‘Gaps’ led to children’s deaths, DFCS admits

Accident: 33 (20 percent)

Homicide: 24 (14 percent)

Suicide: 10 (6 percent)

Pending investigation: 4 (2 percent)

Undetermined: 44 (26 percent)*

* Thirty-nine of the 44 cases for which a manner of death could not be determined involved children less than 1 year old. All 39 died in inappropriate sleep situations, DFCS says.

Source: Georgia Division of Family and Children Services 2014 child fatality analysis

For the first time, Georgia's child-protection agency is acknowledging that "significant gaps" in its performance have contributed to the deaths of children under its supervision.

The admission appears in a new report analyzing deaths in 2014 of children whose families had histories with the Division of Family and Children Services, or DFCS. The report counted 169 such deaths, down from 180 in 2013.

But in the report and in interviews last week, DFCS officials identified serious problems in how the agency investigates reports of child abuse and neglect. DFCS had closed cases on the families of about half the children who died in 2014. Fourteen died in homicides — six in the first 12 months after DFCS ended its involvement with their families. The rest of the children, including nine homicide victims, were in families under active DFCS supervision.

Heaven Woods, for example, was the subject of an abuse report in May 2014 — the ninth involving her family in the 5-year-old’s lifetime. DFCS took no action after a cursory investigation, and Heaven was beaten to death three weeks later.

The new DFCS report, in a section headed “Systemic Factors,” said the agency “recognized significant gaps in the delivery of services and meeting the expectations of the citizens of Georgia.” It added: “Special consideration should be given to lessons learned from child deaths.”

This year, the agency is introducing a new "practice model" intended to guide caseworkers dealing with volatile families suspected of maltreatment. It also will begin meeting with every child who is the subject of an abuse or neglect report before deciding whether to open a formal investigation or refer the family to less-intrusive services, such as parenting classes or counseling.

For now, DFCS Director Bobby Cagle said, the agency faces “a recipe for disaster” created by persistently high caseloads and a 36 percent annual turnover rate among its caseworkers. “That does not make providing high-quality services a realistic outcome,” Cagle said.

In past years, DFCS occasionally admitted mistakes, especially in death cases that attracted news coverage. Even then, it usually blamed specific employees for oversights. Children's advocates said they could not recall the agency's assigning blame to fundamental flaws in its own operations.

The agency assumes this new posture as it continues to deal with the legacy of a decade of budget cuts. It has 20 percent fewer caseworkers than in 2006, but maltreatment reports have mushroomed. In 2014 alone, DFCS logged 102,003 reports, about 25,000 more than the year before.

To handle the higher volume, DFCS wants to hire 175 additional caseworkers and supervisors. Still, the average worker would have 18 cases, more than the 15 that social work experts consider ideal.

The report on 2014’s deaths underscores the agency’s challenges.

DFCS received reports of 296 children’s deaths in 2014, including the 169 from families that had contact with the agency during the previous five years. Almost one-third of the 169 children died from natural causes. But caseworkers substantiated abuse or neglect of about half the children, either at some time before they died or in connection with their deaths. Homicides accounted for 14 percent of the deaths; suicides for 6 percent; and accidents, many of them preventable, for 20 percent.

Authorities could not determine the manner in which 44 children died – 26 percent of the total. Thirty-nine of those children were less than 1 year old, and all 39 died in improper sleeping situations, such as sharing a bed with a parent. In a majority of sleep-related deaths, parents or other caregivers had allegedly used drugs when the family was under DFCS supervision. DFCS, the report said, “believes the majority of these deaths were preventable.”

DFCS’ new “practice model,” developed by a consulting firm, is intended to guide caseworkers in assessing how much risk children face in their homes. For decades, the agency has swung between two extremes: aggressively removing children from families, or leaving them at home even when red flags were apparent. Now, Cagle said, the agency will train workers to “engage” with families to ensure the best outcomes for parents and children. The first step will be to “normalize” behavior in tense situations, Cagle said, partly by mixing positive reinforcement with the hard questions workers must ask about a child’s wellbeing. The workers, he said, will make clear that they “are not in there only to take children away, but to help families.”

The agency will begin using the new approach this year in Fulton and DeKalb counties before expanding it statewide. Fulton and DeKalb comprised the region that recorded the most deaths of children whose families had DFCS histories – 24 – and has historically experienced some of the toughest cases.

“This will introduce a more consistent and substantial framework into our practice,” said Ashley Fielding, a DFCS spokeswoman. “Every situation is not going to fit into a particular policy. But (caseworkers) can feel empowered to make a decision based on the tenets of the practice model.”

While acknowledging systemic problems, Cagle said his agency’s workers often succeed, protecting children who might otherwise suffer serious injury or death.

Quantifying those successes, however, is impossible.

“If we weren’t doing what we do,” Cagle said, “where would we be?”