Boy’s death shines light on agency’s secrecy

In April 2010, Georgia’s child-welfare agency took a child into protective custody at an Atlanta hospital. But it won’t explain why. Nor will it say why it soon disregarded a doctor’s warning that going home would put the child at risk of death.

The agency won’t disclose how the doctor’s prophecy came true.

It won’t even say the child’s name.

Such is the secrecy that undergirds Georgia’s child-protection services, an investigation by The Atlanta Journal-Constitution shows. Even when employees of the state Division of Family and Children’s Services, or DFCS, err so badly that a child dies, the agency makes public only the most cursory information about how it handles cases of abuse and neglect.

The agency says keeping details confidential preserves the privacy rights of deceased children, as well as of their siblings and parents. It also says it has no choice but to follow a state law that severely limits the information it may release. But the agency pushed for that law in the first place, and has never tried to get it changed.

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“We would like to be as transparent as possible in these cases,” Sharon Hill, DFCS’ state director, said in an interview. But “protecting the privacy of the child is deeply important to us.”

Maintaining this secrecy also shields the agency and its workers from difficult questions about their own culpability in children’s deaths. The Journal-Constitution recently examined the deaths of 86 children whose families had previously been involved with DFCS; apparent errors by DFCS workers contributed to at least 25 of the deaths. The number may be higher. In 2012, 152 children died after the families had contact with DFCS, but the agency released documents summarizing only about half those cases.

Assessing the agency’s performance requires working around the scarcity of information it provides.

DFCS redacts not only a child’s name from death reports, but his or her gender, race, age and other identifying characteristics. It removes the most benign references to a specific parent, including “mother” or “father.” It blacks out so many details from the reports as to render large passages nonsensical.

In the case from the Atlanta hospital, the agency’s report quoted notes by a hospital social worker. But for public consumption, DFCS obscured the names of the hospital and the social worker alike. One section, as redacted by DFCS, reads: “The —— stated —— kept —— in the house. … —— states —— has a —— but —— does not have the —— that goes inside the —— .”

The DFCS report also acknowledged that questions remained about its handling of the case. But the nature of those questions was all but impossible to discern: “Documentation fails to indicate the reason —— was —— to —— in 2010.”

Using the minimal details from DFCS, the Journal-Constitution searched a state database of death certificates, examined autopsy and police reports, and scanned obituaries and other public sources of information.

That process led to Jeremiah De’Shawn Tucker, a 4-year-old from Atlanta who died in 2012 from complications of asthma.

The DFCS report left intact few details about Jeremiah, his family or decisions by state caseworkers. This fact remained, though: “Death might have been prevented.”

‘At risk’

Proof that Jeremiah Tucker ever lived can be found only in a couple of places.

One is a YouTube video posted by his mother: 15 jittery seconds of a smiling boy wearing a T-shirt with red and white horizontal stripes. Staring into the camera, he says something unintelligible. And then he is gone.

The other is an autopsy report prepared by the Fulton County medical examiner’s office. It described a “well nourished” child who weighed 50 pounds and stood 3 feet 5 inches tall. He had a pierced left earlobe and two loose front teeth.

Jeremiah was 2 when he came to DFCS’ attention in April 2010. An agency investigator substantiated a report that Jeremiah’s mother had neglected the boy by not treating his chronic asthma. He had gone without one medicine for two weeks, without another for five months.

The boy was so sick that doctors had admitted him to the hospital three times over the previous year. This time, according to a DFCS report, the medical staff at Children’s Healthcare of Atlanta “did not feel comfortable” sending Jeremiah home with his mother, who may have been unable to afford the child’s medications.

In cases of suspected maltreatment, Children’s Healthcare calls in specialists from its Stephanie V. Blank Center for Safe and Healthy Children, which advocates for abused and neglected children. A physician, whose identity DFCS did not disclose, reported back a dire prognosis: Jeremiah was “at risk of death if there was not a change in his environment.”

A day later, DFCS took temporary custody of Jeremiah and asked a juvenile court judge to consider placing him in foster care. But after about two weeks, without documenting any change in Jeremiah’s living situation, the agency withdrew the foster-care request.

Without explanation, DFCS sent Jeremiah home on May 18, 2010.

Open or closed?

Federal law requires states to publicly reveal information about children who die from abuse or neglect, particularly when government intervention failed. How much information is enough remains the subject of debate.

The federal law — the Child Abuse Prevention and Treatment Act — permits states to release a deceased child’s name, date of birth, date of death and other personal details. But it defers to another federal statute — the Health Insurance Portability and Accountability Act — on the disclosure of medical information. The latter prohibits public release of medical records, physicians’ notes and related materials for 50 years after a person’s death. DFCS considers the prohibition to include descriptions of child abuse and neglect.

This collision between mandatory transparency and mandatory confidentiality plays out in various ways across the nation. Georgia is far from the most open state, but it certainly is not the most secretive.

Several states, according to the nonpartisan National Conference of State Legislatures, have in recent years enacted laws that help the public evaluate the government’s performance in child-protection cases. Arkansas, for instance, now places notices of child deaths and near-fatalities on the website of its human services agency. The notices list a child’s name, age, race and gender and summarize the agency’s previous involvement with the child’s family. Texas, Oklahoma, and Alaska are among other states that have expanded public access to abuse and neglect reports.

By contrast, Michigan adopted a law in 2011 requiring the state only to notify legislators when children die in their districts. For the public, Michigan offers only statistical material: the number of deaths from abuse or neglect and how many of those children had been under state supervision.

Similarly, Tennessee refused for years to release anything except the total number of deaths every year. After what seemed to be a spike in deaths, several news organizations, led by The Tennessean newspaper in Nashville, filed a lawsuit seeking more information. The news organizations wanted “to see if there were patterns or if there were practices that might be improved to prevent some of these deaths,” said Deborah Fisher, executive director of the Tennessee Coalition for Open Government.

