Fatal flaws – Part 2 of 4: Tracking N.H. child deaths linked to abuse or neglect

Four days after Katlin Paquette gave birth to a baby girl, child protection workers were among her first visitors. They came to the hospital to investigate whether her daughter, Sadee Willott, had been born exposed to drugs, agency records show.

Over the next 21 months, child protection met with Sadee’s family 29 more times to check whether the blue-eyed toddler was being physically abused and neglected.

Every report was dismissed, except for the last – but by then it was far too late. When the ruling was made, Sadee had already been dead more than a year.

Paquette told police she was trying to get her daughter to sit down in the bath in September 2015, when she pushed her down, causing Sadee’s head to smack against the cast-iron tub.

Sadee is one of at least 25 New Hampshire children whose deaths have been linked to abuse or neglect since 2010, records show. Most died before reaching their fourth birthdays, having been beaten, poisoned, smothered or neglected by parents or caregivers. In a troubling trend, the number of child deaths has risen steadily – from three in 2011 to 15 over the last two years.

At least eight children died under the watch of the Division for Children, Youth and Families, according to agency records obtained under a right-to-know request.

A Monitor analysis of these cases and interviews with experts reveal problems within the agency meant to keep children safe. Facing increased caseloads and high staff turnover, DCYF rarely substantiates reports of abuse or neglect, provides few prevention services to at-risk families, and occasionally doesn’t follow its own investigation protocols.

Monitor analysis shows:

In 2014, only 4.7 percent of abuse reports in New Hampshire were found to have merit, far behind the national average of 19 percent and last in the country. That year, DCYF substantiated 652 reports, out of nearly 13,900, according to most recently available federal data.

Child protection workers at times failed to interview enough people about abuse and neglect allegations, potentially missing information about a child’s safety or risk.

DCYF no longer has funding to pay for child care, counseling or drug treatment for families who want help – a major gap in coverage, experts say, because prevention services can keep kids safe and reduce stress on the system later on.

Sadee’s case is not unique. Child protection workers often looked into multiple allegations of abuse or neglect in a home before a child died, but rarely substantiated the reports and took action.

DCYF investigated treatment of Christian N’Tapolis and his older brother four times before the 8-month-old Merrimack boy drowned unattended in a bathtub, records show. Agency workers looked into the care of 8-month-old Izik Davis-Miller two months before he died from fentanyl poisoning, after his mother’s painkilling patch got stuck to his abdomen, according to DCYF records.

Health and Human Services Commissioner Jeffrey Meyers declined to speak about specific cases, but he acknowledged the state’s low substantiation rate and said the department is working to address it.

One major problem, stakeholders say, is that allegations can be true, but still labeled unfounded in the current system. Those could include cases where a parent admits to spanking a child or using marijuana, but DCYF determines the action doesn’t meet the threshold to go to court.

While other states have a special label for those kinds of reports – acknowledging that something did happen – New Hampshire does not. Experts criticize the state’s practice, saying any evidence of abuse or neglect should be reflected in a family’s file so workers can look back and spot potential patterns.

“If the incident occurred, intentional or not ... the report ought to be founded,” expert reviewer Jerry Milner, with the Center for the Support of Families, said last December when the center released an outside review of the agency. “We’re seeing fairly often a pattern of not only repeat reports, but a trail of unfounded reports, even if those incidents occurred.”

DCYF faces a difficult task: deciding which children are in such danger the agency should petition the court to remove them from their parents.

Experts say personal judgments should be minimized and decisions should be guided by a tool – a computer-based process that projects a child’s risk based on factors such as adequate food and shelter, history of past reports or the presence of domestic violence and drugs.

DCYF has such a tool, but the results have little bearing on agency decisions, according to the outside review. DCYF took no action against parents in all four “very high”-risk cases surveyed by the review. Sometimes, the tool is not used at all.

Former DCYF workers said a supervisor or attorney’s discretion can determine whether reports are brought before a judge or closed out.

“One person’s interpretation of the law can be one way, and somebody else can look at it totally in a different light,” said Laurie Pelletier, who left the agency last October after working there more than 15 years.

