or past involvement with the Children’s Division, or any report with media involvement, requires the completion of a CS-23 and Fatality/Critical Events Summary, and notification to Central Office within specified timeframes.  Additionally, any other critical event, including a non-fatal or serious injury CA/N incident, may warrant notification, also reported via CS-23 and Fatality/Critical Event Summary; Consideration should be given to the physical condition of the child, the risk to the child's life, disfigurement of the child's anatomy and/or, the extent of involvement by law enforcement, the juvenile office, with CD, or the media.  Staff should evaluate through supervisory consultation the decision to make a report to Central Office.

Contact other county offices or states where the alleged perpetrator has resided, as indicated, for purpose of obtaining additional information, including to request prior case records.

Contact other county offices or states where the family has previously resided, as indicated, for purpose of obtaining additional information, including to request prior case records.

Prepare and submit form CA/N-5, Report to Probation and Parole, to the Probation and Parole Officer, or other appropriate pre-sentencing investigator, when an alleged perpetrator has been found guilty of a criminal charge of child abuse or neglect.  A cover letter from the local office to the investigator must be attached to the report explaining its purpose.

Participate in the Child Fatality Review Panel (CFRP) meeting as requested by the CD panel chairperson.  Share all information which is compiled during the investigation with the Children's Division member of the panel in order to assure that the panel has the most current findings.

Related Subject:  Section 2, Chapter 4, Attachment N, Child Fatality Review Panels

NOTE:  Communicate with the CD staff representative on the CFRP to determine how the coroner/medical examiner will code the manner of death on the death certificate.  This will ensure that the code entered for "Manner of Death" on the CA/N-1 will reflect the same finding.

The CSW shall update the CA/N-1 to reflect the fatality in the CA/N automated system.  Staff should ensure the automated system reflects the fatality status of the victim by adding the date of death, manner of death and a severity code of fatal (E).  The addition of this fatality information in the automated system is critical in the Division’s ability to accurately document these fatalities.

4.3.8.1  Fatality / Critical Events Reporting and Review Protocol

The Fatality/Critical Events Protocol is a process that was developed with the assistance of field staff, to report and review certain child fatalities, near-fatalities, serious injuries or other critical events.  (Guidelines for determining which incidents meet this criteria for reporting and review are explained in detail below).  The process consists of a review of information about the child, family, prior involvement with CD, other agencies, and the specifics surrounding the fatality/critical event.  Key information is found by review of data from the CA/N automated system as well as case records, and is captured using the electronic CS-23 form and Fatality/ Critical Events Summary.  The CS-23 and follow-up summary are forwarded to field and Central Office administration within specified timeframes.  Case records may be requested in certain circumstances, and when requested, it is critical that field staff forward the record (CA/N files, FCS files, A/C file, and any other related material) timely to Central Office.

This process provides a way to collect accurate, consistent information quickly on certain fatalities and serious injuries where child abuse/neglect is alleged, or where the Division has a history of involvement with the family, and for cases receiving media attention.  It is the method staff will use to inform Central Office and Regional administration, and at times Department of Social Services administration, of the incident.

The information provided through this process will be used by Central Office staff for reviewing and analyzing the information to identify trends.  A trends analysis report will be completed annually by Central Office.

Local/Regional case reviews and the trends analysis will provide an opportunity for CD staff and management to review and improve policy, practice and to identify and address training needs within the Division.

NOTE:  County staff will collect information from other agencies which were involved in the family’s life prior to the child fatality/critical event.  This additional information, including lengths of service, will allow for a better frame of the family dynamics and needs prior to the fatality.  This frame is important in understanding what the events were that lead up to the fatality/critical event and will be crucial in identifying trends and indicators.  Much of this information may be gathered at the local Child Fatality Review Panel meeting, or through direct contact with the agency.  These agencies include, but are not limited to, the juvenile court (related matters may involve delinquency; status offenses; truancy; child protection; and/or domestic relations); Health Department (Services may include WIC; First Steps; Healthy Start; Visiting Nurses; and/or other in home services); Social Service agencies (Services may include Parent Aide; Special Needs; MC+; and/or Therapy/Counseling; and schools (Services may include Special Education; Suspension)

Intake CSW/Supervisor will receive notification through alert by CANHU of a CA/N fatality incident, non-CA/N fatality referral (F-report), near-fatality, serious injury, or other critical event.  CSW/Supervisor will review case and determine whether case has any allegations of child abuse/neglect, or if there is past or present CD involvement (CA/N, FCS, A/C, Adoption), or media attention.

