Oregon DHS announces changes to child fatality reviews

Shock. Horror. Sadness.

These are the feelings often felt by family, friends, and the broader community when a child tragically dies from abuse or neglect.

As the result of a new Oregon law and Gov. Kate Brown’s executive order on child welfare, Oregonians will soon be able to access more timely information about child fatalities and systemic issues that, when addressed, could help prevent tragedies.

Senate Bill 832, sponsored by Sen. Sara Gelser, D-Corvallis, makes significant changes to the Department of Human Services’ child fatality review process.

“When a child dies as a result of abuse or neglect, there is no way to restore the irrevocable loss,” said Sen. Gelser. “However, we can honor that child’s life by taking a deep look at the circumstances surrounding her death, to learn how we might work better as a community to support children and families. Already, Critical Incident Response Teams (CIRTs) have led to new strategies to address chronic neglect and unsafe sleep practices. This type of candid, open work will help prevent future tragedies.”

The DHS Critical Incident Response Team (CIRT) conducts extensive investigations into child deaths when the victim, their siblings or other child living in the household have had previous interactions with Child Welfare within 12 months of the fatality. The CIRT is focused on identifying whether any systemic issues contributed to the fatality and if so, how they can be addressed and corrected to minimize and prevent future fatalities.

When a critical incident is reviewed, the team seeks to understand the circumstances surrounding the death of the child, as well as the history of the family, the community and the child welfare and other family-serving systems.

Some of the most notable changes in SB 832, which take effect Oct. 1, include:

DHS is now required to assign a CIRT when there is reasonable belief the child fatality was due to abuse or neglect. This most often will occur within 7 days after a CPS Assessment is assigned from Oregon’s Child Abuse Hotline. Previously, DHS declared CIRTs after the completion of the CPS assessment, when the fatality was determined to likely be the result of abuse or neglect. This change is expected to increase the number of CIRTs assigned.
Increased transparency throughout the process. DHS must immediately post information about a CIRT online. Examples of the details to be posted include the age of the child, date of the incident, whether the child was in the custody of the department at the time of the incident, due date of the report and whether the final report is expected to be delayed. This information and more will be published at https://www.oregon.gov/DHS/children/child-abuse/Pages/cirt.aspx.

Governor Brown’s Child Welfare Executive Order, issued on April 18, also ordered DHS to improve its CIRT process and comply with the new statutory requirements for these investigations. There has been significant work to streamline, track, and organize the CIRT process with the management consultant firm hired to assist DHS.

The most significant part of this work is the creation of a team with dedicated resources for CIRT investigations and child fatality prevention, the agency said.

In addition, DHS will publish online updates on systemic issues identified through the CIRT process and the steps it is taking to address those issues. In recent years, many child fatalities investigated by DHS have been related to issues of neglect and parental substance use.

Current efforts are underway to establish consistent and up-to-date education and support for caseworkers when assessing and offering services to families where substance use is identified as a concern.

Since 2017, youth suicide, chronic neglect, and safe sleep have been identified as systemic issues impacting the safety and well-being of children in Oregon who come into contact with Child Protective Services, DHS said.

“The death of a child is always heartbreaking, and it’s important to study these tragedies to determine whether there is anything that could be done to prevent it,” said Fariborz Pakseresht, DHS director. “Improvements to our investigation process will help shed more light on the root causes of child fatalities and identify ways communities can better work together to keep children safe and healthy.”

Number of CIRTs Assigned Annually 2017 – Present

2017: 7 (6 were due to suicide or neglect)
2018: 18 (14 were due to chronic neglect or unsafe sleep)
2019 to date: 17 (Of the 10 completed, 9 were due to chronic neglect or unsafe sleep)

Report child abuse to the Oregon Child Abuse Hotline by calling 1-855-503-SAFE (7233).

KTVZ 2019