44 children left in harm's way: Oregon's child welfare agency struggled to fix problems

Barely three days after 12-year-old Caden Berry of Keizer died, the head of Oregon's child welfare agency ordered a full review of the agency's interactions with his family.

Caden's mother, Amy Marie Robertson, has been charged with murdering her son. Clyde Saiki, director of the state Department of Human Services, wanted to know if "system issues" may have prevented the state from saving the boy's life.

DHS has publicly published reviews for at least 44 children since 2004, involving children the agency knew of who died or were severely injured. These Critical Incident Response Teams (CIRT) mostly consist of DHS staff and can be called together at the discretion of the DHS director. That's what happened in Caden's case, though DHS hasn’t published a report on his death yet.

A Statesman Journal review of DHS' published CIRT reports shows that even after investigators pointed out problems, the agency struggled to implement solutions.

The Statesman Journal's review of the reports found:

• In at least 15 cases, investigators identified problems in state workers' comprehensive assessments. Those deal with how thoroughly child protective services workers determine a child's safety within state guidelines. 
• In a combined 12 cases, lack of foster care screening, incomplete background checks or lack of screening for those close to the child were cited.
• Investigators reported a lack of progress in 10 cases. 
• State employees failed to follow up on complaints with face-to-face contact in at least eight cases. Some complaints were closed at screening; others were handled over the phone.

The reports do not claim to be the final say on how a child died or is injured.

"A CIRT is not intended to be a fact-finding or forensic inquiry or to replace or supersede investigations by courts, law enforcement agencies or other entities with legal responsibility to investigate or review some or all of the circumstances of the child fatality," according to a recent report.

But one of the proponents of the CIRT system said the self-reviews aren't doing enough.

"It hasn’t been as effective as it should have been," said Sen. Sara Gelser, D-Corvallis, who sponsored the bill in 2007 that put CIRTs into statute. "They have not been comprehensive.”

Gelser has introduced a bill to update the law on CIRT reports. Senate Bill 819 would:

•   Add more people to the investigative team from outside DHS;

•   Require investigators to interview people familiar with a case instead of relying on records;

•   Require the final report to include specific tasks, timelines and people who are responsible to carry out the recommendations that investigators give;

•   Require that if investigators found that an incident had to do with "personnel matters relevant to the Department of Human Services," they would have to notify the agency's human resources department.

A DHS official defended the team. "I think that any time you have the capacity to go in and look at something as serious as what we're talking about — a child who's died due to abuse or neglect — I don't know that there's a bad thing that can come from that (review)," said Stacey Ayers, a safety manager for child welfare with DHS and part of the investigative team.

"I think that overall is an effective thing to do," he said.

A governor steps in

The CIRT formed in 2004 under then-Gov. Ted Kulongoski.

“Every year, thousands of children in Oregon are abused or neglected. Some we know about because we read their tragic stories in our newspapers – and I know I can speak for all Oregonians when I say that any child who suffers abuse or neglect is one child too many,” Kulongoski said that year.

“As part of our collective responsibility to protect Oregon’s children, the state must strengthen our state child protective and youth authority services so that Oregonians have confidence that the children and youth who come into contact with those systems will be safe," he said.

Almost 13 years later, the investigative team still has plenty of criticisms for DHS.

Ayers attributes child welfare services' woes in part to chronic personnel problems. “We’ve never been staffed adequately to really do this work effectively,” he said.

He said staffing problems "can't be underscored enough."

Ayers threw out a hypothetical situation for a child welfare worker: “You’re sitting there and you know: Here’s the work I have to do and I can only do two-thirds of it, so what is the third of it that gets left off?"

He added later that it isn't what's going on in staffers' heads. "They're doing as much work as they possibly can to try to make sure that kids are safe and that they're doing the work that's required of them. But, again, what you're left with in the end is: 'We're staffed at a certain level, so what part of the work doesn't get done?'"

Ayers said administrators are struggling with that question. They are "acutely aware" that is how staffers are wrestling — "knowingly or not" — with their workloads, he said.

CPS workers are faced with awesome responsibility as they decide whether a child is safe in his or her own home. Oregon's Department of Human Services received just under 70,000 reports of suspected child abuse or neglect in the budget year that ended in September 2015. Investigations were completed on 27,661 of those reports. The same year, the agency oversaw 28,247 children including those in foster care, family services and investigated by CPS.

The Oregon Safety Model is the Northern Star for child protective services workers when making an assessment. It’s so important that the state has tried consultants and trainers to help staff better follow protocol.

“Because if we’re not following the rule, then what it comes down to more often than not is people kind of just using gut feelings they can’t really articulate (about) why a child is able to be in one place or is able to remain home or needs to be placed in foster care,” Ayers said. “That’s something that we’re trying to address.”

Death of a 2-year-old

An Oct. 24, 2014 CIRT report shows DHS officials had been contacted 13 times about a 2-year-old's family before the child died.

Of the 14 total contacts DHS got about the child's family, half were "closed at screening" and half were "assigned for CPS assessment." Screening happens when a staff member takes the complaint from someone reporting possible problems, whereas an assessment is more in-depth and involves the actual CPS worker.

In September 2013, a report came in to DHS: the child's sibling witnessed the mother and her "live-in companion play 'the punch game,' " investigators said. They said concerns had been raised about the mother's partner possibly being on methamphetamine.

Two officials — at least one of whom was a CPS worker — were sent to check out that report. The mother said she and her companion would "play fight" sometimes, investigators said, but she denied actual violence. "The workers were unable to confirm violence was occurring in the home, although holes were observed in the walls," investigators said in the report.

