Preventable Deaths

Dec 1, 2014

This story first appeared in the March 2014 issue.

Children die even when their tragic situations have been reported to DCFS.

For years, they’ve shuffled across Illinois’ front pages, a parade of tragedy.

There was Christopher Valdez, 4, of Chicago’s southwest side, whose mother’s boyfriend allegedly beat him to death in 2011. Earlier, Christopher’s mother had been convicted of abusing him, but the Illinois Department of Children and Family Services and the courts had nonetheless allowed him to remain in her home.

There was Lamar Hayslett, 8 months old, allegedly beaten to death in 2012 by his father. Four years earlier, DCFS had removed three older siblings from the home because of an unexplained broken femur on one of them. The older children hadn’t been allowed to return, but the agency had let Lamar stay anyway, despite two later abuse allegations against the couple.

And there was Gizzell Ford, 8, killed last year after weeks of alleged torture at the hands of her father and grandmother. She died barely a month after DCFS visited the family to investigate allegations she was being abused. The agency left the third-grader there in spite of what police would later call “deplorable” conditions in the home.

Child abuse has been around for as long as there have been children, and to some sad degree it always will be. What galls the public, politicians and DCFS’ own partners in child welfare is that it keeps happening to children who have already come under what is supposed to be the protective scrutiny of the state.

“The truth of the matter is, there are bad people who do bad things. But let’s not have preventable deaths,” says Dr. Jill Glick, medical director of a special child protective service team at the University of Chicago’s Comer Children’s Hospital. “This should be a ‘duh’ in our society.”

Illinois child deaths caused by abuse or neglect hit a 30-year high last year, topping 100 for the first time since 1989. That increase is partially the result of a DCFS policy change in late 2011 that for the first time counts deaths caused by unsafe sleeping conditions. DCFS has since changed that policy and now only includes sleep deaths if there were signs of abuse or neglect or that drugs or alcohol were involved in the death.

What’s less explainable is why higher numbers of abuse deaths are happening to children who had earlier come in contact with Illinois’ child-abuse safety net — and fell through it.

A series of recent reports by the Chicago Sun-Times and WBEZ Radio found that the number of children who died of abuse or neglect in spite of earlier contact with DCFS rose from 15 in the 12-month reporting year that ended June 30, 2010, to 34 in 2011, and 34 again in 2012. The reports found 27 such cases in 2013, with data from that year still incomplete.

DCFS, which turns 50 this year, has spent much of its history in the midst of these kinds of controversies. At times, the agency is accused of doing too much, separating children from families that should have been kept together. More often, it’s accused of doing too little, failing to separate abused children from parents or other relatives who later killed them.

Between the regular eruption of horror stories, the agency’s procedures, leadership, finances and even something as basic as its data collection have all come under fire lately.

“They keep saying they’re concerned about the well-being of the children, but their actions were saying something different,” says state Sen. Mattie Hunter, a Chicago Democrat. She became so furious during recent hearings about inconsistency in child-abuse data that she called for the resignation of the then-acting DCFS director. “DCFS caseworkers are overloaded. Senior staff aren’t being forthright about the neglect of our children. They have to do a better job of ensuring that children don’t fall through the cracks.”

In 2011, Christopher Valdez, 4, was beaten to death, allegedly by his mother’s boyfriend. Christopher’s mother had been convicted of abusing him, but the Illinois Department of Children and Family Services and the courts allowed him to remain in the home.
Credit WUIS/Illinois Issues

Part of it is the nature of the business. Child welfare work is notoriously difficult, rife with unpredictable outcomes and unavoidable tragedies. And the sheer volume of cases today exacerbates everything. DCFS investigated more than 108,000 allegations in 2013, and took protective custody of 4,217 kids that year. The agency noted in its 2014 budget proposal that it acts upon a report of child abuse or neglect every five minutes, child sex abuse every two hours and the death of a child by abuse or neglect every 36 hours. DCFS is working with data analysts at Northwestern University to try to find patterns in this data that could some day inform policy at the agency.

Still, how it handles those cases is a shifting science. Child-welfare professionals often refer to a “pendulum” effect of policy in the profession, swinging from an aggressive approach of pulling children from potentially dangerous homes to a more interactive approach of providing services to keep families together. It’s a cycle that’s driven largely by whatever perceived child-welfare failure is being highlighted in the media lately.

