How we got the story
This article is the second installment of an occasional series about the failings of Georgia’s child welfare system. In an earlier article, The Atlanta Journal-Constitution reported that mistakes by state child protection workers had preceded the deaths of at least 25 children in 2012.
For this story, the Journal-Constitution reviewed reports from the state Division of Family and Children’s Services concerning Chasidee Crabtree and other children who died after involvement with the agency. The newspaper also examined a report on Chasidee’s autopsy and interviewed former state caseworkers, current DFCS officials, Chasidee’s foster parents and her adoptive parents.
The newspaper identified Chasidee through a state database of death certificates issued from 2011 through mid-2013.
She was born to a mother in foster care. She endured a chronic illness that made her dependent on prescription drugs to stay alive. She behaved so aggressively, trying to kill herself and threatening a teacher, that her adoptive parents asked a judge to send her away. She slept clutching letters her biological father sent from prison.
A social worker hardly exaggerated in describing Chasidee Crabtree’s life as “difficult and challenging.”
The state of Georgia made it worse.
Under orders to reduce foster care rolls, state child protection officials in Columbus decided last year to send Chasidee from a foster home back to her adoptive parents. With the move imminent, Chasidee wrote a goodbye note, swallowed a handful of prescription pills, and went to sleep. A state medical examiner declared her death a suicide. She was 16.
Her death highlights some of the deep flaws in Georgia’s child welfare system identified by an Atlanta Journal-Constitution investigation. In recent years, officials emphasized concepts with such names as “family preservation” and “family support” over removing children from their homes to prevent abuse or neglect. From 2004 to 2012, federal statistics show, only two states reduced the number of children in foster care at a greater rate than Georgia.
By last year, two-thirds of the Georgia children who died after DFCS investigations came from families that had been diverted into programs designed to stem the flow to foster care.
State officials describe the change in focus as more philosophical than fiscal. Still, the cost savings are difficult to ignore: about $120 million a year.
It is far from certain that financial concerns or numerical quotas drove decisions concerning Chasidee Crabtree. But the question is especially relevant in Columbus, where two former officials with the Georgia Division of Family and Children’s Services face criminal charges of falsifying and destroying state records. Deborah Cobb, who was interim director of the Muscogee County DFCS office, and Phyllis Mitchell, who oversaw the handling of maltreatment reports in Columbus, are accused of manipulating the outcomes of abuse and neglect investigations to meet state-mandated foster care targets. Both pleaded not guilty.
In Chasidee’s case, according to three former DFCS employees, supervisors disregarded caseworkers’ warnings that she was desperate to remain in foster care. After she died, the former workers said, the supervisors removed the warnings from DFCS records.
Chasidee’s file contained reports of alleged maltreatment from 2003, 2006, 2008, 2011 and 2012. Although DFCS apparently investigated each complaint, it substantiated only a few allegations. Extensive deletions from documents the agency released to the Journal-Constitution make it all but impossible to evaluate whether the findings were sound.
In February 2011, DFCS cited Chasidee’s adoptive parents for medical neglect after Chasidee, then 15, entered a Columbus hospital because of medication errors. The adoptive parents deny they were at fault, but a DFCS report said they endangered Chasidee by leaving her to her own devices in navigating the complicated regimen surrounding her prescription medicines.
She later used the same medicines to kill herself.
In raw statistical terms, Georgia’s attempt to transform foster care has been a great success.
From 2004 to 2010, the number of foster children dropped from more than 14,000 to less than 7,000 before rising slightly the past two years. Still, the state recorded a decline of 46 percent over eight years.
During that time, Hawaii had the greatest decrease in foster rolls — almost two-thirds — but in a system one-seventh as big as Georgia’s. Maryland, with a 51 percent reduction, was the only other state ahead of Georgia. The number of foster children nationwide dropped by 21 percent.
Many children’s advocates support, in theory, what Georgia attempted.
“As a best practice, children should remain with their families if it’s possible and if they can be safe doing so,” said Ira Lustbader, associate director of the advocacy group Children’s Rights, which used a federal lawsuit to force Georgia to improve its child welfare system in Fulton and DeKalb counties.
But safeguards apparently were not always in place. In at least 50 of 86 case records from 2012 reviewed by the Journal-Constitution, a child died after DFCS had given the family “preservation,” “support” or similar services that kept children at home and out of foster care.
Keeping families together became a priority at DFCS in the mid-2000s. The agency began basing employees’ performance evaluations in part on how many children they kept out of foster care. Of 11 “expectations” listed in one section of the evaluation form, one mentions preventing maltreatment. Three promote diverting at-risk children away from foster care. One of the three requires caseworkers to place at least 30 percent of children in DFCS custody with a relative rather than with foster parents. Another declares: “The number of children in DFCS custody will be reduced.”
“The (foster care) numbers were very heavily emphasized; what was not emphasized was the companion quality piece,” said Melissa Carter, executive director of the Barton Child Law and Policy Center at Emory University’s law school and a former head of the state Office of the Child Advocate.
Supervisors “cannot push this through as a numbers game,” said Tom Rawlings, another former head of the child advocate’s office. Like Carter, Rawlings favors placing as few children as possible in foster care, but said nothing is more important than ensuring a child’s safety.
