OFCO's July 2000 Review of Zy'Nyia Nobles Fatality

STATE OF WASHINGTON
OFFICE OF THE FAMILY AND CHILDREN'S OMBUDSMAN
6720 FORT DENT WAY, SUITE 240, TUKWILA, WASHINGTON 98188

July 13, 2000

To the Zy'Nyia Nobles Fatality Review Team:

The Office of the Family and Children's Ombudsman (OFCO) has recently reviewed the Division of Children and Family Services (DCFS) case files of Aretha Sconiers and her two children, D[ ] and Zy'Nyia. We initiated the review because we wanted to learn more about the department's decision to return the children to Ms. Sconiers' care. We also wanted to learn about the services that were in place to support the family and monitor the children's safety upon their return.

Not wanting to duplicate the efforts of the Review Team, we have decided not to proceed further at this time. Rather, we are bringing to the Review Team's attention four areas of concern that we believe warrant further scrutiny and evaluation. We have also identified three overarching issues that may have broader implications for the child protection system. We request that the Review Team consider and address these items as part of its independent review, which we understand may include interviews with key individuals and expert consultation.

The four areas of concern are as follows:

1. Assessments: There is no indication in the case record that the Division of Children and Family Services (DCFS) ever sought or obtained a psychological/psychiatric evaluation or parenting assessment of Ms. Sconiers prior to placing the children in her care. Nor does it appear that her risk for physical abuse against her children was adequately assessed.

2. Non-compliance: The case record indicates that Ms. Sconiers was only briefly in full compliance with court-ordered services or requirements during the three-year period before her children were returned to her care. Further, there is documentation to indicate that she had not successfully completed court-ordered substance abuse services or parenting classes prior to the children's return. There is no documentation indicating whether she had completed and/or made progress in mental health counseling at the time of her children's return.

3. Post-return monitoring: The case record indicates that the array of in-home services and requirements that DCFS indicated would be in place to support and monitor the family after the children's return home either failed to provide the planned level of monitoring or were never put into place at all.

4. Post-return concerns: The case record documents several instances in which there were concerns that the children may have been at risk of abuse in their mother's care. However, there is nothing in the case record indicating that these concerns were acted upon by the CWS caseworker, the FPS worker, the DCFS-contracted in-home child care provider, and/or others who knew the family.

These concerns are set forth in greater detail below:

Psychological/psychiatric assessment. The lack of a psychological or psychiatric assessment is of concern in light of ongoing concerns about Ms. Sconiers' mental health and her need for prescribed psychotropic medication. These concerns include the following:

In January 1999, Ms. Sconiers reported to her TASC case manager that she had been experiencing mood swings, viewed herself as bi-polar, and was seeking mental health treatment.

In February 1999, TASC reported to the CWS caseworker that Ms. Sconiers may need to be on prescribed medication, and in March 1999 recommended to the caseworker that Ms. Sconiers receive mental health counseling.

In May 1999, the CWS caseworker reported to the court that Ms. Sconiers had been prescribed medication for her "bi-polar disorder."

In August 1999, the court ordered Ms. Sconiers to continue with mental health counseling and medication, if deemed necessary by her counselor.

In November 1999, the TASC case manager reported to the CWS caseworker that Ms. Sconiers had been attending mental health counseling, but was not taking the prescribed medication "as she felt better and did not like the side effects." The case manager also noted that "stress seemed to be a primary trigger for her," and recommended that Ms. Sconiers "be re-evaluated and be consistent in taking prescribed medications." The CWS caseworker noted that the TASC case manager was concerned because Ms. Sconiers "has been known to become very stressed out and overwhelmed without knowing how to cope." However, later that month, the CWS caseworker noted that "if [Ms. Sconiers] feels the need for medication she will inform me."

In a January 2000 CPT Brief Case Summary, the CWS caseworker noted that Ms. Sconiers "has suffered from depression in the past but has maintained by working and keeping on task."

In February 2000, the CWS caseworker reported to the court that Ms. Sconiers had reported to her that she was not having any "major problems" with depression.

Parenting Assessment: There is no documentation indicating that a parenting or bonding assessment had been completed prior to the CWS caseworker's decision to return D[ ] to his mother's care and to place Zy'Nyia there for the first time. This is of concern in light of the following:

The case record indicates that in 1997-98, Ms. Sconiers had a total of 15 supervised visits with her children.

