Fatality review. Three year-old Zy'Nyia Nobles died at home on May 27, 2000. Zy'Nyia's brother saw their mother beating his sister. The mother was arrested and charged with homicide by abuse. The children had been dependent and living in foster care since February 1997. The Division of Children and Family Services (DCFS) returned them to their mother in February 2000, and the family remained under state supervision. The Family and Children's Ombudsman reviewed case records to learn why the children had been returned to their mother, and to find out what services had been in place to support the family and monitor the children's safety. Zy'Nyia's death was also reviewed by a Community Fatality Review Team convened by DCFS. The Team included a physician, attorney, mental health and substance abuse professionals, guardian ad litem, foster parent, legislators, and others. At the Team's first meeting on July 13, 2000, the Ombudsman presented its completed investigation summary and identified several performance and system issues. 1 |
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Performance Issues Lack of Assessments-Case records showed that the DCFS caseworker had returned the children to their mother without obtaining a psychiatric/psychological evaluation or parenting assessment-despite documented concerns about the mother's mental health and parenting capacity. Non-compliance-During the three-year period before the family was reunited, case records show the mother had not completed court-ordered substance abuse services or parenting classes. In addition, there was no evidence that she had completed or made progress in court-ordered mental health counseling. Yet, the caseworker returned the children to their mother. Family Support and Monitoring- In-home services and requirements to support the family and monitor the children's safety either failed or were never put into place by the caseworker. Child Safety Concerns-There is no evidence that anyone involved with the family-including the caseworker and other individuals required by law to report child abuse or neglect-acted on documented concerns about the children's possible abuse in their mother's care. 2 |
System Issues Caseworker Bias-The Ombudsman asked the Team to consider how the system can better protect against caseworker bias. Bias occurs when a caseworker develops an initial belief about a person or event and then becomes resistant to altering that belief-even in the face of conflicting information.3 System Checks and Balances-The Team was asked to consider how the system's checks and balances were overcome. The Ombudsman noted that inaccurate and incomplete information from the caseworker undermined oversight by the court and Child Protection Team. The guardian ad litem did not appear to fulfill his independent investigation and monitoring duties. There was no evidence that supervisory or prognostic staffings occurred after 1998. In-home Service Providers-The Ombudsman asked the Team to assess the role of in-home service providers. DCFS relies heavily upon in-home providers to monitor the safety of children. Yet, many service providers do not see safety monitoring and reporting as part of their role in working with families. | Mandated Reporting-The Team was asked to assess the system for reporting child abuse and neglect. Specifically whether: the categories of service providers required by law to report abuse or neglect should be expanded; mandatory reporters should be required to receive training on their reporting duties; and DCFS should modify its internal system for handling abuse reports made to caseworkers in open cases. The Community Fatality Review Team released its report on November 29, 2000. The report addressed many of the issues pointed out in the Ombudsman review.4 1. Ombudsman July 2000 Review of Zy'Nyia Nobles Fatality, (edited to protect confidentiality): www.governor.wa.gov/ofco. 2. RCW 26.44.030 requires specified categories of professionals and service providers to report suspected child abuse and neglect. 3.Munro, E. (1996) Avoidable and Unavoidable Mistakes in Child Protection Work, British Journal of Social Work, 26, 793-808. 4. Zy'Nyia Nobles Fatality Review (edited to protect confidentiality): www.wa.gov/dshs. |