“You’ve got to find that really careful balance,” Rawlings, a former juvenile court judge, said. “Be very careful of what you tell your employees you expect of them — because they will deliver it.”
DFCS officials acknowledge the drive to keep children out of foster care may have gone too far.
“It’s meant for families with problems but the child is safe,” said Sharon Hill, who became DFCS’ state director in August. For example, Hill said, “if not enough food is reported, they may just need to sign up for food stamps.”
Each day, Hill said, DFCS workers must weigh children’s safety against the goal of “maintaining and preserving the sanctity of families.”
However, she said: “The safety of the child trumps everything else. We cannot maintain a family if the child is not safe.”
As the family-preservation policies took root, Columbus kept pace with the rest of the state in reducing foster care cases. But DFCS workers complained about an unintended effect: a surge in deaths among children whose families had a history with the agency. In early 2011, four children from Columbus died in five weeks.
A’Zayvion Zhi’Derrick Cross, 4 months old, was one of them.
In November 2010, a few days after A’Zayvion’s birth, DFCS opened its second investigation of his family that year. When police officers tried to serve an arrest warrant on the father of one of A’Zayvion’s siblings, the father allegedly fled and left a 1-year-old home alone. Police found guns, three to four pounds of marijuana and other drugs in the house, according to a DFCS report. But the agency took no action against the family and closed the case on Dec. 21.
On March 9, 2011, A’Zayvion died in his crib.
His body showed no obvious injuries but was “very, very dirty,” a caseworker wrote in a memo that was included in the report of an internal investigation. “Diaper does not look like it had been changed in some time. There was blood in the diaper around the rectum and penis. The odor was horrible. There are sores on his leg from the urine and from not being changed.”
The coroner described the scene as one of the worst he’d scene, and police detectives had to turn away, the caseworker wrote. The house, she wrote, was filthy; the crib A’Zayvion shared with his two siblings was littered with Jell-O containers and French fries.
No adults in the home faced criminal charges. An autopsy determined that A’Zayvion died by accident, probably suffocated by a 14-month-old lying across his chest in the crib.
The most obvious question — how DFCS could have considered the home safe just 10 weeks earlier — went unanswered.
‘Nowhere to go’
DFCS may have been the most constant presence in Chasidee Crabtree’s life.
She was born in January 1996 to a teenage mother living in a foster home. She had medical problems, diagnosed as Myasthenia Gravis, an autoimmune disorder that can interfere with breathing, swallowing and chewing. According to former DFCS workers, the disease so weakened Chasidee’s neck muscles that she could suffer a seizure and suffocate without medication.
When she was 2, DFCS placed Chasidee with foster parents Troy and Kathy Crabtree of Columbus. They adopted her about two years later.
In an interview, the Crabtrees described Chasidee as a difficult child who battled psychiatric as well as physical ailments. She broke windows and upset furniture at school. She cut into her own legs and stabbed herself in the arms, saying she wanted to die. In a Facebook post, she threatened to kill one of her teachers. Twice, judges in juvenile court ordered her to wear ankle bracelets so probation officers could monitor her movements; twice, she cut off the bracelets.
“Chasidee was a handful,” Troy Crabtree said. “But I am the kind of person, I wasn’t going to give up.”
Chasidee’s medical disorder seemed to compound her behavior problems, said Wendy Poole, one of her former DFCS caseworkers. Getting the correct daily dosages of her medications — an anti-seizure drug, an antipsychotic and an antidepressant — at the correct times each day was “life or death,” Poole said.
DFCS repeatedly investigated whether the Crabtrees had denied Chasidee appropriate medical care or had neglected her in some other way, according to agency files. Some of these inquiries followed reports by Chasidee herself.
The Crabtrees deny mistreating Chasidee. “She was very manipulative,” Kathy Crabtree said. “She felt we were too strict.”
When DFCS substantiated allegations, it still did not place Chasidee in foster care.
After Chasidee wound up in the hospital in February 2011, for example, caseworkers determined that the Crabtrees had neglected her medical needs by requiring the teen to take responsibility for getting her medications. According to a DFCS report, workers instructed the parents to obtain “family preservation services,” which the report did not describe. Within four months, the report added, “Parents worked their Family Plan and the Family Preservation case was closed.”
In November of the same year, Chasidee told a teacher her parents had slapped her in the face. DFCS workers could see no marks on her flesh and attributed her claim to family drama. The caseworker wrote that Chasidee’s parents, who denied slapping the girl, and her teachers all described her as “a child with problems who sometimes acts out.”
On March 1, 2012, Chasidee again landed in front of a juvenile court judge. The Crabtrees said they wanted Chasidee placed in a treatment facility that could deal with all her emotional and medical problems at once before she returned home.
Instead, the judge sent her to foster care.
Chasidee ended up with Rena and David Hall, a Columbus couple with extensive foster-parenting experience. Rena is a college teacher, David a pastor. They had been taking in foster children for 15 years but had asked DFCS not to place children with suicidal intentions or complex medical problems.
The Halls say DFCS didn’t tell them, but Chasidee had both.
