1. Child Fatalities Near Fatalities High Profile Incidents
Critical Incidents
Child Fatalities
Near Fatalities
High Profile Incidents
Intake is the front line of CA. Most critical incidents are initially reported to intake

2. Critical Incidents Documenting Response FamLink
AIRS (Administrative Incident Reporting System)
Response

3. Critical Incidents Administrative Incident Reporting System (AIRS)
Notification System
FamLink
Both systems generate alerts notifying regional and HQ staff of high profile incidents

4. Dreyfuss – No notification of a child fatality; heard on KIRO first

5. AIRS Who Gets AIRS Alerts RA, Deputy RA, AAs Regional Leadership
HQ staff
Assistant Secretary
Torts
DSHS Risk Management
DSHS Communications
Office of the Family and Children Ombuds (OFCO)

6. AIRS Child Fatalities Near Fatalities Client Related
Client: A child in the care of or has an open case with CA.
Facility Related Incidents
Staff Safety
High Profile
Critical Incidents that require an AIRS report

7. AIRS Client Related: Sexual Abuse: Open case
Serious Injury: CA/N on open case
Sexual Abuse: Open case
Suicide Attempt resulting in death or near fatal injury of child client.
Placement Exceptions: child client spending the night in hotels or CA offices

8. AIRS Staff Safety Threats of harm
Assaults of staff or contracted providers
Theft/Damage of State property
Traffic Accidents
AIRS is completed if:
staff was at fault, or,
child client was a passenger, or,
accident result in injuries to any person in car driven by staff.
Loss of Client information

9. AIRS Facility Related Incidents Involving:
Foster homes, facilities, or private agencies licensed by the Division of Licensed Resources (DLR).
Licensed childcare facilities licensed by DEL.
Other licensed, certified, or state-operated facilities.
WAC
Child abuse and/or neglect;
(b) Spousal abuse;
(c) A crime against a child (including child pornography);
(d) A crime involving violence (including rape, sexual assault, or homicide but not including other physical assault or battery)
(1) Any felony physical assault or battery offense not included in WAC A-0170;
(2) Any felony violation of the following drug-related crimes:
(a) The Imitation Controlled Substances Act (for substances that are falsely represented as controlled substances (see chapter RCW);
(b) The Legend Drug Act (prescription drugs, see chapter RCW);
(c) The Precursor Drug Act (substances used in making controlled substances, see chapter RCW);
(d) The Uniform Controlled Substances Act (illegal drugs or substances, see chapter RCW); or
(e) Unlawfully manufacturing, delivering or possessing a controlled substance with intent to deliver, or unlawfully using a building for drug purposes.
State Op facilities:
JRA, Child Study and Treatment, Daybreak, Contact local DLR/CPS sup.

10. Facility Related
Allegations of licensed provider misconduct is reported in AIRS. May also generate an intake.
These include all other critical incidents also include:
Criminal activity that would disqualify a licensed provider from providing care to children (see WAC & ).
Allegation of sexual abuse/sexual exploitation.
A pattern of high-risk child abuse and/or neglect referrals.
An intake is created for all child fatalities in licensed facilities (may screen in or as Rule Infraction).
WAC
Child abuse and/or neglect;
(b) Spousal abuse;
(c) A crime against a child (including child pornography);
(d) A crime involving violence (including rape, sexual assault, or homicide but not including other physical assault or battery)
(1) Any felony physical assault or battery offense not included in WAC A-0170;
(2) Any felony violation of the following drug-related crimes:
(a) The Imitation Controlled Substances Act (for substances that are falsely represented as controlled substances (see chapter RCW);
(b) The Legend Drug Act (prescription drugs, see chapter RCW);
(c) The Precursor Drug Act (substances used in making controlled substances, see chapter RCW);
(d) The Uniform Controlled Substances Act (illegal drugs or substances, see chapter RCW); or
(e) Unlawfully manufacturing, delivering or possessing a controlled substance with intent to deliver, or unlawfully using a building for drug purposes.
State Op facilities:
JRA, Child Study and Treatment, Daybreak, Contact local DLR/CPS sup.

11. High Profile Intakes High Profile Incidents Media Legislative
Public Interest
Media reporting incidents involving licensed care providers.
More likely will get an AIRS alert
Media attention by family or child involved with CA

12. Child Fatalities
Intake may record fatalities in FamLink (as an intake) and or in the Administrative Incident Reporting System (AIRS).
All fatalities reported in AIRS.
Incident reports
AIRS fatality log
Supervisors and CPS program managers input AIRS incident reports.
Child fatalities, near fatalities and high profile incidents input into AIRS within 1 hour of report to CA.
All other incidents documented within 24 hours

14. Child Fatalities Fatality Log vs. Incident Report General Rule:
If fatality is documented in an intake, it should also get an AIRS Incident Report
Important one is allegations. Not absolute. Could have an incident that may not be documented in an intake, but requires an AIRS report.

