Why No One Saved Gabriel Fernandez

Gabriel Fernandez
Image: LATimes.com

On September 13, 2018, a Los Angeles County judge denied a motion to dismiss felony child abuse and falsification of records charges against four former child welfare caseworkers in the 2013 death of ten-year-old Gabriel Fernandez.  The charges, filed in 2016, marked the first time Los Angeles caseworkers were criminally charged for misconduct connected with their work, and is one of only a few similar cases nationwide.

If Gabriel’s case is one of the few child deaths to result in prosecution of state workers, the egregious nature of the state’s failure explains why. A brilliant article by investigative reporter Garret Therolf shows that for seventh months, evidence of Gabriel’s abuse steadily accumulated. Yet again and again, the Los Angeles Department of Child and Family Services (DCFS) failed to intervene. Some of the worst errors are listed below.

  • Gabriel’s mother had been the subject of at least four calls to the child abuse hotline, had abandoned one child, and had lost custody of a son a year older than Gabriel. Yet, this record was never reviewed by workers investigating multiple reports of suspicious injuries to Gabriel.
  • Each time investigators came to the home, they interviewed Gabriel and his siblings with his mother in the room, against agency policy and common sense. And each time they did so, he recanted his previous statements. Even after he came to school with his face full of bruises from being shot by his mother with a BB gun, he recanted and told the investigator the injuries were from playing tag with his siblings. In the face of visible evidence, the investigators repeatedly chose to believe the repeated recantations
  • Investigators never spoke with neighbors or school personnel (other than the teacher who reported the abuse) but according to Therolf the abuse was known widely among school staff.
  • A computer program had found Gabriel to be at “very high risk” of abuse, requiring that the case be “promoted,” usually involving asking a court to require services or foster care. But the investigator, backed up by her supervisor, referred Gabriel’s mother to voluntary family services. Gabriel’s mother Pearl Fernandez withdrew from these services after three visits.
  • During the brief period of voluntary services, Gabriel wrote several notes saying he wanted to kill himself. Gabriel’s therapist informed the caseworker and supervisor, but they took no action.
  • The therapist had grown concerned that Gabriel was being abused, but her supervisor told her not to call the hotline so as not to jeopardize the mother’s participation in the voluntary case.
  • After three visits, Pearl Fernandez asked for her voluntary case to be closed. The caseworker accepted her decision, stating that there were no safety or risk factors for the children. Contrary to policy, her supervisor signed off on the case closure without reading the file.
  • After the case was closed, a security guard at the welfare office saw Gabriel covered with cigarette burns and other marks and being yelled at by his mother. The called DCFS twice and got lost in the automated system. The 911 operator gave him the non emergency line, which he called. He was later told that a sheriff’s deputy had gone to the home and seen nothing wrong.
  • Gabriel’s teacher, who had lost hope of any rescue from DCFS, called the DCFS investigator one more time late in April when Gabriel showed up looking worse than she had ever seen him. One eye was blood-red, skin was peeling off his forehead, and other marks were on his face, neck and ear. Her call was never returned. Gabriel had only about a month left to live.

Investigators later learned that during the weeks before his death, Gabriel  was spending days and nights locked in a cabinet with a sock in his mouth, hands tied, a bandanna over his face, and handcuffs on his ankles. His solitude was interrupted by vicious beatings and torture sessions in which his siblings were required to participate. On May 22, Pearl and Aguirre tortured Gabriel a final time with a BB gun, pepper spray, coat hangers and a baseball bat. When they finally called 911, paramedics found two skull fractures, broken ribs, several teeth knocked out, BB gun pellet marks, cigarette burns on his feet and genitals, a skinned neck, and cat feces in his throat.

Therolf poses a key question regarding Gabriel’s death: “Was [the] failure …to protect Gabriel an isolated one—the fault of four employees so careless and neglectful that they allowed a child to suffer despite a series of glaring warning signs? Or was it a systemic one, the result of a department so ill-equipped to safeguard children that tragedies were bound to happen?”

While Therolf does not actually answer the question, his report offers a number of key findings and insights that point strongly in the direction of systemic factors as the prime contributors to the failure to protect Gabriel. Therolf found that many of the errors made by investigators, such as failure to interview children alone or to speak with witnesses outside the family, were prevalent in Los Angeles County. Sadly, many of the same failures were evident in the very recent case of Anthony Avalos, also in Los Angeles. And we also see similar failures , and in cases around the country, including Kansas, New York, and Oregon.

The systemic factors that cause these failures fall into two major categories–resource constraints and ideological factors.

