Sounding Board (June 2023): Lessons from Child Fatality Reviews in Washington State

Sounding Board (June 2023): Lessons from Child Fatality Reviews in Washington State

originally published by Dee Wilson in June 2023


Washington State law requires a review of suspected child maltreatment deaths when there was an open or recently open (within 12 months of the child’s death) child welfare case. To fulfill this mandate, the Department of Children, Youth and Families (DCYF) organizes a small committee consisting of two or more DCYF staff, a representative of the Office of the Family and Children Ombuds (OFCO), and community professionals from various agencies, including law enforcement, substance abuse, domestic violence, and mental health agencies, as well as tribal representatives depending on the case. These reviews are posted online and can be accessed at “DCYF Child Fatality Reviews, Washington State” using the ‘Child Welfare’ link.

In addition, every year or two OFCO disseminates a report on child fatalities  which summarizes aggregate maltreatment death data of children known to DCYF either prior to or following a child’s death. The OFCO report also discusses the characteristics of deceased children and their families and makes recommendations for changes in policy or practice.

Child maltreatment fatality is a low base rate phenomenon that one might expect to be highly variable from year to year. Surprisingly, the annual number of child fatality reviews (CFRs) on suspected child maltreatment deaths has been remarkably stable during the past several years (14-16 per year), with the exception of 2020, the first year of the pandemic when there were 9 CFRs and 2018, the peak year with 21. The number of suspected child maltreatment deaths of children known to the state’s child welfare system in the 12 months preceding a child death and subsequent to death has been about 35 per year for most of the past decade.

It is worth noting that OFCO also tracks reports of near fatalities, and these numbers have greatly increased in recent years, which might reflect an increase in incidence or improved classification and reporting of these cases. The total number of child maltreatment deaths in Washington is unknown as there is no requirement to report suspected child maltreatment deaths when there are no surviving siblings in the home. There is no public agency charged with the responsibility of tracking all child maltreatment deaths in Washington.

I reviewed 38 CFRs conducted from 2020-2022 in 39 suspected child maltreatment deaths. Numbers of CFRs in a specific year vary slightly from the number of suspected maltreatment deaths because deaths that occur in the last quarter of the year may not be reviewed until the following year.

Characteristics of child victims and their families

The profile of children in this sample who died of suspected maltreatment is much the same as in other states and nationally:

  • A large majority of children who die due to maltreatment are 0-4; 40-45% of victims are infants, 0-1.

  • Most child maltreatment deaths involve some type of neglect; almost a third of child deaths in this sample were due to unsafe sleep practices with infants.  A small number of children died due to fentanyl ingestion, drowning, car accidents while driving with an inebriated or substance abusing parent, or malnutrition.

  • At least two of the malnourished children were deliberately starved by a parent over a period of months or years, while another baby left in the care of friends by a young mother was not adequately fed, in part because the caregivers spent their resources on drugs rather than food for the baby. The precise ratio of abuse to neglect related deaths depends on how   deaths from malnutrition are classified, i.e., as abuse or neglect related deaths.  Denial of food and water over a prolonged period of time should be classified as torture, a type of abuse that frequently includes beatings and dehumanization of the child.

  • 13 children died from assault which, in one case, included waterboarding, as well as other forms of torture of a 6-year-old boy.

  • One child died in a foster home from unsafe sleep practices; two adopted children died, one from drowning, another from deliberate starvation of a 15- year-old disabled youth.

  • A significant percentage of families had combinations of parental substance abuse, chronic mental health conditions, and/or domestic violence (DV)  (“the big three” of child welfare) along with poverty.

  • More than a third of the families had extensive child welfare histories of 6 to 26 child protective services (CPS)  reports, counting both screened in and screened out reports over a period of many years. In these chronically referring families, most of the reports were on siblings rather than the deceased child, though several cases had multiple reports on child victims, 0-2. There were only 12 cases with 1-2 CPS reports prior to a child’s death.

  • Child victims are disproportionately Black or Native American. According to the 2022 OFCO report, “Child Fatalities and Near Fatalities in Washington State,” in 2021 8.6% of child victims were Black vs. 5.1% of the state’s child population. 17.1% of deceased children were Native American compared to 2.4% of the child population.