15. Child Fatalities
Child fatalities should be documented in an intake if:
Allegations of CA/N related to the death
There is recent CA history or,
The fatality occurs in a licensed or operated facility (DLR)
Caregivers with prior CA history should be strongly considered for investigation.
Recent history within past few years – especially if history is concerning (prior fatalities)
Best practice: create an intake if reported. Generates history that may be helpful in future intakes.

16. Fatality Intakes
Law enforcement: Report fatalities to law enforcement.
Fatality button in the Allegations Tab
Do not screen out fatality intakes because there are no surviving children in the home.
Do not make intakes Risk Only if no other child in the home.

19. Types of Fatalities Reported To CA
Natural/Medical: diseases, illnesses and health related
Accidental: No evidence of intent (car accidents, falls, drowning, layovers)
Suicidal: intentionally self-inflicted
Homicide: intentional harm
Homicide by Abuse: Homicide by a parent or caretaker
Homicide by Third Party: Homicide by anyone not a parent or caretaker
Unknown/Undetermined: insufficient evidence or information
Be critical of the Accidental deaths – these are more likely to generate screened in referrals for supervision
Davis brothers – ME ruled accidental. Charged with Vehicular Homicide
Layovers- unsafe sleep

20. Medical Examiner / Coroner Findings
At least 50% of child fatalities related to maltreatment are not coded as a homicide by medical examiners.
These are national standards
2015 – 9 founded fatalities (of those reviewed) only 3 were ruled homicides by medical examiners.
of 7 fatalities ruled homicides
Maltreatment is the abuse or neglect of a child as defined by the Washington Administrative Code (WAC).
CA has historically used medical examiner’s and coroner’s findings of homicide to determine the number of fatalities resulting from maltreatment.
However, research indicates that nationally less than half of the children who died as a result of maltreatment had death certificates that were coded consistently with maltreatment.

21. You will have to answer the fatality review question to proceed

22. Near Fatalities
A near-fatality is defined as an act that places the child in serious or critical condition (RCW ). Child near-fatalities must be reported in AIRS if:
The near-fatality is a result of alleged child abuse and/or neglect on an open case or on a case with CA history within 12 months.
The near-fatality occurred in a CA or DEL licensed facility.
Critical condition resulting in hospitalization (ICU)

23. Near Fatalities
A new AIRS report is not required when a near fatality is already documented in AIRS and the child later dies. Update the near fatality report

26. Aiden’s Act

27. Reviews
CA is required to conduct reviews of child fatalities and near fatalities if:
The death or near fatal injury is suspicious for CA/N and,
the child received services from CA within 12 months of the near fatal injury or death.

28. Reviews Fatality and Near Fatality review committees include
Professionals from the community
CA staff
OFCO
Law enforcement
Medical professionals
GAL
Service providers
CD professionals
DV professionals

29. Reviews Committees regularly discuss intake screening decisions.
Committees make findings and recommendations.
Findings
The Committee disagreed with the decision to screen out the February 5, 2015 intake and felt that it met screening criteria for neglect and should have been assigned for investigation.
The Committee recommends that Aberdeen DCFS attempt to work toward improving the referral process with the specific law enforcement agency identified during the review. The goal would be to develop a more reliable system for forwarding and tracking the intakes sent to the law enforcement agency thereby improving timely assignments to detectives.
Remind CA’s intake supervisors of the importance of a comprehensive review of a parent’s history of involvement with CA when making intake screening decisions. The Committee recommends the statewide intake program manager for Children’s Administration provides this reminder in a “lessons learned” format to all intake supervisors.
Regional Core Training through the Alliance for Child Welfare Excellence should include specific training on searching for history on individuals named in intakes.

30. Critical Incident Protocol
Protocol in response to critical incidents

31. Critical Incident Protocol
Critical Incidents:
Child Fatalities
Open case
CA activity 12 months prior to death
Near Fatalities
High Profile cases

32. Critical Incident Protocol
Critical Incidents:
Media coverage
Legislative interest
Public interest
Serious physical abuse on open cases or kids in care
Sexual abuse of kids in care
Criminal activity by licensed providers

33. Critical Incident Protocol
Response:
In the first hour:
Notify chain of authority including the appointing authority (RA).
The RA notifies HQ
Document in AIRS
The Ops Manual reads that child fatalities must be reported within the first hour. All other reports within 24 hours.