Resource Constraints

Child welfare involves a balancing act between too much intervention  or “erring on the side of child safety” as Therolf puts it and too little or “erring on the side of family preservation.”  Striking this critical balance requires a combination of  knowledge, skill, and time. In other words, as Therolf puts it, “it requires a highly trained workforce with the resources to carry out a thorough investigation in every case.” Therolf rightly contends that most agencies don’t have these resources. One has only to read the constant stream of news reports of overwhelming caseloads and poor training of child welfare workers around the country. All of this reflects the unwillingness of taxpayers and legislatures to provide what is needed to protect children. Inadequate funds mean caseloads are too high and salaries are too low, both resulting in low standards for caseworkers.

More funding and could buy both lower caseloads and higher salaries, which are necessary to obtain more qualified investigative workers. After reading so many similar stories, and recalling my own rudimentary training as a Child Protective Services (CPS) worker I am beginning to think that ultimately CPS Investigation should be a specialty in Masters in Social Work Programs. Students would learn advanced interviewing skills and how to assess the truthfulness of children and adults rather than, for example, believing children when they recant allegations with their parents in the room.  Alternatively, CPS Investigations could be folded into the growing field of Forensic Social Work. In any case, a Masters-level specialization could be required in order to be a CPS worker, also adding a needed level of prestige to an important, difficult and hard-to-fill  job.

Ideological Constraints

Inadequate resources might result in a random distribution of agency errors between those that involve too much intervention and those that involve too little. But the dominance of a particular ideology may skew the errors in one direction or another. And Garrett Therolf alludes to the rise of an ideology prioritizing family preservation nationwide and particularly in California during the years preceding Gabriel’s death. This ideology contributed to the decline in foster care numbers around the nation and particularly in Los Angeles, where Therolf reports the number of children in foster care fell from about 50,000 in 1998 to 19,000 in 2013. Much of this decline occurred during the tenure of DCFS administrator David Sanders, who later went on to lead Casey Family Programs, a foundation worth over two billion that has played an outsize role in national child welfare policy. The same year that Sanders took over at Casey, it declared a new goal to reduce the number of children in foster care by half by 2020.

Therolf was right to point a finger at Casey Family Programs. In my post about the death of two children by child abuse in Kansas, I wrote about how Casey leverages its massive wealth to affect policy directly, bypassing the voting public. It provides financial and technical assistance to state and local agencies, conducts research, develops publications, and provides testimony to promote its views to public officials around the country. Through its wealth in an underfunded field, Casey has been able to directly influence policy at the federal, state, and local levels.

Therolf points out that opinions on child welfare often cut across traditional political groupings. While Casey tends to support progressive causes, its emphasis on family preservation is often shared by conservatives who desire to reduce the government’s incursions on parental authority and at the same time to reduce spending. Working together, Casey and the George W.  Bush administration created a waiver policy that allowed child welfare agencies to direct unused foster care funds toward family preservation services–a policy change which created an incentive to reduce the use of foster care. Therolf links this incentive to the drastic decline in the Los Angeles County foster care rolls between 1998 and 2013, stating that “When Gabriel came to the attention of DCFS, the chances of an abused child being placed in foster care were “lower than they’d been in many years.”

Perhaps all of the factors that led up to Gabriel’s death can be summed up by a striking statement by the supervisor on Gabriel’s case, who is currently standing trial in Gabriel’s death. He told Therolf that he had  “concluded long ago that some of the children who depended on the department would inevitably be injured, if not killed.” He expressed frustration that administration and the public expected him to prevent all such deaths. This is not an acceptable attitude. It is true that a child welfare agency cannot prevent deaths among children who are unknown to the agency. But to expect that children will die under the agency’s watch–that is a low expectation indeed. We must do better by our most vulnerable children.

 

 

How to prevent more Hart cases

Hart family
Image: katu.com

In my last post, I discussed the tragic case of the six children adopted by Jennifer and Sarah Hart. The entire family is presumed dead in the crash of their SUV off a cliff in California on March 26. Multiple system gaps resulted in the failure to rescue these children before their tragic death. Below are some suggestions for filling these gaps so that children do not continue to suffer and die in abusive homes.

