The fourth annual report by the state inspector general for child welfare in Nebraska focused on 22 deaths or serious injuries of kids involved with the child welfare or juvenile justice system that were fully investigated.
“Too many of the children and families touched by our child welfare and juvenile justice systems experience tragic outcomes,” Inspector General Julie Rogers wrote in this year's report, which was released Wednesday.
The report also outlined results of an investigation of deteriorating conditions and a lack of programming for some of the most troubled young men at the residential treatment center at Kearney.
State Department of Health and Human Services spokesman Russ Reno said the report represents the worst of the worst outcomes for children during the past 2½ years. But, he noted, hundreds of children in the system safely live with their families.
"We are one of many system partners and we are committed to continued collaboration and working together to improve outcomes for the families and children we serve," Reno said. "We are often the first responders to families in crisis who are experiencing multiple and complex needs. We take this responsibility seriously because it’s a part of our mission of helping people live better lives."
During the past year, the number of cases referred to the inspector general for review increased 40 percent, to 577. In addition to Rogers, the office includes two assistant inspectors general and an intake assistant. Each case receives a preliminary review and all incidents referred are tracked. Only a small number lead to final investigative reports.
In the 2015-16 fiscal year, 20 child deaths were reported. The majority were boys younger than 5. One-fourth had no previous involvement with child welfare, and investigations were opened on 13 of the 20 by Rogers’ office.
The office also investigated two suicides of state wards in the past year: a 16-year-old girl at her family home and a 16-year-old boy placed in a psychiatric residential treatment facility.
One of the cases of serious injury investigated by Rogers’ office involved a 4-year-old whose family was voluntarily participating in the system, rather than being ordered to by the courts. The boy was hospitalized after repeated physical abuse that included a skull fracture and body bruises.
An investigation showed that in the six months before the skull fracture, the child abuse hotline had received 11 reports of alleged physical abuse by the boy's father, five of which were investigated by HHS, law enforcement or both.
Sudden deaths of infants
Between May 2013 and December 2015, the inspector general received seven reports of infants with prior or current child welfare involvement and four reports of infants in licensed child care centers dying suddenly and unexpectedly. The infants ranged in age from 18 days to 12 months, four of them between 2 and 3 months, when Sudden Infant Death Syndrome risk is particularly high.
Every death investigated showed unsafe sleeping situations, such as babies being placed on their stomachs, having soft blankets or other objects in the crib, or being in a bed or on a couch with an adult, the report said.
In one such death, these risk factors were identified: unsafe sleeping position in car seat, overheating, presence of environmental smoke, presence of soft blankets and bedding and medical history involving inadequate prenatal care.
In another case a 2½-month-old state ward was found not breathing in her crib. The investigation showed her clothing was wet and smelled of cleaning fluid and that home conditions were unsanitary, including mold in the baby’s bassinet, curdled formula in her bottle, debris and broken glass, trash and human feces in a number of rooms. Children in the home tested positive for methamphetamine.
High child welfare caseloads
Chief among the challenges Rogers found in her investigations was a high caseload burden on Nebraska’s child welfare workers — the front-line staff working to protect children at risk of abuse or neglect.
It is the fourth year the inspector general has pointed out high caseloads for child welfare caseworkers as a primary obstacle to keeping maltreated children safe and delivering quality services, she said.
When staff have too much work, corners get cut, things get missed and errors are made, Rogers said.
Although minimum caseload standards for child welfare staff were put into law four years ago, HHS still cannot meet them, she said.
Children and Family Services needs to create additional positions to meet its obligations, she said.
“However, little action to truly address caseloads has been taken to date," Rogers said. "DHHS will continue to be out of compliance with Nebraska law and staff will continue to struggle to complete thorough, timely work to ensure children’s safety.”
She also recommended increasing the number of supervisors at the Child Abuse and Neglect Hotline and assess hotline workload and ongoing training and supervision.
Data shows the hotline received 5,877 to 7,258 calls each month during 2015, with each supervisor responsible for reviewing and catching any errors on an average of more than 1,500 calls each month, in addition to other duties.
New supervisory review expectations will go into effect at the hotline this month. However, HHS has no plans to increase the number of supervisors at this point, Rogers said.
Reno said the system is stronger than it was, and the department is working to improve it every day.
During the period covered in the report, HHS met, for the first time, the six federal child welfare performance measures in place at that time.
Kearney youth treatment center
During the 2015-16 fiscal year, Rogers’ office saw a more than 300 percent increase in complaints and critical incidents related to the Youth Rehabilitation and Treatment Center-Kearney, Nebraska’s secure facility for young men in the juvenile justice system.
The critical incidents included an increase in escapes -- from 29 in 2014-15 to 62 in 2015-16 -- and five reports of suicide attempts, 16 reports of self-harming behavior, 20 of assaultive or destructive behavior and 11 of youth needing significant medical treatment.
An investigation showed widespread noncompliance with state law, and that administrative oversight and decision-making allowed a deterioration of conditions to go unchecked for months while the center was without a full-time administrator.
Mark LaBouchardiere of River Ridge, Louisiana, was named administrator at the Kearney treatment center in April. Doug Weinberg, director of HHS’ Children and Family Services, said at the time his immediate focus would be to stabilize the center.
LaBouchardiere has 20 years of experience working at high-risk youth facilities in four states.
Reno said there have been no escapes from the treatment center campus since May 18. LaBouchardiere has also made changes that have reduced assaults there.