“Children dying who have been involved with DCFS is a horrible thing,” says Glick, the Chicago doctor. But she and others warn that merely getting more aggressive about pre-emptive separation of families isn’t the answer. “It’s easy to remove kids from home. But that’s a tragedy, too.”

As difficult as the job is, Springfield hasn’t been of much help. DCFS’s budget has seen tens of millions of dollars in cuts in recent years, and the agency has dramatically lost headcount — down by more than one-third since 2000, according to the American Federation of State, County and Municipal Employees.

Those cuts, of course, have come at the hands of the same legislature that is now angrily demanding more success and accountability from the agency.

The human impact of that lost money and people is real.

DCFS has a legal mandate to determine within 60 days of a report of abuse or neglect whether it’s “founded,” meaning there is reason to believe the allegation is legitimate. The Illinois Auditor General’s office last year found that DCFS had failed to meet that 60-day deadline in 884 of the almost 65,000 cases it investigated in 2012. That was the highest rate of missed deadlines since 2006. In fact, 274 investigations in 2012 weren’t even initiated within 24 hours of a call to the state’s child-abuse hotline, says the audit. That’s the highest number of late initiations in at least 10 years.

Once those investigations finally are initiated, the possibility of system failure can be even greater because of a lack of resources, including medical expertise.

At the core of the tragedy of child deaths with previous DCFS contact is a simple but frustrating fact: It’s often difficult to tell the difference between an abuse injury and an accidental one. To err on the side of caution could mean that an innocent backyard fall leads to pulling a child from a stable home — a nightmarish scenario, as any parent could imagine. To err in the other direction can mean leaving an injured child in an abusive environment that later kills her.

Determining which is which often comes down to an analysis of medical issues by DCFS investigators who have no medical training.

“A kid comes into an emergency room, an 8-month-old kid, for swelling on the side of the head. [It turns out to be] a skull fracture. The mother says, ‘I have no idea how it happened,’” says Glick. At that point, the case normally leaves the hands of the doctor and is taken over by a DCFS investigator, “who now has to determine whether it was abuse.”

Glick has spearheaded a program in Chicago that inserts teams of doctors into DCFS investigations throughout the process, where their expertise can help answer that question. Doctors know, for example, that an accidental, unnoticed skull fracture — a scenario that might sound unlikely to nonphysicians — is in fact common in newly walking babies, due to falls. With that information, an investigator can then focus on questions about the family’s setting and background, any previous incidents, and other indicators that put the injury in a context to help determine whether it might be abuse. Conversely, doctors will often know immediately that other types of injuries are by definition rarely accidental.

Gizzell Ford, 8, was killed last year after alleged torture at the hands of her father and grandmother. She died about a month after DCFS visited the family to investigate the allegation she was being abused but left her in the home.zzell
Credit WUIS/Illinois Issues

Such consistent coordination between doctors and DCFS investigators might sound like common sense. But in fact, outside of Glick’s limited Chicago program, the relationship is generally more of a handoff, from doctor to investigator, with little ongoing contact or consistent partnership.

Glick’s efforts to get DCFS to formally coordinate with specific hospitals and doctors statewide has been met with mixed reaction from the agency — depending on who is currently in charge — and with trepidation from hospitals about who is going to pay for it.

“I have been pushing for years with DCFS, saying they need this. They don’t get it. They tell me, ‘We can’t afford it, Jill,’” says Glick. She argues it will save money in the long run by making DCFS investigations more efficient and will decrease errors in abuse investigations.

Taking Glick’s program statewide is among possible legislative fixes being considered by state Sen. Julie Morrison, a Deerfield Democrat. Morrison, chairwoman of the Human Services Subcommittee on Issues Relating to DCFS, says she’s also looking at ways to get the agency to focus more heavily on prevention, to stabilize the agency’s high employee turnover rate and to address other issues — none of which will come cheap.

“I think because we have had DCFS in the headlines lately, that will weigh on legislators a little more heavily” to find new money for the troubled agency, Morrison says. She also hopes to focus on keeping track of kids who move around from foster home to foster home by tracking them through schools and agencies that might be providing them with services. “We’ve got agencies that don’t communicate very clearly with each other, and we need to do a much better job.”

Of course, all the money in the world won’t solve a key problem at DCFS: Instability at the top.

To some extent, shifting of leaders and resulting changes in policy and philosophy are a fact of life in elective government. But, like so much else today, it seems to be worse at DCFS.