In May 1998, Ms. Sconiers canceled visits for the month because of reports by D[ ]'s foster parent that he is acting out after visits.

In September 1998, the CWS caseworker indicated that he would [remainder of sentence has been redacted.]

The case record indicates that in 1999, Ms. Sconiers had a total of 28 of 39 scheduled supervised visits.

In June 1999, Zy'Nyia's foster care case manager told the CWS caseworker that Zy'Nyia's former foster parent had reported to the manager that Ms. Sconiers "makes promises that she does not honor. Promises to buy D[ ] things if he combs his hair." The caseworker told the case manager that she "had spoken with the Mother and told her not to tell child such things."

In July 1999, [rest of paragraph has been redacted.]

In November 1999, [rest of sentence has been redacted.] The foster parent notes that his mother told him he'd be home by his birthday in October, and later said he'd get a GameBoy for his birthday (she later told him he'd get it when he returned home.)

In a November 1999 staffing with Zy'Nyia's foster care manager and foster parent, it was reported that her visits with her mother were going well, "but Zy'Nia usually wants to end the visit to go see [name redacted] (her foster parent.)

In November 1999, the CWS caseworker noted that Ms. Sconiers told her that "she [Ms. Sconiers] does not think she can do this meaning care for her children because she has been put down so much that she thinks she cannot care for them."

In a December 15, 1999 referral to Advantages Plus for Family Preservation Services (FPS), the CWS caseworker identified stress as a "high" risk factor in this case and requested that FPS "help mother with appropriate discipline."

In December 1999, Ms. Sconiers and the children had an overnight visit at Christmas. The CWS caseworker noted that D[ ] told his foster parent that he had a good time, "but mentioned that he spent the night at his [former foster parent's] home."

In the January 2000 CPT case history and summary, the fact that Ms. Sconiers had not parented for two years [OFCO note: Ms. Sconiers had not parented for almost three years at this point] was identified by the CWS caseworker as "a significant risk factor." The caseworker also identified as a "significant risk factor" Ms. Sconiers' ability to use appropriate discipline, but assessed the risk "as low at this point." OFCO found nothing in the case file to support this assessment (other than the CWS caseworker's note that Ms. Sconiers had been caring for two toddlers for over a year without incident; there is no documentation indicating whether or how this was verified by the caseworker.)

In [ ] January 2000, [remainder of sentence has been redacted.]

In an August 1999 ISSP, the CWS caseworker states that "it is believed that Ms. Sconiers is the best resource for her children. She attends visits weekly and has shown the capacity to parent." However, no basis or explanation is provided as to how her parenting capacity had been demonstrated. Case records do indicate that her supervised visits generally went well and she was appropriate with the children. However, the documentation also indicates that, while she had completed three parenting classes in prison, Ms. Sconiers attended but twice failed to complete court-ordered parenting classes in November 1998, and in August 1999.

Child Abuse Risk Assessment. There is no documentation indicating whether Ms. Sconiers' risk for physical abuse against her children was adequately assessed prior to the children's return.¹ This is of concern in light of the following:

Ms. Sconiers had a history of physical abuse as a child (she reported that she was twice placed into protective custody as a child).

Ms. Sconiers had a significant history of criminal assaults (including First Degree Assault and First Degree Robbery) through November 1996 when Zy'Nia was born, and Ms. Sconiers assaulted and injured a hospital security guard.

In mid-1998, the department received [ ] records indicating that [remainder of sentence has been redacted.] (Ms. Sconiers had an open CPS case in December 1996.) [Remainder of paragraph has been redacted.]

In April 1999, D[ ] and his foster mother told the CWS caseworker that D[ ] had received the scar on his forehead from having been pushed by his mother.

¹The Child Abuse Potential Inventory is one such assessment tool.

2. Non-compliance: The case record indicates that Ms. Sconiers was only briefly in full compliance with court-ordered services and requirements during the three-year period before her children were returned. Further, there is documentation to indicate that she had not successfully completed court-ordered substance abuse services or parenting classes prior to the children's return. There is no documentation indicating whether she had completed and/or made progress in mental health counseling at the time of her children's return. With regard to Ms. Sconiers' compliance history, the case record indicates the following:

In November 1996, after Zy'Nyia's birth, Ms. Sconiers agreed to participate in various services and to submit to random UAs. In January 1997, DCFS filed a dependency on both children based, in part, on Ms. Sconiers' refusal to participate in services and her two positive UAs in December for pot and cocaine.

