Tag: child fatalities

Would a broader birth match have saved Antoine Flemons?

Antoine Flemons 3
Photo from GoFundMe fundraiser by Geneva Flemons

Little Antoine Flemons never had a chance. Prince George’s County Maryland Prosecutors described how his father, Antoine Petty, “dangled the infant by the arm and repeatedly struck him before handing the baby to his mother to feed. When the baby continued to cry, Petty dealt another round of blows, quieting the child forever.”

Antoine’s parents left his body in the car for over 24 hours before burying him, according to police.  The Judge sentenced Petty to 40 years in prison for his son’s murder. Antoine’s mother pleaded guilty to involuntary manslaughter and will be sentenced in December.

Information shared by the prosecutors revealed that Petty, the father of nine, had a long history with Child Protective Services dating back until at least 2007. He was reported for carving a three-inch cross into a five-year-old daughter’s arm, pushing a five-year-old down stairs, giving a ten-year-old a black eye, forcing a daughter to watch him having sex with a girlfriend, and failing to adequately nourish an eleven-month-old. One of his children was found at age 11 months to have rib fractures which were found by a doctor to be ‘not accidental.”

How could this father be allowed to mistreat child after child and this mother to fail to protect them for close to ten years when so many acts of maltreatment were reported to CPS? It would be more appropriate to ask how such a parent can be stopped. When an abusive parent has a new child, there is no mechanism in most states to trigger protection for that child.

Interestingly, Maryland is one of the few states that does have such a mechanism– a “birth match” program. Under birth match, birth records are matched against a list of parents who had their parental rights terminated within the last five years due to abuse or neglect. Parents thus identified receive a visit from a social worker to assess the child’s safety. If the parents refuse the visit, a case can be opened if there is reason to expect abuse or neglect.

But Maryland’s birth match law did not protect little Antoine. It is unlikely that his parents had their rights terminated in the past. Perhaps Antoine would have been protected by a broader law, such as Minnesota’s, which triggers an investigation or family assessment under a broader set of circumstances. These include when a parent has subjected a child to “egregious harm,” has failed to protect a child from such harm, has committed child neglect endangering physical or mental health, and has committed first second or third degree assault among others.

We don’t know if a broader birth match law would have protected little Antoine because no information has been released about the results of the prior investigations against Antoine’s parents.

As I discussed in an earlier post, all deaths of children in families known to CPS should be investigated immediately and the results made available to the public. Only with such an investigation can we know how and why the system failed little Antoine.

There has been a shocking lack of calls for such an investigation from Maryland legislators and child advocates. Only  the Washington Post broke the silence, asking, Could this 2-months old’s death have been prevented? Nobody who cares about children in Maryland should rest until they know the answer, and until measures have been put in place to prevent similar tragedies in the future.

To Prevent Further Tragedies, Require Immediate Fatality Reviews

On November 6, 2016, Trinity Jabore was born in the District of Columbia with marijuana in her system and weighing less than five pounds. On December 25 of the same year, Trinity’s lifeless body was taken to the morgue. A pathologist determined that Trinity’s brief life had been one of suffering. She weighed less than her birthweight, she had multiple fractured ribs, and she died from consuming water that had been mixed with condensed milk.

Soon the Washington Post learned that the District’s Child and Family Services  Agency (CFSA) had received multiple calls reporting neglect of other children born to Trinity’s parents. The final call occurred early in the month of her death. A teacher reported that her brother had showed up in school with a bruise under his left eye and stated that his mother had punched him because he “wasn’t listening.” Three weeks later, the investigators had talked to the brother but had not managed to contact his parents. They were still “trying to make contact” when Trinity died.

Trinity’s story is unfortunately very familiar. I have written about the deaths of Zymere Perkins in New York and Yonatan Aguilar in Los Angeles. A recent series published in the Fayetteville Observer revealed that more than 120 North Carolina children have died within a year of a child maltreatment report.  Each of these deaths is the tip of the iceberg of system failure. We have no idea how many children are suffering in toxic homes as you read this column. Tonisha Hora was left in an abusive home for ten years despite repeated calls to CPS about her plight and that of her sister.

The first response to Trinity Jabore’s death should have been for an independent panel to conduct a comprehensive review of her parents’ prior contacts with the child welfare system to determine how she was left unprotected . This review should have been conducted immediately and included recommendations to prevent such tragedies in the future.

Unfortunately, Trinity has been dead for 9 months and no such review has been released. Like other jurisdictions, the District of Columbia has a Child Fatality Review Committee, upon which I serve. But I have been disappointed by the long lag times and lack of thoroughness of these reviews.

The Committee is about to issue its annual report, which will contain reviews of deaths that occurred between 2012 and 2015. It takes some months for the panel to receive notice of child deaths and all the relevant information including pathology reports. Because the panel is understaffed, there is a further delay after cases are received. The District of Columbia Auditor recently found that the percentage of child deaths reviewed by the CFRC has been declining as the panel’s budget has been cut drastically. Similar issues plague other child fatality review teams, such as the one in North Carolina.

There is another problem with child fatality review panels as a mechanism for reviewing systems’ failure to identify children at risk. In about half the states, these teams review all child fatalities, not just those that are due to child maltreatment, or those of children known to child welfare agencies. The District’s panel reviews all fatalities of young people aged 18 and younger, including all premature infants, gun violence victims, children with terminal illnesses, and accident victims. It does not review the actual files but brief summaries provided by overworked CFRC staff. And Trinity’s death will be mentioned only briefly in an annual report devoted to all of the child deaths that were reviewed in the same year.

An internal CFSA review has probably already occurred, but the public will not know about it for some time. It was  in April 2017 that the agency released its review of child deaths occurring in 2014 and 2015. Moreover, Trinity’s death will  be folded into a report on all deaths of children known to CFSA within four years of their death–a total of 30 deaths in 2015.

The death of a child known to the system should be treated like a plane crash or the loss of the space shuttle Challenger. It should be reviewed immediately and exhaustively by experts of the highest caliber. The point is not to allocate guilt or punishment but to change policies or practices to save children in the future.

In the State of Washington, the Children’s Administration (CA) conducts a review when the death or near-fatality of a child was suspected to be caused by child abuse or neglect, and the child had any history with CA (including a hotline report that was not investigated) at the time of death, or in the year prior.  The review committee is made up of individuals with no prior involvement with the case, and typically includes CA staff, ombudsman staff, and community professionals selected from diverse disciplines with expertise relevant to the case. The review committee has full access to all records and files relevant to the review. The agency must release review results within 180 days following the fatality, unless granted an extension by the Governor.

These reports are subject to public disclosure and must be posted on the Department’s website. The Department is authorized to redact confidential information contained in these reports.  In order to promote accountability and the consistent implementation of recommendations, the state’s family and children’s ombudsman is required to issue an annual report to the Legislature that includes an update on the implementation of recommendations issued by fatality review committees.

Every state or other relevant jurisdiction should follow Washington’s example and require a thorough, immediate independent review of all all cases of children children who die, are seriously injured or disappear (as in the case of Relisha Rudd in the district of Columbia) when there is a family history with CPS. This should be a requirement for federal funding.

No more children should suffer because of agency incompetence, extreme family preservation ideology or underfunding. Let us take the first step and ensure all of these terrible cases are investigated immediately and acted upon fast.