The state settled the lawsuit by agreeing to release information on specific deaths “with (victims’) names properly redacted,” Fisher said. “Everyone understood there are certain privacy issues when you’re dealing with children. But these are cases where children had died. There is some public good to the release of that information.”

Nearly 14 years ago, Georgia lawmakers opened files on any child who died within five years of his or her family’s engagement with DFCS. The move followed revelations in the Journal-Constitution about the state’s gross mishandling of numerous cases. For most of a decade, DFCS routinely released entire case files after many deaths.

But in 2009, lawmakers cut off that access, forbidding the agency from disclosing information that would identify deceased children or members of their families. This change came through an amendment to a low-profile child-welfare bill; the measure’s sponsor has said he didn’t know where the amendment originated, but it passed almost unanimously.

The agency contends the 2009 amendment also applies to a section of the law that allowed “legitimate research for educational, scientific, or public purposes.” So in most cases, the only public information comes through summaries that DFCS prepares. The documents usually run four to five pages, with many details blacked out.

The agency will provide full case files after making extensive redactions — but often charges as much as $600 for the time it takes to conceal information it deems confidential in each file. At that rate, obtaining files on all 152 DFCS death cases from 2012 would cost as much as $91,200.

The agency can be transparent without revealing everything it knows about a child’s death, said Ron Scroggy, a former DFCS director.

Scroggy instituted a process to review the death of any child whose family had a history with DFCS. By conference call, DFCS gathers representatives of the state child advocate, prosecutors, police officers, medical examiners — “whoever might be pertinent,” Scroggy said — to fully air the agency’s handling of a case. This process led to the creation of the case summaries, generally the only record of deaths that becomes public.

“Every one of those deaths we should look at, we did look at,” he said. “We tried to tease out any lesson learned to make sure no child died in vain.”

Hill, who succeeded Scroggy at DFCS this summer, said she hopes to engage organizations that might identify gaps in the child-protection system. These “community resources,” as Hill called them, could receive more information about deaths than is generally made available to the public.

But Hill wasn’t sure which organizations should be included or how much information should be shared.

“That,” she said, “probably demands a separate work group.”

Questions remain

The 2010 case involving Jeremiah Tucker technically remained open until December of that year, seven months after DFCS reunited the boy and his mother. But during those months, no one from DFCS visited or otherwise made contact with Jeremiah’s family even once.

More than two years later, DFCS learned Jeremiah was in the hospital, near death.

Jeremiah and his mother, Specialle Tucker, had been living with a friend and seven other children in the Adamsville section of southwest Atlanta: 10 people in a five-room, 1,000-square-foot house. By the morning of July 28, 2012, according to a medical examiner’s report, Jeremiah had been sick for four days, and he awoke wheezing and fighting for breath. His mother dialed 911. When paramedics arrived, the boy wasn’t breathing at all.

At Children’s Healthcare at Egleston, a social worker wrote in Jeremiah’s file that whether he had been getting the medicine he needed was unclear. “There are concerns of medical neglect,” the social worker wrote.

Doctors placed Jeremiah on life support.

His mother remained hopeful, posting messages on Twitter. “I know my baby going make it,” she wrote July 29. A day later: “Whatever your health condition or circumstances, God is the God of miracles.”

Jeremiah lingered five days, despite what tests showed as a lack of brain activity. Doctors pronounced him dead the morning of Aug. 2. On Twitter, his mother wrote, “I LOVE JEREMIAH DE’SHAWN TUCKER.”

The child appeared to have “died due to complications of his asthma, but the possible neglect angle has not yet been factored into the manner,” a medical examiner’s investigator, Mark Guilbeau, wrote. In a section of his report describing the disposition of the case, Guilbeau wrote, “Suspicious.”

An autopsy found that Jeremiah’s asthma resulted from natural causes.

In its review of Jeremiah’s case, DFCS appeared to blame the mother. She had a history of not obtaining the correct medications, according to the redacted version of the agency’s report, examined by the Journal-Constitution. “It appeared, then as well as now,” the report said, that the mother “failed to either accept the gravity of his illness” or that “medical non-compliance” could affect his health.

Recent efforts to reach Specialle Tucker were unsuccessful.

DFCS said a pediatrician who had treated Jeremiah gave conflicting accounts of whether the mother had tried to keep a “steady supply” of medication for the boy.

But nothing in the agency’s case summary indicates that its workers spoke to the mother about the medication, either before or after Jeremiah’s death. Likewise, the report does not discuss the more than two-year gap between Jeremiah’s reunion with his mother and his death. In particular, the report does not say whether the agency made any effort to help Jeremiah’s mother obtain his medications, or whether it did anything at all to guarantee his well-being during that time.

The case summary said little about the agency’s role in Jeremiah’s death. It said one caseworker had been told Jeremiah’s illness was “not all that significant.” But it doesn’t say who said so, or why. Two employees who handled the 2010 case had left the agency by the time Jeremiah died.

The summary also said the 2010 case file contained little beyond the doctor’s warning. Agency employees did not document why they chose to reunite the boy with his mother.

Late Friday, 16 months after Jeremiah’s death, DFCS made its first public statement on the case. In response to inquiries by the Journal-Constitution, the agency said its decision to return Jeremiah to his mother’s custody in 2010 “was based on information that both the mother and the child’s caregiver had been trained to tend to the child’s medical needs and the mother had taken steps to obtain insurance coverage.”

Several key questions remained unclear: What training did the mother receive? Who was the other caregiver? And did the mother actually obtain and keep insurance coverage?

As is its policy, DFCS won’t say.

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