In June 1997, the court found Ms. Sconiers not to be in compliance with court-ordered services in prison and ordered DCFS to file a petition to terminate her parental rights (TPR).

In August 1997, the State filed a TPR, noting that Ms. Sconiers had been discharged from a drug and alcohol program in a prison pre-release program "due to a services infraction which was not disclosed." She was released with "unsatisfactory" results.

In October 1997, Ms. Sconiers entered a drug dependency program in prison at Purdy Correctional Center. Later that month, the Guardian ad Litem (GAL) reported to the court that she was "pleased that Aretha has recently engaged in substance abuse services and parenting classes," but has "some reservations that she will fully comply with the program requirements as she has history of failing to follow through with services. This guardian ad litem is extremely concerned that Mom denies that Zy'Nia was born drug impacted."

In February 1998, DCFS recommended, and the court approved, changing the permanency plan from termination/adoption to dual track because Ms. Sconiers was in compliance with services at Purdy.

In June 1998, after her release from prison, Ms. Sconiers told the CWS caseworker that she was willing to do all that was necessary to get her children returned. When asked for input on what she must do, she said "just give them back to me, and get out of my life."

In August 1998, the court found that Ms. Sconiers was not in compliance with services, and was failing to make progress. The court ordered her to participate in counseling starting in September 1998. DCFS noted that the "central issue in this dependency has been mom's drug and alcohol problems. Mother continues to use drugs, deny her problems. Her inability to follow through with recommendations from the court indicate that she is unlikely to be a parental resources in the near future." The new GAL reported that "like the previous GAL, I too have some reservations about her ability to fully comply with program requirements."

In November 1998, DCFS reported to the court that Ms. Sconiers was in partial compliance with services. During this month, a CWS supervisor sent Ms. Sconiers a letter reminding her that the court had ordered her to begin counseling and referring her to Greater Lakes Mental Health.

In December 1998, Bates Technical College reported that Ms. Sconiers did not complete her parenting class, attending 7 out of the 8 minimum required classes.

In January 1999, TASC reports that Ms. Sconiers reported that her attorney had informed her that she need not attend recommended outpatient treatment because the court had not ordered it. She indicated that she would therefore not participate.

In March 1999, the court found that Ms. Sconiers was not in compliance with service, and was failing to make progress. DCFS noted that Ms. Sconiers "has consistently shown that she is incapable of full compliance with services. . . "

In May 1999, Ms. Sconiers' newly-assigned CWS caseworker reported to the court that Ms. Sconiers was now involved in court-ordered mental health counseling and had been prescribed psychotropic medication. The caseworker stated that there "has not been enough time to monitor mother while she is taking her medication nor has there been enough time to monitor mother's compliance with mental health services." The caseworker also noted that Ms. Sconiers had been referred to a parenting class that was scheduled to begin that month.

In August 1999, the CWS caseworker reported to the court that Ms. Sconiers was in compliance with court-ordered services. The court found her to be in compliance and as having made progress. The court ordered that the children be returned to their mother's care as soon as she obtained housing.

In September 1999, Greater Lakes Mental Health reported to the CWS caseworker that Ms. Sconiers was keeping her counseling appointments and had been participating adequately in group and individual therapy.

In November 1999, TASC reported that Ms. Sconiers had been discharged in a "neutral" status. This discharge was based on Ms. Sconiers having been in the program for more than one year. According to the report, Ms. Sconiers reported for 28 of 34 random UAs: 20 were negative; four were positive for THC (10/27/99, 2/22/99, 1/12/99 and 10/9/98) and four were unacceptable (because the sample appeared dilute) (10/4/99, 8/20/99, 4/21/99, 10/9/98). There were four no shows and two appointments were excused. The Discharge Report recommended that Ms. Sconiers be referred to MICA treatment at Greater Lakes. TASC described her prognosis as positive "if she seeks MICA treatment and is consistent in taking prescribed medication."

In November 1999, the CWS caseworker noted that "if [Ms. Sconiers] feels the need for medication she will inform me."

In December 1999, the Family Preservation Services (FPS) provider reported to the CWS caseworker that Ms. Sconiers indicated that she "is not truly wanting to work with us" but is willing to in order to have her children returned.