  1. Improve Vetting of Potential Adoptive Families. States that are desperate to find adoptive parents for large sibling groups or other children with special needs should not overlook obvious red flags. Clearly a past investigation for abuse of an adopted child–as in the Hart case– should have resulted in serious reconsideration of their application to adopt the sibling group that was currently living with them for a trial period. But the home study process should also be sophisticated enough to identify more subtle problems. These might include parents with a “white savior” complex who are adopting for the wrong reasons and are not suited to parent traumatized children.
  2. Monitor adoption subsidy recipients. The Harts received almost $2,000 a month in adoption subsidies, but the children were never monitored to ensure that all was well. All agencies paying adoption subsidies should verify periodically that the children are alive and well and still living in the adoptive home.  Submission of an annual doctor visit report, and/or an annual visit by a social worker could be used for such verification. There has been little support in the past for monitoring families receiving adoption subsidies, on the grounds that adoptive families should be treated the same as biological families. But the addition of money to the arrangement modifies the picture. Adoptive families sign contracts with the state, which could include a requirement that they cooperate with monitoring. When taxpayers are financing the care of our most vulnerable children until they reach adulthood, they should demand that the well-being of these children be regularly monitored.
  3. Regulate homeschooling. The Harts removed all their children from school after their child abuse case closed in Minnesota. The Coalition for Responsible Home Education (CRHE), an advocacy group for homeschooled children, recommends barring from homeschooling parents convicted of child abuse, sexual offenses, or other crimes that would disqualify them from employment as a school teacher. CRHE also recommends flagging other at-risk children (such as those with a history of CPS involvement) for additional monitoring and support and requiring an annual assessment of each homeschooled child by a mandatory reporter.  Unfortunately, the powerful homeschool lobby has beaten back attempts to impose such requirements in many states. But the climate may be changing, with a raft of horrific cases around the country (most recently the Turpins) resulting in proposals to require regulation.
  4. Adopt universal mandatory reporting and educate the public about reporting child maltreatment. If a friend who witnessed abuse by the Hart parents in 2013 or their Washington neighbors had reported their disconcerting observations earlier, the children’s lives might have been saved.  Eighteen states already require all adults to report suspected child abuse; the rest impose this requirement only on specified professional groups. All states should adopt universal mandatory reporting, but more importantly they should inform their residents about the signs of child maltreatment and the need to report. Public information campaigns should emphasize that the reporter need not have proof that there is maltreatment before making a report. As one child advocate puts it, “a reasonable suspicion that a child is at risk” warrants a call to the child abuse hotline. Better safe than sorry.
  5. Make investigations more child-friendly. A family friend who reported that the Harts deprived their children of food as punishment was told that CPS could not verify the allegation because the children had apparently been coached to lie. We need to rectify the pro-parent bias that allows many true allegations of abuse to be unsubstantiated or even not accepted for investigation. Investigators must be required to interview children before they can be “coached” by parents. If children appear to be coached, the case should be kept open until enough information is gathered to ensure they are safe.

The Hart children can be seen as victims of a “perfect storm”–adoption by unqualified parents, home schooling, neighbors who failed to report, history not shared between states, and inadequate investigations.  But it only takes one system failure to kill a child or scar one for life. All of these systemic gaps must be addressed, so that all children can have a real childhood and grow to be happy, productive adults.

 

 

Why Kansas let Adrian and Evan die

 

Dianne Keech, a former Kansas child welfare official and currently a child safety consultant, was asked by the Wichita Eagle and Fox News to analyze case files regarding the highly-publicized deaths of Adrian Jones and Evan Brewer.  I asked Ms. Keech to prepare a guest blog post about the factors contributing to the deaths of Evan and Adrian. She prepared a ten-page document, which you can access here. Below, I highlight some of her conclusions. 

Calls to the Kansas child abuse hotline began when Adrian Jones was only a few months old. There were 15 screened-in reports for Adrian before he was six years old. Out of 15 reports in total that KCF investigated, Keech found that there was only one substantiated allegation of abuse, and that was based on an investigation by law enforcement.  After Adrian was removed from his mother’s custody due to lack of supervision and placed with his father and stepmother, calls alleged that there were guns all over the house, that the stepmother was high on drugs, that Adrian had numerous physical injuries, that he was being choked by his father and stepmother, and that he was beaten until he bled.  Adrian’s father and stepmother consistently denied every allegation and the agency did nothing to verify their stories.  Adrian’s body was found in a livestock pen on November 20, 2015. It had been fed to pigs that were bought for this purpose. It was later found that Adrian’s father and stepmother had meticulously documented his abuse through photos and videos. They are serving life terms for his murder.

DCF received six separate reports of abuse of little Evan Brewer between July 2016 (when he was two years old) and May 2017. These reports involved methamphetamine abuse by the mother, domestic violence, and physical abuse of Evan. Only three of these reports were assigned for investigation and none were substantiated.  In the last two months of Evan’s life, the agency received two reports of near-fatal abuse, one alleging that he hit his head and became unconscious in the bathtub and the other alleging that his mother’s boyfriend choked Evan and then revived him. The first of these reports received no response for six days and the investigator apparently accepted the mother’s claim that the child was out of state. The investigator of the second report also never laid eyes on Evan.  On September 22, a landlord found Evan’s body encased in concrete on his property. Horrific photos and videos documented Evan’s months of torture by his mother and her boyfriend. His mother and her boyfriend have been charged with first-degree murder. 

Looking at Root Problems

Keech believes that there are three root problems that led to Adrian and Evan’s deaths: a dangerous ideology, the pernicious influence of a well-heeled foundation, and faulty outcome measures used by the federal government. These are discussed in order below.

