When children die on Oregon’s watch, state officials may soon have to say more about what went wrong

The Department of Human Services in Salem, Oregon. Beth Nakamura/Staff

Oregon lawmakers are on the verge of requiring officials at the state’s embattled child welfare agency to inform the public more quickly and thoroughly when children die by abuse after recent intervention -- or inaction -- by their department.

Under the new mandate, the Department of Human Services would have to notify the public about a child’s abuse or neglect death soon after case workers learn how the child died. It also would impose stricter standards for the details the agency must disclose about the child’s death.

State law already requires child welfare officials to promptly review the deaths of children killed by abuse or neglect if the child or a sibling came to the state’s attention in the year before they died. The public reviews are supposed to examine the steps that case workers took after receiving reports of concerning behavior within the child’s family and identify any missteps that may have occurred before the child died. The idea is that fixing what went wrong could save lives.

But reporting last fall and this spring by The Oregonian/OregonLive showed the agency regularly failed to meet existing deadlines and gradually told the public less about the department’s actions before a child’s death. Senate Human Services Chair Sara Gelser, D-Corvallis, drafted a bill outlining the reforms the day the first story published.

Three more Democratic lawmakers and seven Republicans signed on as sponsors of Senate Bill 832 during the legislative session. The bill passed without opposition in the Senate late Thursday and will move on to the House of Representatives. If passed, the new rules would apply to all child abuse deaths that occur after Oct. 1.

Meanwhile, children whose safety was called to the state’s attention continue to die. A seven-month-old infant whose family was known to the department died June 2 after he was thrown from a car that veered off Interstate 84 near Boardman, court documents say. The department launched a review into his death Monday, nine days after police concluded the driver was drunk.

The agency’s poor track record complying with public records law is one reason Gov. Kate Brown declared a “crisis” at the Department of Human Services in April, installed her own oversight board and hired outside consultants to oversee change at the agency.

Department officials insist they have made progress meeting the current reporting laws and are preparing to meet the stricter standards that appear poised to pass in the Legislature.

“We’re doing that to make sure that we’re able to immediately start complying with it the second it’s in effect so that there aren’t any further issues,” said Jake Sunderland, a spokesman for the Department of Human Services.

Since The Oregonian/OregonLive first reported about its failure to report on some child deaths in a timely manner and to report on other children’s deaths at all, the agency has posted a steady stream of fatality reports. But the department’s backlog of unreported child deaths

stretches as far back as 2017. It has never published a list of pending but delayed reports, despite the fact that is required under the current version of the law.

Department officials took five months to determine that they must review the August 2018 death of a Jackson County infant. They still have not disclosed their review into his death on the agency’s website, more than 150 days later.

Gelser, long a champion of vulnerable children, said the department’s persistent failure to post required updates or timely reports has signaled to her that the reforms are necessary.

“I have become more convinced that the bill is very important because the department has not improved,” she said.

The proposal gives the department seven to 10 days, depending on the exact circumstances, to publish basic facts online after a child dies and department officials decide to launch a review. Those details include the child’s age, the date they died or suffered critical injuries that resulted in their death and whether they were in foster care.

Under the new rules, such reviews would have to begin within 10 days after case workers and department officials have reason to believe a child has likely died from abuse or neglect. That’s a change from waiting until case workers make a final determination, a process that can last months.

“I think our hope is always to declare as soon as we feel confident,” said Tami Kane-Suleiman, manager of the department’s child safety division.

The review teams would be required to finish a comprehensive report within 100 days, unless the agency’s director, Fariborz Pakseresht, were to determine that publishing the reports could imperil a law enforcement investigation. The reports would have to be published on the agency’s public-facing website within 10 days of being finished.

The current law requires the department to complete and disclose an initial report in no more than 70 days, but agency officials routinely ignore that deadline. The department is also supposed to post updates every 30 days after that deadline has passed but does not.

The new bill makes clear what department officials must include in the reports, such as a description of all reports about the child or others in the same home that reached the department, along with all the department’s actions regarding the family before the child died. The proposal would also require the reports to disclose concerns that came up during the review and recommendations on specific steps the department can implement.

The reporting law, like the one it will likely replace, is written to focus on the agency’s past interactions with particular children, not necessarily their caregivers. For instance, the department still would not be required under the new law to review the death of a child killed in

an unlicensed day care after case workers investigated allegations that the caregiver had abused a different child.

Unlike the initial draft of the bill, the final version also does not require the department to complete reviews for all unexpected deaths of foster children, only those that appear likely to have resulted from neglect or abuse. The change means the department will not have to issue a public review if, for example, a foster child were killed in an unavoidable car crash.

“I realized that we could end up picking up things that we shouldn’t, and that could draw resources away,” Gelser said.

Department officials, state lawyers and representatives from Gov. Kate Brown’s office weighed in on the final language of the bill, Gelser has said.

Since The Oregonian/OregonLive revealed the extent of the reporting delays last November, the department has published at least 16 child death reports. The content of three of them was entirely redacted at the request of police or prosecutors.

The agency is still trying to clear a backlog that until Thursday went as far as 667 days.

In that case, a Portland-area infant died in August 2017 as he slept with his mother, who witnesses said was intoxicated. The report blamed a clerical mistake for the delay. The report lists four recommendations that came out of the review into his death, including training case workers to clearly understand the impact of substance abuse.

Other recent reports into the causes of infant and child deaths have offered far less insight. Two of the reports do not say exactly when the child died. Leaving out the dates was an oversight, the department said in a statement issued Thursday to The Oregonian/OregonLive. The statement also pointed out that the current version of the reporting law does not have “any actual standardized definition of ‘relevant information.’”

The department used a grant to hire a University of Chicago researcher to help it standardize and improve the review process, Kane-Suleiman said.

Even without those improvements, the department’s examinations of child deaths on its watch has directly resulted in improvements to the system, said Child Welfare Director Marilyn Jones. Three reviews published in the past year involved two boys and one girl who died by suicide in 2017. In response, Jones said, the agency implemented new suicide prevention training based on research that shows talking about suicidal ideations can decrease the chances that a child will attempt suicide.

Reviewing the circumstances of a child’s death and their case history is heart-wrenching yet necessary to ensure “that we do whatever possible that another family does not find themselves in this place,” Jones said.

The agency says it is currently working on 12 more reviews it will make public, including its report into the death of a 1-year-old boy who died 596 days ago.

None of the reviews are listed on the agency’s website.

-- Molly Young

myoung@oregonian.com

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