In January 2000, the FPS worker noted that Ms. Sconiers is "very resistant," that she "has problem with someone coming to her home," and that he had spoken to the CWS caseworker "to help push Ms. Sconiers to comply more . . . with recommended services and my assistance."

In February 2000, the court ordered Ms. Sconiers to provide DCFS with written documentation of her compliance with services.

In May 2000, Catholic Community Services (CCS) sent DCFS a letter indicating that Ms. Sconiers had not completed her August 1999 parenting class, attending 10 out of the 12 minimum required classes.

There is no written documentation in the case file indicating whether Ms. Sconiers completed mental health counseling.

Significantly, Ms. Sconiers' lack of cooperation continued after the children were returned to her care. In his February status report, the FPS worker noted that Ms. Sconiers that month had allowed a relative with a criminal background into her home to watch her children. It is unclear whether this occurred before or after Ms. Sconiers moved into her new apartment. In any event, in her February 9, 2000 ISP, the CWS caseworker stated that the "children will not be allowed with anyone who has not had a background clearance."

In addition, on February 22, 2000, the court ordered Ms. Sconiers to "cooperate with service providers such as FPS. . ." In his February status report, the FPS worker indicated that he planned to inform Ms. Sconiers that he would "be doing surprise visits to monitor the safety plan and address concerns" and that he would also be checking up to make sure she followed up on the UA he had requested she take on March 1, 2000." He also indicated that he would "continue to educate Ms. Sconiers on the system and the court-ordered recommendations she will need to comply with." On March 8, 2000, the FPS worker noted that Ms. Sconiers was "very upset and disrespectful, and refused to let him go to the store with D[ ]. He noted that Ms. Sconiers "does not want to speak to me regarding non-compliance with treatment" and refused to sign release of information authorization for D[ ]'s school. She wants new FPS worker." On March 15, 2000, the CWS caseworker noted that Ms. Sconiers is "upset and feels she cannot trust" the FPS worker. The caseworker told Ms. Sconiers that she would look into changing FPS provider." On March 17, 2000 the CWS caseworker transferred the case to a new FPS worker.

3. Post-return monitoring: The case record indicates that the array of in-home services and requirements that DCFS indicated would be in place to support and monitor the family after the children's return home had either failed to provide the planned level of monitoring or were never put into place at all.

Prior to the children's return in February 2000, the CWS caseworker indicated to the CPT that a FPS worker and home support specialist were in place and that family counseling and child care ("close to the home") would be provided. On February 22, 2000, shortly after the children's return, the court ordered Ms. Sconiers to comply with these services and also to submit to random UAs. The court further ordered Ms. Sconiers and D[ ] to begin family counseling "ASAP." However, the case record indicates:

FPS Worker. The December 28, 1999 Initial Treatment Plan indicated that one to two visits would occur per week. However, a total of five FPS visits occurred in the four months following the children's return. There were no FPS visits in February. There was one FPS visit in March. The next FPS visit occurred over a month later in April. During April, there were two no-shows early in the month, and three FPS visits later in the month. There were no FPS visits in May (four no-shows). There is no indication that either FPS worker ever saw the children alone.

Home Support Specialist. There is no indication that a home support specialist was involved with the family after helping Ms. Sconiers move into her new apartment in early February.

Family Counseling. There was nothing in the case file documenting the provision of family counseling services after the children were returned. On January 27, 2000, the FPS worker noted that he would make referral to Greater Lakes. On April 11, 2000, the CWS caseworker brought [name redacted] therapist to a home visit and introduced him to Ms. Sconiers as someone who would be working with the family. On April 28, 2000, the CWS caseworker noted that Ms. Sconiers reported that they had not yet seen the therapist because he was on vacation.

Random UAs. There is no documentation indicating whether the CWS caseworker requested any random UAs. In a February status report, the FPS worker indicated that he told Ms. Sconiers that she would have to submit to a UA on March 1st. On March 15th, Ms. Sconiers had a UA that was negative.

Child Care. The only indication that child care services were provided was a handwritten invoice, dated April 25, 2000, and signed by [name redacted.] The invoice indicates that [name redacted] had been providing in-home child care for both children since February 9, 2000. The invoice indicates that [name redacted] provided child care for Zy'Nyia on weekdays, and for both children on the weekends. An undated "ASAP" request for a background check on [name redacted] was made by the CWS caseworker. An April 25, 2000 background report indicated that she had no CPS or criminal history.

