Written by Anita Wadhwani, The Tennessean
Attorneys for the Department of Children's Services return to federal court today under a judge's order to produce a better plan for investigating child deaths.
DCS is responsible for reviewing the circumstances behind the deaths of children in state custody and children who had been reported to DCS for suspicions of abuse or neglect and subsequently died.
But a Tennessean investigation found that the agency was taking no formal approach to examining child deaths. The agency fell behind in its work - up to two years in the cases of some children - and kept sparse notes. Instead of following a long-standing and detailed policy outlining the steps to take in each investigation, agency officials adopted an informal 213-word protocol that offered loose directions.
It was a system that New York-based watchdog group Children's Rights, which has oversight over children in Tennessee's foster care system, called "grossly incomplete."
Last week, DCS submitted a detailed 87-page plan to overhaul its child death investigation system.
The agency will now take a "fundamentally different approach," said Dr. Tom Cheetham, newly appointed deputy commissioner for Child Health.
The one-page protocol is gone, and its author, Child Safety Executive Director Carla Aaron, was disciplined along with two other staffers for allowing the death review process to languish.
"Clearly there were issues," Cheetham said of the agency's past approach under Commissioner Kate O'Day, who resigned Feb. 5 amid mounting criticisms over agency misstatements on the number of child deaths. "We basically started from scratch."
The agency's new approach includes a more rapid response to investigating child deaths, a tight timeline for completing investigations and more public transparency. The agency plans to publish an annual report on child deaths and near-deaths on its website.
"This is very much more demanding," Cheetham said. "We have such a responsibility to learn everything we can, from the point of view of trying to prevent future deaths."
DCS to release numbers
This year, seven children have died while in DCS custody. The agency has said it will soon make public the number of children who died this year after having some contact with the agency, but were not in custody. In 2012, a total of 105 children died who either were in state custody or had some contact with DCS in the three years preceding their deaths. In 2011, the agency reported 91 such child deaths.
Cheetham said that the agency will also undergo a broader cultural shift that encourages staff to be forthcoming about safety issues.
The agency's new plan includes:
• Requiring staff to make a phone call to DCS chief Jim Henry within one hour of a child's death.
• Requiring child deaths to be entered into the agency's central database within four hours.
• Requiring an independent physician and outside parties to review child deaths or near-deaths.
• Creating an internal Child Death Review Team consisting of a safety analyst, agency nurse, caseworker unassigned to the child, internal investigator, and outside parties including an independent physician and other professionals. The team will be overseen by a director of child death review - a newly created position.
The team will identify factors that may have contributed to a child's death. It will also publish statewide data and make recommendations to improve child safety, inside the agency and out, including recommending legislation, identifying trends and changing the way the agency operates.
The plan requires the approval of U.S. District Court Judge Todd Campbell, who will preside over today's hearing.