The challenges of child protection

It is next to impossible for anyone with experience in child protection to read a large number of summaries of child maltreatment deaths on open or recently open child welfare cases without becoming harshly judgmental regarding CPS practice in some cases. In several cases, CPS actions and inaction contributed directly to a child’s death; and in several other cases, CPS interventions were inept and sometimes not even conscientious. There were also a few cases where CPS caseworkers did exemplary work, even though children died, e.g., in the case of a mother who killed her twin girls and then committed suicide, events that could not have been reasonably foreseen by child welfare staff. In other words, there was a wide range of competence in child protection evident in CFR’s varying from unconscionably inadequate to excellent practice, and much practice that CFRs refer to as “lacking curiosity” or demonstrating an absence of critical thinking.

Learning practical lessons from child maltreatment deaths is impossible without tempering judgmental reactions through recognition of the legal context and challenges of child protection. CPS is a tough job even for experienced caseworkers, and many of the caseworkers were not experienced. They sometimes lacked basic knowledge of essential subjects such as substance abuse, DV, mental illness, chronic multitype maltreatment, attachment, malnutrition, and child torture. They often worked in offices with vacancies and extreme workload pressures that reduced their ability to have consistent contact with families after their initial investigative contacts had been completed, or to make collateral contacts.  As a result, caseworkers often quickly lost touch with the turbulent lives of families, and rarely followed through on safety plans as needed.

The troubled families they worked with were highly mobile, making parents difficult to locate. Persons living in the home changed frequently without caseworkers’ knowledge, often undercutting monitoring of child safety. Shelter staff in adult facilities sometimes shielded parents from CPS and did not inform caseworkers when parents left the shelter. In one case (A.C.G.), a court reunified an infant severely abused by his father and dismissed the dependency over the objection of DCYF after the mother separated from the father. The parents reunited within several months of dismissal of dependency. CPS knew of the father’s presence in the home but did not seek to remove the toddler who was murdered by the father in Mexico a few months later.

There were several instances in which a CPS case was opened for investigation or FAR assessment after a positive tox screen was reported by a hospital.  In several of these cases, there were no legal grounds for child removal and no services readily available that would have met the needs of a chronically ill or disabled child. In several cases, the casework that preceded a child death from unsafe sleep practices left much to be desired but was nevertheless not a direct contributor to a child’s death.

Few of the parents consistently engaged in services, and some parents  were resistant to services or any contact with CPS caseworkers. Even when parents participated in substance abuse treatment, there was little or no effect on parents’ use of drugs or alcohol. In summary, caseworkers (many who were inexperienced) under extreme workload pressures were charged with protecting young children in families whose caregivers had untreated or ineffectively treated substance abuse and mental health conditions, as well as periodic DV, and without essential support services for disabled and chronically ill children, and sometimes without the cooperation of shelter staff and other key community professionals. In these circumstances, it’s surprising that there were not more child maltreatment deaths. The responsibility for child maltreatment deaths in open or recently open cases does not solely lie with inadequate CPS interventions; there is plenty of blame to share with other agencies, the courts and policymakers.

Lessons from child fatality reviews

Child welfare staff who cannot recognize and do not understand the following types of child maltreatment cannot possibly protect children living in unsafe homes:

  • Physical abuse that begins with minor sentinel injuries and becomes more severe as a caregiver is gradually desensitized to the physical and emotional harm inflicted through harsh punishment. Some children died after intake staff or CPS caseworkers ignored clear signs of danger. An 11- year-old girl (R.M.) living in a home with chronic multitype maltreatment supposedly died from choking on a piece of candy a few months after telling school officials she was afraid to go home and 17 months after CPS intake screened out a report of the mother choking the child “to toughen her up,” based on the rationale that the child’s pain was “transient” and because the child said her breathing was not impaired.  Law enforcement suspected that the child’s death was not accidental. I question whether this child was ever safe at any point in her brief life, though CPS did nothing to protect her despite 11 CPS reports (most screened out) and her pleas for help.

  • Deliberate starvation of a child over a period of months or years. Two children died after afterhours staff and CPS caseworkers did not recognize that a child was malnourished and possibly starving and did not take the child to an emergency room or seek medical consultation. CFR committees did not call out systematic denial of food and water as a type of torture, though there have been more than a dozen child deaths due to denial of food and water and other types of torture in adoptive homes in Washington since 2005. OFCO issued a report on this subject in 2012.