Caseworker/GAL contacts. The CWS caseworker visited the family on three occasions (in February, March and April) after the children were returned. There is no documentation indicating whether she saw the children alone during those visits. The Guardian ad Litem (GAL) visited the family once in late February. There is no indication that the GAL thereafter contacted the family or was independently monitoring the provision of services.

4. Post-return concerns: The case record documents several instances in which there were concerns that the children may be at risk of abuse in their mother's care. However, there is nothing in the case record indicating that these concerns were acted upon by the CWS caseworker, the FPS worker, the DCFS-contracted in-home child care provider, and/or others who knew the family. These include the following:

Parent-child interaction. In her first appointment with Ms. Sconiers on April 10, the new FPS worker noted that Zy'Nyia was crying but would give no reason as to why. The worker also noted that Ms. Sconiers expressed concerns in this meeting about "the children's untruths" and their "not following through." In her second appointment on April 17, the FPS worker noted as a concern that the "children appear to be afraid." She noted that she had to do a lot of prompting to get them to talk and that they "look at mom for each response." The worker also noted as a concern Ms. Sconiers' discipline and, in particular, her tone which "is very overly assertive and very intimidating. . . " In her third meeting on April 25, the FPS worker noted as a concern that Ms. Sconiers was now unemployed and was unsure how she was going to pay next month's rent. She also noted that Ms. Sconiers "has exhibited very little interaction with the children while in my presence. [Ms. Sconiers] has a very intimidating voice." It is unclear whether and when the FPS worker forwarded these concerns to the CWS caseworker. In any event, there is no documentation indicating that any action was taken to follow up on these concerns.

Zy'Nyia's burned foot/feet. During a home visit on April 17th, the CWS caseworker noted that there were "no issues, but [Ms. Sconiers] said [D] ran a bath for Zy'Nyia and the water was too hot and she burned her foot. [Ms. Sconiers] took her to the doctor and she is doing fine." There is no documentation indicating whether the caseworker examined Zy'Nyia's feet, interviewed the children and/or confirmed that Zy'Nyia had in fact received medical treatment. The media have reported that Zy'Nyia's godmother (and a licensed foster parent), [name redacted], left a voice message on the CWS caseworker's phone near the end of March notifying her that Zy'Nyia's feet had been scalded. There is no documentation of [name redacted]'s call in the case file. The department has stated publicly that the caseworker "doesn't recall" receiving the voice message.

Missed FPS visits. As indicated above, Ms. Sconiers missed two FPS appointments in early April (April 3rd and 4th), after her last appointment on March 8th. Ms. Sconiers missed four appointments in May (May 1st, 8th, 16th and 22nd). On May 17th, the FPS worker noted in her handwritten notes that she had spoken to the CWS caseworker about Ms. Sconiers' missed appointments. She also noted that someone (it is unclear whether she is referring to Ms. Sconiers or the caseworker) indicated that the missed appointments were due to "job hunting." In any event, there is no documentation indicating what, if any, action the caseworker took to follow up on the FPS worker's concern.

Post-death reports of abuse. After Zy'Nyia's death, several individuals reported that they were aware that Ms. Sconiers was abusing Zy'Nyia, but did not take action. These include the DCFS-contracted in-home day care provider, [name redacted], who reportedly told a police detective that she was aware of the abuse and had seen "many bruises" on Zy'Nyia. It also includes a family support center worker (a mandated reporter) who called CPS in early June to report that [identifying information redacted] had seen Ms. Sconiers give Zy'Nyia a black eye in late May. Moreover, an anonymous referent reported to CPS in early June that a person who on several occasions had provided care for Zy'Nyia knew that she was being abused, but did not report it.

In the course of assessing the aforementioned areas of concern, the Review Team may wish to consider whether, and to what extent, the following issues affected the course of this case, and their broader implications for the child protection system.

1. Caseworker Bias. The case record documents that the CWS caseworker clearly believed that Ms. Sconiers could safely parent her children. What seems problematic is the caseworkers' apparent failure to test her belief with an independent assessment of any kind, e.g., psychological, psychiatric or parenting evaluation. It also appears that the caseworker did not keep an open mind regarding Ms. Sconiers' ability to parent which appeared to lead her to minimize or discount information that did not support her belief, e.g., Ms. Sconiers' refusal to acknowledge her drug problem and her failure to comply with court-ordered services; Ms. Sconiers' uncertainty about her ability to parent; reports that Ms. Sconiers' had physically abused D[ ], and; the report of Zy'Nyia's burned foot/feet.