“Her life was so complicated,” Rena Hall said recently. “She said she never forgot the day they broke her away from her (biological) mom. It never left her mind. She wanted her mom.”
Hall spent a lot of time in the car with Chasidee, driving her to almost daily appointments with physicians, a psychiatrist, her probation officer. That was when Chasidee would open up about her feelings of rejection.
“The things she was saying to me were deep,” Hall said. “They weren’t things you’d normally hear a child say. It was just the love of her mom that she wanted.”
Caseworkers described Chasidee as “obsessed” with her biological mother. At one point, she used a blade to etch the word “mom” into her arm.
Several times, Hall said, Chasidee’s biological mother sent “ugly” text messages saying she wanted nothing to do with her. Chasidee would go into such a rage that Hall had to call the police. Sometimes, Chasidee had to be hospitalized so she wouldn’t harm herself.
“Even though she was trashing my house, nobody was mad at her,” Hall said. “She would say, ‘I just want to be loved by my mom. Why won’t she love me?’ You couldn’t be mad at her.”
At DFCS, the Columbus office prepared for a periodic review of its foster care cases. Supervisors decided to return Chasidee to her adoptive parents.
The Crabtrees said Chasidee was warming to the idea of coming back. Hall said Chasidee worried the Crabtrees would cut off her only contact with her biological father — the letters he sent from prison. Chasidee wrote a letter to the juvenile court judge, asking to stay in foster care.
“She felt like she had nowhere to go,” Hall said.
Sensing Chasidee’s desperation as the family’s reunion neared, Wendy Poole, the DFCS caseworker, said she inserted a note into the case file:
“This child won’t live long like this.”
‘Left at risk’
As a social worker at a Columbus hospital, The Medical Center, Tegrin Averett had many reasons to call DFCS: pregnant adolescents, drug-exposed newborns, children injured in unlikely accidents.
But while attempting to pare its foster care roster, the Columbus DFCS office also strongly discouraged new reports of child abuse and neglect. This had the effect of further reducing the number of potential foster children.
“I would get grilled on why I made a report and what we could do at the hospital to help rather than calling in DFCS,” Averett said in an interview. “They made it challenging.”
Often, Averett said, DFCS workers would ask whether a child was in immediate danger. If she acknowledged the child was still in the hospital, she said, a DFCS worker would say no immediate threat existed – and would refuse to accept the report.
“I would say, ‘We’re being proactive,’” Averett said. “They would be, ‘No.’
“DFCS is reactive,” she said. “They are not a proactive organization.”
An internal DFCS investigation into the Columbus office in 2011 verified accounts such as Averett’s. In one instance detailed by investigators, DFCS “intake” workers, who screen abuse and neglect calls, told a hospital official that a child’s being born under the influence of illegal drugs didn’t constitute abuse. The worker refused to accept a report on the child, meaning no one from DFCS would look into the case.
Investigators also found that intake workers never entered some reports into the statewide computer system known as SHINES that tracks abuse and neglect cases. Workers may have closed some cases with no scrutiny at all.
The investigative report concluded: “Child abuse referrals that have been disregarded, not entered into SHINES, or inappropriately assessed have created the potential of numerous children being left at risk.”
The strong language was not mirrored by the punishments that followed.
DFCS ordered additional training for workers in the Columbus office, and it sent a “memo of concern” to four supervisors.
By June 2012, Chasidee Crabtree knew her time in Rena Hall’s foster home would soon be up. DFCS might pick her up at any time.
Somehow, Chasidee had convinced herself that the Crabtrees might arrange a reunion with her biological mother, Hall said. The morning of June 2, a Saturday, Chasidee told Hall said she wanted to visit the Crabtrees that day so she could see her birth mother. Hall told her to call her “mom” — her adoptive mother — to arrange the visit. Upset, Chasidee ran into her bedroom and slammed the door in front of Hall.
“That was the last time I actually saw her,” Hall said.
When DFCS placed Chasidee in her home, Hall said, a caseworker had told her the girl could manage her own medication. But because Chasidee often spilled pills in her purse and all over her room, Hall began giving her only enough pills for a week at a time. The rest, she locked away in a cabinet.
Hall usually secured the key in her bedroom. On June 2, someone left it on a hook in the kitchen.
Just before 7:30 the next morning, Hall found Chasidee’s body in her room. A plastic bag that had held her supply of pills lay on the floor. A medical examiner would later say that either of two drugs could have killed her.
The Crabtrees told friends Chasidee died at home in her sleep. Now, Kathy Crabtree said, “we would like DFCS to pay for what they did.”
“They put me through pure hell,” her husband said. “I will always blame DFCS.”
After the suicide, Hall and her husband stopped accepting foster children. Almost a year and a half later, Hall cries when she talks about Chasidee, a sweet girl, she said, who asked for nothing but her mother’s affection.
Hall always took Chasidee to church, even though she didn’t believe in God and felt her prayers had been spurned. A few days before she died, Hall said, Chasidee asked her, “How do you get saved?”
Hall isn’t sure anything could have saved Chasidee.
“I don’t know,” she said. “I don’t know. I don’t know. I don’t know.”