Dangerous Ideology: Signs of Safety is a child protection practice framework that was never officially adopted by Kansas. But Keech alleges that its philosophy has permeated all aspects of child welfare practice in the state. The Signs of Safety framework, according to its manual, seeks to avoid “paternalism,” which “occurs whenever the professional adopts the position that they know what is wrong in the lives of client families and they know what the solutions are to those problems.” Signs of safety links paternalism with the concept of subjective truth, citing  “the paternalistic impulse to establish the truth of any given situation.” According to Keech, this implication that all truth is subjective  means that investigating “facts” is a worthless task.  Workers are encouraged to “engage” parents, not investigate them.  Keech gives numerous examples of how this practice approach left Evan and Adrian vulnerable to further abuse. When Adrian’s younger sister was brought to the hospital with seizures, she was diagnosed with a subdural head trauma that was non-accidental. But when Adrian’s stepmother insisted that Adrian inflicted the injury with a curtain rod, DCF believed her and did not substantiate the allegation–not even finding her neglectful for letting the child be hurt. When DCF received a report that Evan’s mother was using methamphetamine and blowing marijuana in his face, they accepted her denials and closed the case with no drug test required.

Along with a new practice framework, Kansas adopted a new definition of safety. As in many other states, safety in Kansas has been redefined as the absence of “imminent danger.” This is in contrast to “risk,” which connotes future danger to the child. As a result, children can be paradoxically found to be at high risk of future harm but safe–which happened twice with Adrian. (He was found to be at “moderate” risk three times.) As long as a child is deemed “safe,” the child cannot be removed from home. The decoupling of risk from safety explains why both Adrian and Evan were found to be “safe” 18 times in total, when they were anything but. This is a common situation in many other states. “Risk,” on the other hand, triggers an offer of services, which can be refused, which is what Adrian’s father and stepmother did when he was found to be at risk. I’ve written about the case of Yonatan Aguilar in California, who was found four times to be at high risk of future maltreatment but “safe.” His parents refused services. He spent the last three years of his life locked in a closet until he died.

Pernicious Influence: Casey Family Programs is a financial behemoth with total assets of $2.2 billion. Its mission is to “provide and improve, and ultimately prevent the need for, foster care.'”Over a decade ago, Casey set a goal of reducing foster care by 50% by the year 2020.  Casey works in all 50 states, the District of Columbia, two territories and more than a dozen tribal nations.  It provides financial and technical assistance to state and local agencies to support its vision. It conducts research, develops publications, provides testimony to promote its views to public officials around the country.  As Keech puts it, “There is not a corner of child welfare in the United States where Casey is not a highly influential presence.” Keech has experienced firsthand Casey’s efforts to pressure Kansas to reduce its foster care rolls.  At a meeting in that Keech attended in 2015, Casey used “peer pressure” to “shame one region for having a higher foster care placement rate.  Casey adopted and promoted the Signs of Safety approach discussed above.

Faulty Federal Outcome Measures: The Child and Family Services Review (CFSR) is an intense federal review of the entire child welfare system.  If a state does not pass the review (and no state has passed, to date) then the state must agree with the federal government on a Program Improvement Plan (PIP) or lose funding. Keech feels that the federal reviews can be manipulated by states to improve their outcomes at a cost to child safety.  For example, one of the two measures of child safety is timely initiation of investigations. When a hotline screens out a report (as was done three times with Evan)  or a case manager fails to report a new allegation (which was done three times while Adrian had an open services case) the agency does not need to worry about timely initiation of an investigation. Another CFSR outcome is “reduce recurrence of child abuse and neglect, ” which is measured by calculating the percentage of children with a substantiated finding of maltreatment who have another substantiated finding within 12 months of the initial finding. This outcome can be improved by failing to investigate reports, or investigating them but failing to substantiate. Only one of the allegations involving Adrian was substantiated; three of the allegations involving Evan were not even investigated and the other three were not substantiated. By not substantiating allegations, Kansas reduces its recurrence rate. 

The factors that Keech discusses are not unique to Kansas and are occurring around the country, in states including most of America’s children. All of these states should consider Keech’s recommendations for protecting Kansas’ children from the fate of Adrian and Evan.  Most importantly, states need to prioritize the safety of children over and above any other consideration.   The primary goal of child welfare must be the protection of children, not reducing entries to foster care. The artificial division between risk and safety should be eliminated and risk should be allowed to inform safety decisions. States must treat substance abuse, domestic violence, criminal activity, mental health issues, and parental history of maltreatment, as real  threats to child safety. Workers must be empowered and required to gather all of the information needed to determine the truth of allegations, not rely on adults’ self-serving denials. And they must be allowed–and required–to request out of home placement when there is no other way to protect a child.