Adherence to this policy will require an immediate system check by local staff of fatality reports received to determine if there is any CD involvement with any person listed on the report.
Supervisor immediately notifies Regional Director/Designee of any fatality involving CA/N, or having any past or current CD involvement or media attention.

CSW/Supervisor will notify Central Office via a completed CS-23 sent by e-mail to: CD.CriticalEventReport (and cc’d to Circuit Manager/Regional Administrator) within the following timeframes:

Within three (3) hours (or by 9:00 a.m. the following business day for reports alerted after hours):

• Any case receiving media attention
• Un-concluded prior CA/N at time of fatality
• Open FCS case
• Child currently in CD custody (open A/C case)

Within 24 hours:

• Any new CA/N incident in which child abuse/neglect has been alleged as a factor in the fatality, where no prior CD involvement exists.
• Any case with past CD involvement (CA/N, FCS, A/C, Adoption), except for reports of death due to premature birth only, for which, professional discretion may be used.

If the residence county or state differs from the county receiving the notification of the fatality, the county that received the alert is responsible for completing the CS-23 and summary, however, it is expected that the reporting county may need to explain on the form that the other county (or state) may have additional information.

NOTE:  An electronic version of the CS-23 and Fatality/Critical Events Summary is now available in MS word format and is available on the CD Intranet under E-Forms.  The One-Form version of the CS-23 is now obsolete and will no longer be accepted.  Workers should assure the One-Form version is removed from their hard drives.

An updated CS-23 should be sent as new pertinent information becomes available about the case, such as the identification of parties involved, change in medical status of child, determination of manner of death or new media attention.

A Fatality/Critical Events Summary must be completed for all instances when a CS-23 was required above.  The Circuit Manager of the circuit completing the CS-23 will designate staff to complete the summary and, after review, the Circuit Manager will be responsible for forwarding the summary by e-mail to: CD.CriticalEventReport (and cc’d to Regional Administration).  The completed summary should be factual and thorough, and should include:

• The cause of the death, if known;
• Summary of CD history with the family (CA/N, alternative care/adoption, prior FCS history);
• Current case status information (date of case opening, including reason, name and address of GAL if relevant, summary of court activity if any, past and current services received by family);
• List of other children remaining in the household with the alleged perpetrator and how their safety has been assured (may attach a safety re-assessment form);
• A summary of progress or lack of progress made recently (may also attach most recent treatment or safety plan);
• Date(s) of most recent contact(s) made with the family;
• List of other agencies involved;
• Other pertinent facts of case

NOTE:  The Circuit Manager shall assure that for any open case, the investigator assigned to the prior un-concluded CA/N report, or the Case Manager of the FCS or FCOOH case will be responsible for completing the summary.

The summary must be completed by staff and forwarded to the Circuit Manager within enough time so that the Circuit Manager can review and forward the summary to Central Office within 72 hours.  A local case review will be completed as indicated at the Circuit Manager or Regional Administrator’s discretion.

Regional administration shall assure that the Director has been notified of the fatality as required per protocol.

Director/Designee will notify Office of Child Advocate and DSS Administration of incident as indicated.

CS-23 will be received via e-mail at Central Office.  Designated Central Office staff will review CS-23 and arrange phone conference with county office as necessary to discuss details of case as necessary.

Designated Central Office staff will regularly meet to review cases having CD involvement.

Director/Designee will request Regional case review as indicated.  Regional administrator will provide a summary of any such review to Director as directed.  Regional administration will access resources that are available to address practice or training needs discovered through the review process, such as Social Work Specialists, FCS consultants as available, or the Quality Improvement and Field Support Unit, as well as advising the Central Office Policy Unit Manager regarding recommendations for improved policy.

4.3.8.2   Child Fatalities During a Pending Investigation

The Division may not close a pending child abuse or neglect investigation if a child involved in the investigation dies during the course of the investigation.  This includes CA/N fatalities as well as non-CA/N Fatalities. 

Staff will use code "Z (other)" on the FACES Delayed Conclusion screen and fill in "Child Fatality pending subsequent investigation or Fatality Review".  Prior to closing the pending investigation, staff must document in the narrative one of the following:

• Finding of subsequent investigation;
• Result of Fatality Review Board; or
• Fatality Review Board found circumstances did not warrant review. (example:  non-suspicious natural causes)