34. Critical Incident Protocol
At the direction of the Assistant Secretary, a staffing may be held, in person or via conference call.
Regional staff conduct the staffing.
The staffing may include:
Assistant Secretary
Deputy Assistant Secretary
Director Field Operations
Other CA Directors, as needed
DSHS Communications
Regional Administrator
Deputy Regional Administrator and/or DLR Administrator
Area Administrator
Supervisor
Social Worker
INTAKE STAFF MAY BE ASKED TO PARTICIPATE
Staffing the case:
Most recent information on the case or incident.
Status of case (if open)
Case history
Status of law enforcement and CPS investigations
Condition of child (near fatality)
Condition of surviving siblings, if necessary
Case or safety planning, if necessary

37. Lessons Learned Where Are Lessons Learned
Critical Incidents
Case Reviews
Torts
Constituent Relations
Third Founded Finding Reviews
CAPTA Reviews
Lessons Learned cases occur in all program areas, including Intake.

38. The Seven Cs Critical Thinking Curiosity Collaterals Corroboration
Collaboration
Communication
Comprehensive
Critical Thinking
Bias (CUSTODY BATTLE)
Curiosity
Household Composition
1) Who lives in the home and what are the relationships?
2) What do we know about their criminal/Famlink history?
Caution: Inaccurate spelling impacts search results at intake.
3) How do the children respond to the adults in the home?
4) How are you verifying who lives in the home?
We should be exploring the daily functioning of all the
adults in the home without regard to the reported event
(global assessment – information focus) not just the parent
5) How do we respond when new people move into the home?
What steps should we take?
6) Our safety framework says the gathering and assessing information
provides with a comprehensive household assessment that looks
beyond the current incident and really emphasized daily family
functioning.
Did the child disclose? This is only one piece of your investigation!
1) What might investigators do when the child doesn’t disclose CA/N
but there is other concerning information? (e.g. non-verbal)
2) Collateral contacts and medical consultants are the best method of
determining CA/N under these situations.
3) Children who are abused frequently deny the abuse for a variety of reasons
that are valid for them.
Look for patterns
1) Look for all patterns, not just signs of physical abuse.
2) Does the alleged perpetrator drink on weekends?
3) Does the DV victim return to the perpetrator and change her reporting of
concerns shortly after CA case closure? What do you do under this situation?
4) Do witnesses/collaterals report similar concerns?
Incident Focused Investigation
1) Negative: Injuries looked at in isolation
2) Positive: Thorough investigation that includes risk.
3) Child interviews should not be specific only to the allegations.
Collaterals:
Referrer
1) Timely
2) Strongly consider contacting referrers of PAST screened out intakes.
They can be a wealth of good information
Communication
Shared Planning Meetings
Supervisor Reviews
Consultation
Documentation
Comprehensive
Case Example Recommendations – Benjamin Miron, Jolan Wilson (Zubriski/Wilson Review) and Takeisha Howtopat
Do we have what we need to ensure child safety and make good case decisions.
Remember we assess safety, permanency and well-being throughout the life of a case
Did you look at the family from a global perspective?
Always ask: Are all of the kids safe, not just the identified victim(s)?
Do we know what we need to know about all of the children(s) caregivers?
Did you give all information its appropriate weight?
1) Avoid confirmatory bias. Don’t just look for information that supports
our existing opinion.
2) Do we have and did we seek out available information regardless of what
we think we will find? Critical information is frequently found from
unexpected sources. Re-evaluation previous conclusions including findings
1) Findings and conclusions are made with the information available at the time.
2) Do we have no information available that may cause us to challenge the
previous conclusion?
Joseph Smith – near fatality case
 the Jacob Smith scenario (the FAR case from Spokane).  The intake worker who took the call when the child was injured was at the training and provided additional information:  In February, when the child was injured, the referrer called intake based on 3rd hand information that the child was injured but she wanted to remain anonymous.  The intake worker made an extra effort to talk her into being confidential so that the intake wasn’t screened out.  I wish we had known that when we did the review, because the worker deserved some recognition.   I let him know that I’d add his part of the story to the scenario.  I thought you would appreciate it because you have used this scenario with the intake staff and I think it really highlights how much they can help the CFWS and CPS workers. Intake #

39. Shared Decision-Making
Consulting and staffing with supervisor, colleagues, collaterals, experts as needed.
Using the Chain of Authority.
Intake and Safety Program Managers, CPS Program Manager, Practice Consultants Field Operations
In critical incident cases, intake screening decisions are viewed more favorably when difficult screening decisions are staffed and documented.

40. AIRS reporting requirements found in Operations Manual 6302.
Questions about the Critical Incident protocol to:
Paul Smith
DSHS Communications
Norah West

41. Crisis Management and Secondary Trauma
Peer Support Request Peer Support: