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An investigation into the involvement of the Department of Children and Families with a 2-year-old girl who died in Auburn and the foster home she was living in concluded that DCF staff did not follow the agency's policies and failed to provide proper oversight of the foster home.
The report revealed "several instances where DCF staff failed to appropriately assess the foster mother and identify risks to the children in her care," and did not properly follow its own policies in approving Kimberly Malpass to be a foster mother.
For the second time this week, Gov. Charlie Baker, HHS Secretary Marylou Sudders and DCF Commissioner Linda Spears held a press conference to discuss problems at the child welfare agency and a plan of action to address those problems.
Additionally, DCF did not take action despite receiving a report that Malpass's boyfriend, who allegedly used drugs and was charged with unarmed robbery, was staying in the Auburn home.
"Today's report unveils a series of failures within the department leading up to the devastating loss of a little girl and the near death of another little girl," Gov. Charlie Baker said. "The failures that are outlined by this report are unacceptable. The failures outlined in this must, and will be, promptly corrected to ensure the safety of other children in the care of the department."
On Aug. 15, Malpass called 911 to report that two DCF foster children in her care were unresponsive. Upon arrival at a Worcester hospital, 2-year-old Avalena Conway Coxon was pronounced dead and a 22-month-old girl was dehydrated, suffering from respiratory failure and was deemed to be critically ill, according to DCF. The 22-month-old girl is now in "stable" condition, DCF said.
At the time of the incident, four other children -- Malpass's three children and another DCF foster child -- were living in her home in Auburn. The foster child was immediately placed in another DCF foster home and Malpass's children were removed from the home by DCF and placed with a relative.
The DCF Case Investigation Unit began a review of all DCF involvement with Malpass and the children in her care. The review found:
- There was not enough physical space to accommodate the children placed in Malpass's home;
- The DCF family resource worker did not follow up on a concern raised by Malpass's children's doctor that she was overwhelmed by managing her own children's medical needs;
- Malpass had been the subject of two previous DCF reports of abuse or neglect, both of which had been dismissed;
- DCF did not assess Malpass's health, her parenting capability and the safety of her home;
- DCF staff charged with supervision and oversight of the licensure process neglected to ensure that DCF policies were followed;
- DCF family resource workers made only half of the home visits required during the first six months after Malpass's home was licensed as a foster home.
Additionally, DCF guidelines governing how many children can live in any one foster home and restrictions on the ages of children in foster homes were not followed in Malpass's case, the review found.
"It shouldn't have been a foster home. If you actually followed the practice standards and the policies that were in place, it wouldn't have ever gotten licensed as a foster home," Baker said. "And even if it had gotten licensed it wouldn't have had as many kids in it as it ended up having in it over that period of time. There was just a policy breakdown there."
Baker was joined Thursday by Health and Human Services Secretary Marylou Sudders and DCF Commissioner Linda Spears for a second press conference on the beleaguered child welfare agency this week.
As a result of the report's findings, two DCF employees involved with the Auburn foster home -- a social worker and a supervisor -- have been reassigned to administrative duties pending the outcome of show cause hearings or further investigation to determine disciplinary action, Sudders said.
The governor said a corrective action plan based on the findings of the Auburn report has already begun to be put in place, including the retraining of all family social workers, supervisors and managers on family resource policies and the foster home licensing procedure.
Each foster home in the Worcester East office will be subject to "an enhanced safety assessment" during its next assessment period. DCF will also modify the foster home approval process to require contact with local law enforcement officials to obtain information related to police and emergency responses to potential foster homes.
"Without exception, child protection workers believe in accountability. Whether systemic challenges or individual action, any factor that plays a role in a tragedy must be fully investigated and addressed accordingly," Peter MacKinnon, chapter president of SEIU Local 509, which represents DCF social workers and supervisors, said in a statement. "This case is no different, and we will continue to work with law enforcement and the Administration to ensure appropriate action is taken."
On Monday, MacKinnon joined Baker to announce steps to improve procedures for tracking children and making sure social workers do not miss any warning signs of abuse and neglect. State officials are working toward reducing the overall number of cases handled by individual DCF social workers and grappling with a series of tragic cases involving children who had interactions with the department.
DCF has been under scrutiny as a result of several high-profile cases including the death of Bella Bond, the toddler whose body was found in a trash bag on Deer Island in June, the 2013 disappearance of 5-year-old Jeremiah Oliver, whose body was later found along a highway in Sterling, and the case of a 7-year-old Hardwick boy who fell into a coma after he was allegedly abused and starved by his father.
On Thursday, Baker contrasted the Conway Coxon case with that of Jack Loiselle, the boy from Hardwick.
"In the Hardwick case, bad policies, old policies, non-policies led to that particular case with that particular young man playing out the way it did," he said. "I would argue in the Auburn case, the policies were there, they were not followed and not executed properly by the people who were involved in licensing and overseeing that foster home."
Though the problems at DCF began before Baker took office, the governor said Thursday that fixing what he called systemic problems at DCF is a priority for his administration, which for months has faced repeated questions about the agency.
"I do not want to be another administration that sort of -- the word I want to use here I can't say on TV -- that just sort of chases what I would describe as a half-baked solution to this problem and hopes it all goes away," Baker said. "We want to be the folks who actually stick with this all the way through and get it right. That will take a little longer than the quick fix."
Report: http://www.mass.gov/eohhs/docs/dcf/reports/case-review-malpass-9-30final.pdf
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