In August 2011, then-DCFS Director Erwin McEwen announced he would step down the following month. A holdover from the administration of impeached Gov. Rod Blagojevich, McEwen’s only public explanation for the surprise exit was to say he’d achieved reforms at the agency and wanted to move on. “In ways never done before, we are now reaching out to families to help them succeed before a crisis occurs,” McEwen said in a glowing self-evaluation at the time.

Less than a month later, the agency was engulfed in a different kind of crisis. The Illinois inspector general issued a report alleging McEwen had steered millions of dollars in grant money to a close friend, George E. Smith, who operated several social service businesses in Chicago. The report alleged that Smith landed some $18 million in state contract money altogether — mostly through DCFS — using forged signatures and ghost payrollers to get it and then misspent much of it on things like sports tickets and artwork. A suit against Smith, filed by Attorney General Lisa Madigan this past December, puts the alleged misspending at $8 million.

McEwen was replaced in 2011 by Richard H. Calica. Calica resigned late last year to undergo treatment for cancer and died in late December.

The agency was then briefly under acting Director Denise Gonzales — though not so briefly that there wasn’t time for DCFS’ critics to demand her removal.

“Every single one of you need to resign,” Hunter, the state senator from Chicago, angrily told Gonzales and her staff during a hearing in December at which they acknowledged that their previously reported numbers of children’s deaths were wrong. “I don’t trust anything they’re saying right now,” Hunter told reporters after the hearing.

Not everyone agreed with the assessment. Glick says Gonzales “was very engaged” in working with her to create medical teams to partner with DCFS investigators statewide. “I have no idea” whether that cooperation will continue under the newest regime, says Glick.

DCFS spokeswoman Karen Hawkins said in a statement that the Senate hearings where Hunter leveled her criticism “gave us a unique opportunity to hear from our partners and colleagues in child welfare, and we look forward to continuing those important, solutions-driven conversations.’’

“Our mission of protecting children and supporting families remains our highest priority,” says Hawkins. “Even as the leadership of DCFS has changed over the last few years, the staff’s commitment to safety, permanency and well-being for every child in Illinois has remained constant.”

On January 24, Gov. Pat Quinn’s office announced the appointment of Arthur Bishop to replace Gonzales. Bishop become the fourth person to head DCFS since 2011. (Gonzales had been an interim director and wasn’t removed as a result of Hunter’s demand.)

A week later, a Quinn spokeswoman elaborated a bit on a request for comment on the agency’s troubles. “The governor is committed to keeping children who are at risk of abuse or neglect safe. That is why he supported an overhaul of the agency in recent years to increase case workers who are on the front line,” Katie Hickey wrote. “Child safety must always be the top priority for DCFS. This is a very challenging agency, and we are confident that Arthur Bishop is the right leader for the job.”

Bishop’s DCFS staff declined in late January to arrange an interview with him for this article, citing the fact that he had been appointed to the job only days earlier. But with more than a decade’s experience at various posts in DCFS, and then as director of the Illinois Department of Juvenile Justice since 2011, his appointment was immediately encouraging to some of the agency’s critics. “I think it’s a very good sign,” state Rep. Gregory Harris, a Democrat from Chicago, said at the time. “He has been very fierce in the juvenile justice arena about not being afraid to shake things up.”

Within weeks of Bishop’s appointment, things were shaken up, all right. In mid-February, the Sun-Times and WBEZ reported that Bishop had pleaded guilty to stealing from clients of a Chicago social agency in the 1990s, and that he was later sued for paternity on behalf of a daughter he’d denied. Bishop stepped aside, and Bobbie Gregg, a former DCFS administrator, stepped into the job on an acting basis.

And things likely won’t settle down at DCFS any time soon. After Bruce Rauner is sworn in as governor, there will be personnel changes throughout the executive agencies. “Everything right now seems to be on hold because of a new governor and a new administration,” Morrison says. “I feel like that agency is sort of just treading water.” She says that if there are no new revenues included in next year’s budget, then DCFS will likely take another hit. But she says she is trying to stay positive and is looking forward to Rauner’s budget address, which is scheduled for February. “Hopefully we’ll have a snapshot of what his thoughts are and some of his priorities.”

Kevin McDermott is a political reporter at the St. Louis Post-Dispatch.

Illinois Issues, December 2014