Child Fatality Review #05-19
Region 4
Office of African-American Children’s Services
Case Overview
This two-month-old African American female died on August 15, 2005 due to Sudden Infant
Death Syndrome (SIDS).
Children’s Administration received a call from the King County Medical Examiner reporting the
death of a child, age two months. The family has Child Protective Services (CPS) history and an
active case. Other children remained in the home at the time. It was stated that the twins slept
with the mother in her bed. The mother woke to feed the babies at 4:30 a.m., and they all went
back to sleep. At 9:30 a.m., the mother was awakened by the cries of the other twin. At that
time, she found the decedent face down lying next to her and unresponsive. She called out for
help, and an aunt came in and began cardiopulmonary resuscitation (CPR). Medics responded
and did not attempt resuscitation as the decedent was found to be “down too long.” The decedent
had no signs of external trauma. The mother appeared appropriate and did not seem to be under
the influence of drugs or alcohol.
The cause of death is SIDS per the King County Medical Examiner, confirmed December 21,
A safety plan was developed to ensure the safety of the other twin. The plan was an agreement
between the Division of Children and Family Services (DCFS) and the mother. The goal of the
agreement was to ensure the safety and well being of other twin. The safety plan included: 1)
The other twin was taken to the doctor. The mother was to follow up with all recommended
medical treatment. 2) The mother was to attend the August 31, 2005 intake at Therapeutic
Health Services (THS). 3) The maternal grandmother was to be the primary caretaker of the
twin until the cause of death is determined.

The mother had given birth to four children by two different fathers. The father of the two oldest
children, born December 18, 1993 and July 7, 1999, was the same. The twins, born on June 3,
2005, had a different father than the older children. There is no father named on their birth
On December 3, 2002, CPS received a referral that was accepted for investigation for negligent
treatment/maltreatment and physical abuse. At that time, the three-year-old reported his father
punched him in the neck. Interviews with both of the children, the mother and father, and the
maternal grandmother occurred. At that time the mother was a client at THS. The investigation
was unfounded and explained as play wrestling between the father and son.
On May 6, 2003, CPS received an information only referral. The oldest child told an employee
at her school about an incident in a grocery store in which the mother was apparently intoxicated.
On August 18, 2003, CPS received a referral that was accepted for investigation for negligent
treatment/maltreatment. The oldest child called 911, and the mother was transported to
CFR #05-19 (AIRS 1303)
Region 4 – Office of African American Children’s Services
Harborview. The mother was partly conscious. She tested positive for “amphetamines, opiates,
benzos and methadone.” This investigation was founded. The third report in 2003 came on
October 10th and was accepted for investigation of physical abuse. The second oldest child said
his father hurt his ear. This was unfounded. There was one report in 2004 that was information
only dated July 8, 2004. During 2004, the family received two authorizations for Intensive
Family Preservation Services (IFPS). There were multiple instances in which the mother’s
behavior appeared to be drug-seeking.
The twins were born June 5, 2005. Swedish Hospital made a report to CPS on June 6th. This
report of negligent treatment/maltreatment was accepted for investigation. The mother tested
positive for methadone and opiates. Both babies also were drug positive, according to the
Service Episode Record (SER). The mother told the assigned CPS worker that the maternal
grandmother was taking care of the second oldest child at her home in Redmond, Oregon and
would soon have the oldest child there when school ended for the summer. The mother’s initial
plans were to live with the twins at a friend’s home, then move to public housing.
The mother left the hospital with the babies to live at an address in Seattle. The service plan with
CPS included at least one urinalysis and a referral to Child Haven for the twins. Soon after, the
mother and the twins left for a visit with the maternal grandmother and the other siblings in
Oregon. On August 15, 2005, the King County Medical Examiner contacted CPS to report the
death of this twin.
The surviving twin was subsequently hospitalized for medical testing. He was placed in foster
care on a Voluntary Placement Agreement (VPA), and then placed with a relative with a
dependency petition filed.
Court records document several incidents of domestic violence between the mother and the
father of the older children. There is a current No Contact Order that is in effect until August 20,
2006. There are no records concerning domestic violence between the mother and the father of
the twins.
Issues and Recommendations
I. Practice Issues
A. Issue: The importance of case history in helping to determine the case plan. It
appears that the assigned worker may not have carefully reviewed the case file before
deciding on a course of action. A review would have provided ample information
when the twins were born that the mother was continuing a several-year pattern of
abuse of pain killers while marginally participating in a Methadone maintenance
program. With that information in hand, it may have been clearer that legal action
would be warranted.
Recommendation: Read the case file and if it is not physically in the office, read it
CFR #05-19 (AIRS 1303)
Region 4 – Office of African American Children’s Services
B. Issue: Using Voluntary Services Plans when parents have known substance abuse
issues. Workers want to provide reasonable efforts and services to prevent placement
and legal intervention. On the other hand, voluntary plans may not be effective with
substance-abusing clients who are in denial.
Recommendation: Voluntary plans, if used at all, need to be for very short time
frames, such as thirty days. Compliance should be very closely monitored.

C. Issue: Using Family Preservation Services (FPS) or IFPS when a parent is not clean
and sober. This family actually received two authorizations for IFPS. The substance
abuse issues continued throughout both episodes.
Recommendation: Preservation services should not be employed when a parent is
using. The goals cannot be met and the safety of the children will not be enhanced.

D. Issue: Making referrals to the Public Health Nursing (PHN) Early Intervention
Program (EIP). In this case the hospital made a “regular” PHN referral, but the CPS
worker did not subsequently request an EIP PHN. Doing so means the PHN will
obtain consent for release of information and will provide the worker with written
progress reports.
Recommendation: Where available, request an EIP PHN for families with infants
and children under age three, or with any child that has medical issues

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