Substantiation rates can vary across offices. Child protection workers in Coos County determined more than 15 percent of abuse and neglect reports in 2012 had merit, while those in Merrimack County substantiated just 5.1 percent, according to a Dartmouth College policy brief from 2014.

Meyers said there’s a lack of common understanding about how child protection laws operate, which he said can be solved through better training for courts and DCYF staff.

Facing a staff shortage and a rising number of reports, DCYF doesn’t always enforce its own protocols, leading to incomplete investigations that remain open far beyond the agency’s deadline. Workers have 60 days to take action on a report or close it out.

Records show a DCYF investigation into the treatment of 2-year-old Noah York was still open on Day 62, which is when the agency got word the sandy-haired toddler had been brutally smothered by his mother’s boyfriend.

While policy requires DCYF workers talk with the child victim, siblings, parents and at least two people outside the home, that doesn’t always happen, records show.

Child protection workers never met with a North Country family at the center of a neglect report in May 2014 because the mother refused, agency records show. Weeks later, she dropped her infant twins out a second-story window and then jumped herself, landing on her son Barry McGuire, who later died of his injuries, according to prosecutors.

It’s reports like those – assigned the agency’s lowest priority level in its three-tier system – that face delays and less thorough investigation, records show.

Overwhelmed by rising caseloads, former workers recall having had to push off work on lower-level reports to deal with incoming high-priority ones, where children can be in immediate danger.

“When you have a Level 1, you say, ‘I must drop everything and see this child,’ ” said Heather Raymond, a former DCYF worker who left the agency last year. “By having these tiers you emphasize the emergency of the Level 1 to such an extent that it’s easy to then de-emphasize the level of 2s and 3s.”

Meyers said he has concern about the three-tier system and plans to look into why child protection workers don’t have access to other tools that can aid in investigations.

Social media, such as Facebook and Instagram, are blocked on most DCYF computers, meaning workers can’t look up a what a parent is posting about their children or home life online.

“There are appropriate uses for social media, and it is relevant to DCYF,” Meyers said. “It’s an area that I am going to be following up on with the Department of Information and Technology.”

For thousands of troubled families, assistance is out of reach.

Experts say prevention can save money and, more importantly, children’s lives. But New Hampshire’s Legislature eliminated funding for such voluntary services five years ago.

Now, only the most problematic parents that DCYF brings to court can get child care, counseling or drug treatment covered by the state. For the thousands with unfounded reports, DCYF can recommend services, but parents have to pay their own way. An agency referral doesn’t bump someone to the top of a waiting list, so families may struggle for weeks before getting into an addiction program or mental health counseling.

“Prevention is such a high priority,” said John DeJoie, with Child and Family Services of New Hampshire. “If we don’t find a way to offer services to these families that want help and need some help, they are just going to wind back up in the protection system, probably with more severe injuries.”

DCYF can’t force parents with unfounded reports deemed unfounded to get help. Over the course of eight DCYF investigations deemed unfounded, Sadee’s family was given a crib, referred to a parenting program and encouraged to have the toddler “followed regularly by a primary care physician,” records show.

One former DCYF worker frustrated by the lack of options said she would keep investigations open past the 60-day deadline to keep checking in on families, scheduling their doctor’s appointments or helping them work through problems.

Becky Carpenter and Evan Thorsell-Cary were basically homeless, living in a single-bed motel room in Rochester, when one of their infant twin sons stopped breathing in May 2016.

The couple had been investigated by DCYF three times prior for neglect allegations, including “unstable housing.”

Though Carpenter said they did nothing wrong, their son Dennis died of sudden infant death syndrome, the couple reluctantly agreed to sign papers admitting to neglect. A finding was the only way they could get DCYF-funded services, she said, which ultimately helped them get off a waitlist and into a two-bedroom townhouse.

“We needed help and we wanted help,” she said. “We didn’t know how else to get help.”

Fatal flaws – Part 1 of 4: Inside the last year of Brielle Gage’s life
Fatal flaws – Part 2 of 4: Tracking N.H. child deaths linked to abuse or neglect
Fatal flaws – Part 3 of 4: DCYF faces staff shortage, heavy caseloads

(Allie Morris can be reached at 369-3307 or amorris@cmonitor.com.)