A special committee that reviewed what role DHS had in child deaths since 2010 identified problems at the agency but also concluded there appeared to be “much blame to go around.”
In a report released Thursday, the committee made 37 recommendations that could help prevent child deaths.
At the top of the list was a call for better cooperation between child welfare workers at the Department of Human Services and judges, public defenders, district attorneys, educators, health officials, law enforcement and others.
“It is not just OKDHS who is responsible to protect children,” the committee reported.
The committee also called for training for teachers, doctors, day care workers and others in identifying and reporting child abuse and neglect.
In one child death case, both an apartment manager and assistant apartment manager had urged a mother to get medical help for her child but neither “called authorities to report the seriousness of the child's obvious frail, listless physical condition,” according to the 38-page report.
DHS commissioners created the special review committee in 2011 after being heavily criticized for not publicly addressing the deaths of children in DHS care. A new commissioner, Wes Lane, took charge of the special committee and recruited experts from outside the agency to help in the review.
The special committee finished the report even though voters in November abolished the DHS commission.
The special committee looked broadly at 135 cases of child deaths and near deaths between January 2010 and mid-2012.
It then selected for an in-depth review 31 of those cases where a child died from abuse or neglect and DHS had some level of involvement with the family in the previous 12 months. Only one of those children actually was in state custody at the time of her death.
The committee also did an in-depth review of five cases of near child deaths.
“Our role was not to serve as a proverbial judge and jury as to who did what in each case but rather to ask larger questions,” Lane, a former Oklahoma County district attorney, told reporters Thursday.
DHS officials said the agency already is making major changes to its child welfare practices. Those changes include hiring more child welfare workers, paying the workers more and reducing their caseloads.
DHS agreed to make many of the reforms when it settled a class-action lawsuit over the care of foster children.
The Legislature also required changes.
“I'm upbeat,” Lane said. “I'm upbeat about where things are going. I'm encouraged. I hope the public is, too.”
In a letter at the beginning of the report, Lane wrote, “Was OKDHS doing everything it could possibly do to protect children? The answer is clearly, no. Are they working hard to correct that? The answer is clearly, yes.”
New DHS Director Ed Lake said the agency is trying to support its child welfare workers and help them make decisions.
“As we like to say: ‘We're all in this together,'” Lake said.
The committee called for better cooperation among those involved with at-risk children because it found failures to communicate in cases resulted in serious consequences.
“On several occasions, case workers would have benefitted from receiving information, histories known by other agencies such as courts, police, school, etc.,” the committee reported. “In one case, the court was not provided with significant information related to the well-being and safety of the child, resulting in the death of the child.”
The committee also found cases where judges did not follow DHS recommendations, resulting in child injury or death.
“We found our entire government ‘system' at times inadequate,” Lane wrote in the letter.
The committee reported many times DHS caseworkers committed extraordinary acts of kindness and behaved with consummate professionalism.
It also noted, though, that frequently in the cases, a child welfare worker did not implement an “obvious step.”
“While there is a tendency to label this as a ‘lack of common sense' on the part of the caseworker, it may have been the result of many complex factors: lack of experience, lack of a feeling of empowerment by the worker, fear of termination if a bad outcome results, fear of media, etc.,” the committee reported.
The committee expressed serious concerns that children were injured or died because DHS policies left them in homes where drug abuse and domestic violence may be present.
“Occasionally, child death cases involved a situation where both the newborn and birth mother tested drug positive and were allowed to go home from the hospital together. In some of those cases … OKDHS had recommended treatment as part of safety plan but there was not clear follow-up and/or additional monitoring to ensure safety,” the committee reported.
“Sometimes there was a tendency to ignore drug abuse in the home because the ‘medications were prescribed,'” the committee also reported.
The committee concluded DHS workers need to have the authority to order parents to get drug tests. “We saw a lot of times we wish they could have,” Lane said.
The committee called for DHS to be more consistent in whether newborns who test positive for drugs are removed from their homes. “Indeed, children must be removed when certain drugs are being used by the mother,” the committee wrote.
The report disputes a claim by two legislators in an October 2011 news release that “50 children — on average — continue to die annually” under DHS care.
“What we actually found was that over a 10-year period, there were an average of 12 children who died each year in state custody, and the majority died from natural causes or of the injuries they suffered at the hands of their abusers,” Lane said.
The special committee is known to have reviewed the high-profile death of Serenity Deal but it did not name any children in its report.
Serenity is the 5-year-old girl whose death in June 2011 sparked public outrage against DHS.
Serenity's father killed her less than a month after she began living with him full time at his Oklahoma City apartment at the recommendation of DHS workers. She was placed with her father even though she had been injured twice in January 2011 during overnight visits with him.
She had been in foster care. After her death, DHS workers fired two child welfare workers for mistakes made in the handling of the case.