  • Chronic multitype maltreatment that includes neglect, physical and often sexual abuse and emotional abuse and neglect  in homes with substance abuse, mental illness, and interpersonal violence.

Seven cases had 11-26 screened-in or screened-out reports beginning when their children were infants and continuing into the adolescence of older siblings. For the most part, child welfare caseworkers gave little weight to these extensive report histories, all of which involved chronic multitype maltreatment. In one hard to believe example, caseworkers allowed parents with 20 CPS reports over the past two years and whose older children were legally dependent and in foster care to retain custody of an infant born after the older children were made legally dependent. The child died within 2-3 months of birth from unsafe sleep practices despite conversations with the parents re safe sleep guidelines for infants.

In summary, many caseworkers were conceptually ill-equipped to recognize or effectively respond to safety threats, and they made little use of the Structured Decision Making (SDM) risk assessment tool or the agency’s safety framework to inform their decision making. CFRs frequently refer to inaccurate information on risk assessment forms and an absence critical thinking about child safety. Most caseworkers were more influenced by their impressions of parents from one or two home visits than by information in voluminous case records. They were also usually focused on the most recent alleged incident of maltreatment rather than patterns of maltreatment that had occurred for months or years.

In-home safety plans

One of the most important lessons from CFRs is that in-home safety plans are not a reliable way of protecting young children’s lives when parents have co-occurring substance abuse and mental health disorders, often combined with DV.  The Plan of Safe Care required when an infant has had prenatal substance exposure does not – and in my view cannot – protect infants from unsafe sleep practices, fentanyl ingestion, car accidents caused by drunk driving or a wide variety of accidental injuries.

The CFR on D.B. (2021) states: “The committee opined that it is necessary for caseworkers to actively monitor safety plans. … ineffective and/or insufficient safety planning and monitoring is a concerning trend within the agency. … the Committee discussed the disconnect between what is learned in training versus how the training concepts are applied to actual cases.” And “The committee finds that the safety plan monitoring policy was not followed in this case and that many agency staff are not proficient in developing effective safety plans.”

Safety plans cannot work without a parent or caregiver actively cooperating with the caseworker, service providers and safety monitors and without conscientious weekly (at least) follow-up by caseworkers in implementing plans. These  elements of effective safety planning were rarely present in the CFRs I reviewed.  Parents moved frequently and were often difficult to locate. Safety monitors lost touch with the family or did not follow the safety plan. Caseworkers did not conscientiously check on the status of safety plans and when parents violated the plans (a common occurrence) there were no consequences.

Even when caseworkers followed safety planning guidelines, they did not prevent deaths caused by unsafe sleep practices. Informing parents of safe sleep guidelines and observing a baby’s sleeping arrangement often fails to prevent parents with substance abuse or mental health challenges from co-sleeping with their baby to meet their emotional needs. Co-sleeping with infants  is dangerous when a parent is misusing drugs or alcohol.

Safety planning is the weakest element of CPS practice, both in Washington and nationally. Public agencies need to develop partnerships with child welfare scholars to strengthen safety planning, which is currently endangering the lives of young children.

Support services for disabled and chronically ill children

Children at highest risk of maltreatment deaths are disabled or chronically ill and present difficult childcare challenges for any caregiver, much less a parent with serious functional impairments due to substance abuse or mental illness. CFRs reveal a distressing lack of caseworkers’ interest and attention to the special needs of these children. The effectiveness of child protection can be greatly improved through intensive support services provided by case aides, and nurses designed to reduce parents’ childcare burden and build their capacity to nurture young children with complex medical needs. Risk and safety assessments should give clear-eyed attention to the fit between children’s special needs and parental impairments, with an awareness that a child’s life may be at stake. Service plans should make the maximum possible use use of childcare, respite care and crisis nurseries provided from birth until until children are old enough for Head Start or kindergarten.


Next month’s Sounding Board will discuss the strengths and limitations of CFRs as a means of preventing child maltreatment deaths, and will consider some of the recommendations from these reviews. ©


Child Fatalities and Near Fatalities in Washington State, Washington State Office of Family and Children’s Ombuds, August 2022

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