As indicated below, the caseworker's belief was so strong that, at various points in the case, it appears that she assumed the role of Ms. Sconier's advocate. This undermined her ability to act in the children's best interest. For example:

In a May 1999 affidavit, the CWS caseworker stated that the inconsistency of Ms. Sconiers' visits with her children up until that point was due to the foster parent [name redacted], and not Ms. Sconiers. (The caseworker did not report that cancellations by Ms. Sconiers and the transporter had accounted for three of seven missed visits.)

In a May 1999 Service Episode Report (SER), the CWS caseworker noted that she told Ms. Sconiers "that we may have to figure out a way to get the children away from [name redacted] because of her interfering with the case plan. [Ms. Sconiers] agreed."

In July 1999, a visitation supervisor noted that the CWS caseworker informed her and Ms. Sconiers that "she is working for [Ms. Sconiers] and not the family [name redacted.] Weekend visits [with name redacted] will cease until [Ms. Sconiers] has her own place."

In a July 1999 meeting with Zy'Nyia's foster care team, which included the CWS caseworker, it is noted that "it is quite clear that Aretha's family continues to interfere with her progress which can ultimately result in termination of her parental rights . . . I believe Aretha has a fair chance of her children returning home, however, the family has been consistently ignoring the boundaries which reflects on Aretha's ability to set boundaries as well."

In a August 1999 ISP, the CWS caseworker reported to the court that the "children are doing well." (The caseworker did not report that D [remainder of sentence redacted.] The caseworker also stated that Ms. Sconiers "did have one positive UA in February" but "has been clean since." (The caseworker did not report that Ms. Sconiers also had one unacceptable UA in April and one missed UA in May.) The caseworker also stated that "it is believed that Ms. Sconiers is the best resource for her children. She attends visits weekly and has shown the capacity to parent." However, the caseworker provided no basis or explanation as to how Ms. Sconiers' parenting capacity had been demonstrated.

In a September 15, 1999 affidavit, the CWS caseworker stated that "Ms. Sconiers has been complying with services . . . It is felt that Ms. Sconiers is doing her very best to get her children returned to her care." (The caseworker did not also report that Ms. Sconiers had an unacceptable UA in August.) Earlier, in a September 10, 1999 SER, the caseworker noted that, with respect to the unacceptable UA in August, Ms. Sconiers had explained that she had been in a hurry after court. The caseworker also noted that Ms. Sconiers had "a dilemma" that day (Sept. 10) as she had to miss her UA due to job training. On September 22, the CWS caseworker noted that Ms. Sconiers had contacted her to report that she did not make her UA on that day due to work.

In a November 3, 1999 meeting, Ms. Sconiers admitted to the CWS caseworker that she had smoked pot. The caseworker noted that Ms. Sconiers told her that "she [Ms. Sconiers] does not think she can do this meaning care for her children because she has been put down so much that she thinks she cannot care for them." The caseworker told Ms. Sconiers to find an apartment, that in-home services would be provided, and "that her children want to be with her." The caseworker noted that Ms. Sconiers "reluctantly agreed" to a staffing with her attorney.

In early November 1999, TASC recommended to the CWS caseworker that Ms. Sconiers be consistent with prescribed medications. On November 11, the caseworker noted that if Ms. Sconiers "feels the need for medication she will inform me."

In a January 12, 2000 CPT Case Summary, the CWS caseworker reported that Ms. Sconiers had experienced two relapses in the past year. (Ms. Sconiers had in fact experienced three relapses in the past year (10/27/99, 2/22/99, and 1/12/99). The caseworker did not also report in the summary that Ms. Sconiers' last relapse was in October 1999, that she also had three unacceptable UAs in the last year (10/4/99, 8/20/99 and 4/21/99), or that she had missed both UAs in September 1999. The caseworker did report in the summary that Ms. Sconiers had completed a drug and alcohol program, a parenting class, and mental health counseling at Greater Lakes. However, the caseworker did not make clear in the summary that Ms. Sconiers' discharge from TASC was neutral and based on her being in the program for over one year. The caseworker also did not report in the summary that TASC recommended Ms. Sconiers be referred to the MICA program and be consistent in her medication. Moreover, there was no documentation in the record at that time verifying that Ms. Sconiers had in fact completed her parenting class or mental health counseling.