But later in the report, investigators suggest those workers hadn't done their due diligence.

"There was information in the assessment that indicated the children were unsafe at the conclusion of the assessment," investigators say in the report. "The reported concern regarding neglect does not appear to have been assessed."

In February 2014 — mere months after this assessment — DHS was notified that the 2-year-old was dead.

"The child was found in the bathtub drowned after reportedly being left unsupervised," investigators said in the report. "The mother and her partner were in the home at the time of the child's death."

There were warning signs.

The September 2013 report followed numerous others that show the 2-year-old's sibling was possibly being neglected and at least one in 2009 where the sibling's father had allegedly assaulted the mother, the report shows.

Both parents denied the 2009 assault and DHS closed the issue. Investigators said that more information collected about the "family condition may have provided a different picture of what was happening within this family and informed the safety decision at the conclusion of the assessment."

CIRT's first year

The first CIRT cases trace back to December 2004. That's when 5-month-old Ashton Parris was rushed to Oregon Health & Science University in Portland with a skull fracture, blood pooling in his brain and retinal hemorrhaging. The baby died two days later.

A week earlier, 5-year-old Jordan Knapp was flown from her foster home in Gresham to OHSU with a skull fracture and bleeding brain. She was thin, malnourished and in a coma. Unlike Ashton, she survived. She and her three other siblings were taken from the foster parents, Thelma and William Beaver.  Coverage of the conditions of the double-wide trailer she shared with her foster parents and seven other children caused a statewide uproar.

CPS had previously taken custody of Ashton because his mother smoked methamphetamine while she was pregnant with him, but he was returned to his mother less than two months before his death, according to case documents.

His father, then 27-year-old Darrell Parris, was arrested for murder and later found not guilty by a Clackamas County jury. His mother, Wendy Harsh, was not charged in connection with Ashton's death. But in 2014, she was convicted of abusing her daughter. She was sentenced to three years probation and ordered to comply with DHS directives. She's currently serving a two-year prison sentence for identity theft.

Jordan was released from the hospital and adopted by a new family, but she continued to suffer lifelong medical problems. Thelma Beaver was convicted of two counts of first-degree criminal mistreatment and sentenced to five years in prison. William Beaver was sentenced to two years probation for a lesser charge, according to the Oregonian. Jordan and her brother received payouts of $3.5 million from the state for the department's inaction.

A review of Ashton's case found calls to CPS about the family were not followed up with face-to-face contact, communication between staff was not well-documented, domestic violence and substance abuse issues were not addressed, and Darrell's probation officer was not consulted when making critical safety decisions.

Read more:

Keizer woman arrested in connection with son's death

'I was so broken': 14 years in foster care

There could soon be more ways to help Oregon's foster children

The report also said the focus of most meetings was "more on family reunification than child safety."

Jordan's CIRT review also noted a lack of coordination and communication among caseworkers and assistants. It determined records in the foster care case were incomplete and unorganized, screening was incomplete and face-to-face contact was limited.

With each finding, investigators recommended a solution to fix the flaw or gap in the system, but more than a decade after the CIRT's creation, children are still dying after they've been in the state's care.

'Reasonable cause or belief neglect occurred'

Child services had received three reports about 2-year-old Natalia Lee's family before she died in 2008 at Salem Hospital from blunt force trauma.

A police investigation revealed the toddler had been kicked hard enough to damage her liver and break her rib, and she had been raped.

Her mother's boyfriend, then 22-year-old Russell Ros, was arrested on murder, sex abuse, and assault charges. A jury convicted him of murder by abuse, two counts of first-degree criminal mistreatment, first-degree sexual abuse, assault and unlawful sexual penetration. He was sentenced to life in prison.

Natalia's mother, Amanda Burciaga, who left Natalia and her brother in Ros's care despite knowing about his violent outbursts and abuse, was convicted of three counts of first-degree criminal mistreatment and sentenced to 10 years in prison.

The critical response team found CPS did not open a child welfare case in 2006 after receiving a report of neglect even after determining there was "reasonable cause or belief neglect occurred."

DHS received another report the following year about Ros abusing the two young children. The agency concluded abuse likely took place but did not open a child welfare case. Instead, workers created a written safety plan. It was signed by the children's maternal grandmother, not Ros or Burciaga.

A third call into CPS about Ros abusing the mother and her two children was not investigated and was closed at screening.

Staff followed department policy, according to the CIRT report. But the CPS manager immediately issued instructions to field offices "reinforcing (the agency's) existing policy, which requires a CPS case be opened whenever a safety plan is adopted."

Investigators also recommended that CPS's procedures and policies relating to accessing information, background checks and documenting assessments be revised.

The investigative team's future

The Statesman Journal reported last month that DHS failed for almost a decade to adopt rules required by law to regulate the team before finally instating temporary rules this year.

DHS in a Secretary of State filing acknowledged failing to move quickly by taking up the rules "will result in serious prejudice to the public interest, the department and the welfare of children in Oregon."

Sen. Gelser's legislation, Senate Bill 819, would rework the investigative team's makeup, adding new outside team members. That could mean a court-appointed special advocate and two state lawmakers, for example. Sen. Alan Olsen, R-Canby, also sponsored Senate Bill 819.

Gelser said, "Even though the CIRTs themselves have really not until the past year led to any significant change in practice, it has created a relatively rich record now that we're paying attention."

For questions, comments and news tips, email reporter Jonathan Bach at jbach @statesmanjournal.com, 503-399-6714 or @JonathanMBach; Whitney Woodworth at wmwoodwort@statesmanjournal.com, call 503-399-6884 or follow on Twitter @wmwoodworth.