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RI Child Advocate recommends system overhaul after deaths of four children

The Rhode Island Office of the Child Advocate has made 31 recommendations after investigating four children’s deaths and the near deaths of two other children, all from families known to the Department of Children, Youth and Families.
The Rhode Island Office of the Child Advocate has made 31 recommendations after investigating four children’s deaths and the near deaths of two other children, all from families known to the Department of Children, Youth and Families.
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The Rhode Island Office of the Child Advocate has made 31 recommendations after investigating four children’s deaths and the near deaths of two other children, all from families known to the Department of Children, Youth and Families.

The state advocacy group’s Child Fatality Review Panel said the recommendations pointed out in a 67-page report released Thursday will target systemic issues and will improve the safety of children.

“It is incumbent upon the State of Rhode Island to facilitate a complete overhaul of the current system to better align the model with national best practice standards and to ensure that our child welfare system delivers consistency when it pertains to the assessment of risk and protection of children,” wrote the advocacy group.

Some calls not investigated

While the children (ages two months to 18 months old) in those six cases were not in state custody, all six families were known by DCYF due to previous Child Protective Services reports and all four cases involving fatalities, CPS had been contacted regarding the families prior to their deaths. The calls, however, were never investigated by CPS.

“The prior calls made regarding these families, which were categorized as an information/referral report (I/R) involved reports such as inadequate housing and substance abuse by parents, which in accordance with DCYF policies and state law, should have prompted an investigation, not an I/R report,” said the report. “It was apparent that each call into the hotline, was treated as a unique call, with little to no regard for the case history, prior family or individual involvement with DCYF.”

In one of the cases, an infant death was reported to DCYF afer the baby was found unresponsive in bed with a caretaker and later pronounced dead at the hospital. It was the fifth report to CPS about the safety and well-being of the baby within six months. One of the five reports were investigated by CPS was investigated and flagged for neglect after a caretaker admitted to drinking alcohol and dropping the baby.

"This case closed to DCYF one month later, despite on-going concerns, including struggles with mental health and substance abuse on the part of the parent," said child advocate's report.

Rader Wallack, acting secretary of the Executive Office of Health and Human Services said having a child advocate holds the DCYF accountable.

“Having a strong, independent, engaged Child Advocate provides added accountability to DCYF’s reform efforts," Wallack said in a prepared statement. "I appreciate the work that the Child Advocate and her panel members put into this report. I know that Director Piccola and her team will take these findings into serious consideration.”

DCYF Direcotor Trista Piccola said she plans to meet with Jennifer Griffith, the child advocate, to discuss the report's findings at length.

"It would be very concerning to any director or new director coming in here," she told NBC 10 News. "It's one of those things - and I've said this to the staff - that for me cause me to pause and say, 'Gosh, is anything I'm doing here making a difference?'"

“I am taking the panel’s findings, some of which I find troubling, and recommendations very seriously as I know we all share the same interests in building a better child welfare system for our state," Piccola said. Since I started at DCYF last month, I have taken steps to address some of these concerns—filling vacancies in our frontline staff, starting a thorough analysis of how families enter our system, and finding ways to better support our workforce.”


The panel made a number of findings including that there is a lack of standardized intake process, overuse of the information and referral policy. For example, in an eight-month period, 4,340 calls to the Child Abuse and Neglect Hotline were categorized as an Information/Referral or I/R report. The panel evaluated at nearly half of those calls and found that 486 of those calls met the criteria for an investigation.

For example, five calls were made to the hotline in a two-week period about a family with allegations of physical abuse, sexual abuse and suicide attempts. Those calls were recorded as I/R calls, but were never investigated by DCYF.

Another family with a DCYF history, had five calls into the hotline in a three-month period, but were recorded as an I/R with no follow up, according to the advocate’s report.

“There are just several examples of the hundreds of cases we have flagged involving families with multiple calls to the Hotline in a short period of time, relaying numerous risk factors and claims of abuse and neglect, with no follow through by Child Protective Services.”

Inadequate staffing

The report points to a cry for help over inadequate staffing and a high rate of turnover at the DCYF and points to the problem being brought to the attention of the Senate Task Force with little resolution mainly because the caseloads remain unconscionably high, front line workers continue to be overworked and little support provided to staff. Low staff morale was also brought to the task force’s attention, according to the state advocate report.

“The front line workers are supporting children and families through unimaginable struggle, trauma and grief,” said the report. “DCYF will need to support its staff by hiring additional workers, reducing caseloads to a more manageable level and ensuring that each worker has the proper care and support to continue to perform their job duties.”


The advocate suggested a complete overhaul made clear by the 31 recommendations in the report. Those recommendations include better training, filling vacancies, educating the public and creating better tools to assess and process calls.

Two of those recommendations are about DCYF staff. One suggests that DCYF fill vacancies left empty by social workers, intake and CPS and to be sure that there is enough staffing on each shift, every day of the week. “This was a recommendation made by the prior Child Fatality Review Panel and is being recommended again by the current panel,” said the report.

A second suggestion is that the department reinstitute its training unit to provide better training for incoming DCYF employees, as well as ongoing training to current employees.

The Child Protective Services Unit (CPS) should shift from an incident-based system to a risk-based system by adopting a set of investigation and risk assessment tools that address the needs of children and families at every level of their involvement, with particular attention to the process for kids under the age of six, suggests the advocate.

The state also needs to reinstate the use of the legal supervision by DCYF law which will place the family under the supervision of the Family Court and DCYF so that the family complies with community-based services. This move will reduce the risks to the children and possibly prevent the removal of the child or children from their home, according to the report.

Medical marijuana use by the family needs to be evaluated as a risk factor, similar to alcohol and prescription medication, regardless of its legality, according to the advocate.

The state advocate is also recommending a new public education campaign on the dangers of co-sleeping after three of the fatalities were infants co-sleeping with a caregiver.

"I look forward to working together with the Child Advocate and agency staff, to build on the initial progress made by reform efforts at the Department and to continue to focus on improving outcomes for Rhode Island’s children and families," Piccola said.

Elizabeth Burke Bryant, who is the executive director of Rhode Island KIDS COUNT, a local advocacy group, told NBC 10 that DCYF and the Office of the Child Advocate need to work together to make wholesale changes.

"There are so many different parts of this, so I think what the report does is it comes at a time where we have a new director who's really looking at the system,” Burke Bryant said.

The statistics are eye-opening. According to KIDS COUNT, in 2015 close to 3,200 children were involved in abuse and neglect cases, which is something that the report seeks to change.

"We want Rhode Island's kids to be safe," Piccola said. "There's no question about that."

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