In a February 9, 2000 ISP, the CWS caseworker reported to the court that Ms. Sconiers had complied with services, and completed her TASC requirements and probation. (However, she did not report on Ms. Sconiers' failed UA in October 1999.) The caseworker also reported that Ms. Sconiers has a job and "has been able to maintain steady employment." (However, there was nothing in the case record at that time documenting or confirming Ms. Sconiers' employment or completion of her parenting class or mental health counseling.) The caseworker stated that "Ms. Sconiers must be commended for her role in getting her children placed back in her care. For some time it appeared that she did not possess the self confidence or strength to be a resource for her children. However, she overcame her insecurities and was able to get an apartment. . . "

On March 23, 2000, the CWS caseworker sent a letter to the court regarding repayment of Ms. Sconiers' fines. In the letter, the CWS caseworker stated that "to the best of my knowledge, Ms. Sconiers has tried very hard to be responsible and repay her fines" and "is more than willing to fully cooperate with the court to resolve this matter." She also explained that "Ms. Sconiers has maintained stable employment; however there have been some months in the past that she was unemployed, therefore unable to make any payments." The caseworker also noted that Ms. Sconiers "has worked very hard and diligently to have her children returned to her care . . . [and] is doing her absolute best to continue to meet the needs of her children."

Caseworker bias was a significant feature of the Lauria Grace fatality case, as well as the Wenatchee child sexual abuse cases. Moreover, it has been and continues to be a persistent theme in cases routinely handled by OFCO. Bias occurs when a caseworker develops an initial belief about a person or event and then becomes resistant to altering his or her belief - even in the face of conflicting information.² Caseworker bias can place children and families at risk of serious harm. For this reason, we believe the Review Team should consider whether and how this issue might be addressed systemically, e.g., through improved training and supervision.

²See Munro, E., (1996) Avoidable and Unavoidable Mistakes in Child Protection Work, British Journal of Social Work, 793-808.

2. System Checks and Balances. The case record suggests that Zy'Nyia's death was potentially avoidable. However, the checks and balances in the child protection system did not prevent this fatality. There is no documentation in the case record that any supervisory staffings occurred after 1998. Further, the respective independent evaluation and oversight functions of the CPT and the court appeared to have been undermined as a result of having received information from the caseworker that was not entirely accurate or complete; moreover, the GAL did not appear to flag the caseworker's inaccuracies or omissions through his own independent investigation or monitoring. In addition, it appears that in the three and half months following the children's return home, none of the professionals responsible for contacting this family (the CWS caseworker, the two FPS workers, or the GAL) ever spoke to the children alone. Finally, there may have been a communication/coordination breakdown between the CWS caseworker and the FPS worker. The case record clearly indicates that the FPS worker had concerns about the family, but it does not appear that these concerns were ever addressed by the caseworker. Whether and how the FPS worker forwarded her concerns to the caseworker is unclear from the record. Similarly, whether and how the caseworker followed up on the concerns that did come to her attention is unclear.

The Review Team should explore whether and how the system's checks and balances were overcome in this case and, if appropriate, how they might be strengthened. The Review Team should also take this opportunity to assess the role of home-based service providers such as FPS and their relationship with DCFS. The department places heavy reliance on home-based service providers to monitor the safety of children in their homes. Yet it is not clear that providers such as FPS are adequately trained to identify and assess risk to child safety, or that they even see this function as an aspect of their role when working with families.

3. Mandated Reporting. The case record indicates that several individuals suspected or knew that Zy'Nyia's mother was abusing her. Two individuals, a licensed foster parent and a family support worker, are mandated reporters under law. The family support worker indicated that she did not make a referral, while the foster parent indicated that she notified the child's caseworker of her concern, but that the caseworker did not respond. A third individual, a DCFS-contracted child care provider, may not be a mandated reporter under law. The Review Team should inquire into how effectively the system for reporting abuse and neglect is working. Specifically, the Review Team should consider whether: 1) the definition of a mandated reporter should be expanded; 2) mandated reporters should be required to receive training and/or continuing education on when and how to report as a condition for receiving a state license, certification or contract, and 3) DCFS's internal system for handling reports or abuse or neglect to a caseworker in an open CPS or CWS case. This issue is of great interest and concern to OFCO and we would welcome the opportunity to discuss it with you in more detail.

Sincerely,

Vickie Wallen
Director Ombudsman