Child Fatality Review #05-29
Region 1
Spokane Office
Case Overview
This six-year-old Caucasian male died in the Spokane area on December 7, 2005 from a gunshot
wound to his head.
On the evening of December 6, 2005, at approximately 5:00 p.m., an eleven-year-old reportedly
shot his younger brother, age six. They were at their home alone when the eleven-year-old shot
the six-year-old in the head with his father’s gun. The six-year-old was airlifted to the hospital
where he died the next morning.
The parents did not adequately provide supervision for their children. This was a recurring theme
in several previous referrals. Child Protective Services (CPS) had received a total of 12 referrals
regarding this family.
The parents were offered substance abuse evaluations and marital counseling following the first
referral received by CPS in May 2001. The parents refused to participate in these services. In
January 2002, substance abuse evaluations were offered again following a new investigation by
CPS. The father complied and was diagnosed as alcohol dependent with recommendations for
intensive outpatient treatment and community support groups. The mother also completed an
evaluation and was diagnosed as alcohol and cannabis dependent. She was recommended to
participate with intensive outpatient treatment and sexual assault counseling. Neither of the
parents followed through with the treatment recommendations.
The siblings were also referred to individual counseling because of reports that they were
engaged in sexualized behavior. There was not an opening available when the referral was made.
The counseling center only had one counselor available in the parents’ community. Due to a
possible conflict of interest, at least one of the children would need to participate in counseling in
Spokane. The parents stated this posed a hardship due to their hours of employment and
transportation issues.
In March 2002, a referral was received for Sexually Aggressive Youth (SAY) treatment for the
older boy. The Spokane County Prosecutor made the request for services. The parents did not
respond to the services offered for their oldest son.
In February 2003, following a protective placement by Law Enforcement, the assigned social
worker attempted to engage the parent’s in intensive outpatient treatment, counseling, and
counseling for their children. For five months the parents failed to follow through with any
In February of 2003, the older brother was placed in a behavioral intervention classroom and the
decedent was accepted in a pre-school through the school district. The school provided the
transportation for pre-school. The school counselor contacted the parents to offer school based
mental health services to the children. The parents refused to allow the children to participate.
Several referrals were received in 2005 that required CPS investigation. The father had agreed to
a voluntary service plan that included Family Preservation services (FPS), counseling for the
older children, as well as appropriate childcare whenever the father was not home. The father
quit participating after three contacts by the FPS provider. The FPS provider reports that she
addressed gun safety at a meeting with the family on July 9, 2005. The father said that all of his
guns were locked up and he wouldn’t allow his oldest son to have a gun because he hadn’t
completed a gun safety course. The FPS provider also identified childcare resources for the
father. He never arranged for the children’s counseling and did not have adequate supervision for
the children on the day the shooting occurred.
On September 29, 2005, a Child Protection Team (CPT) recommended that the children remain
in the home. The team expressed concerns for the children’s safety and suggested that the
Department staff the case with an Assistant Attorney General (AAG) and the father should get a
substance abuse evaluation. According to the Social Worker, the AAG said that there was not
sufficient information to pursue a dependency petition.
On November 1, 2005, the school reported to CPS that the oldest boy smelled of alcohol at
school. They had reports that the children use alcohol and drugs at home and that the daughter
had pulled knives and pellet guns on the boys. CPS investigated these allegations, which were
founded for negligent treatment. The school helped develop a safety plan for the children to be
supervised by a friend’s parents after school.
On November 2, 2005 CPS received an informational report that the daughter had snorted
On December 7, 2005, CPS received information that the youngest boy had been shot by his
older brother and died.
A safety plan was implemented in the father’s home immediately after the child’s death.
However, both siblings were informally placed shortly thereafter. The older daughter was placed
with a relative and her brother was placed with a friend of the father’s. A dependency on the two
children was granted in March, 2006. The brother is currently in a BRS placement and the
daughter is in a foster home.

Civil Rights 0

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

Civil Rights 0

Child Fatality Review #05-34
Region 3
Bellingham DCFS Office
This three-year-old Native American male was killed in October 8, 2005, when a car accidentally
rolled over him in a private driveway at the home of a third party.
Case Overview
The child’s family was homeless and the parents went to look at a fifth wheel trailer that was for
sale. When they arrived at the home, the parents turned off the motor, exited the car and left their
three sons (ages 8, 5, and 3) sleeping inside the car. The parents met with the owner of the fifth
wheel and were looking at it but were within sight of their children in the parked car
approximately 75 feet away. The parents heard the sound of crunching and responded
immediately. They attempted to lift the car tire off the child, called 911, moved the car and then
administered CPR. The child apparently got out of his car seat, out of the car and was run over in
the driveway after one of his siblings knocked the car out of gear. The investigating law
enforcement agency reported to CPS that they viewed this as an accident.
The family had prior history with Children’s Administration. The child’s mother was possibly a
victim of child abuse in her family when she was about sixteen. There is no prior CPS history on
the father.
The first referral concerning the family was received in 1997. An emergency room (ER)
physician made a CPS referral about the parents’ first born son who was then six months old.
The mother brought him to the ER with bruises and contusions on his face and head. The mother,
supported by her sister and her sister’s child, stated that the injuries occurred when the mother’s
three-year old niece climbed into the child’s crib and beat him with his bottle. This occurred
when the mother and her sister stepped out onto the porch for a few minutes. The child’s injuries
healed with no permanent effects. The case was closed after investigation with a finding of
Unfounded and with referrals for services for the three-year old niece.
The next time CPS became aware of this family was in 2000. The mother was pregnant with
their second son. While at the doctor’s office with her oldest child, the mother had been
admonished by the doctor for being impatient with him and “yanking” on his arm. There was no
injury. The mother was working with a public health nurse, who had never seen anything of
concern. The referral was taken as Information Only.
Two months later, the mother was in the hospital delivering her second son. Hospital staff called
CPS to report that the father had physically abused the oldest child as they were leaving the
hospital. They observed the child crying for his mother and the father yanked him, screamed at
him and threw him to the ground while going to the car. The referent also reported the mother
claimed she had been physically assaulted by the father six months earlier. The father was
attending anger management classes because she reported the incident to police. The mother also
told the referent hat she used marijuana weekly during her recent pregnancy.
The newborn did not test positive for drugs and he was allowed to go home with his parents. The
investigator learned that the father had been assessed and diagnosed with severe alcohol and
marijuana dependence, and methamphetamine dependence in remission. He was required to
attend chemical dependency treatment as a part of his domestic violence case and a Driving
under the Influence charge. He did not comply with treatment and was ordered to 15 days of inhome detention. The treatment facility report indicated that his prognosis for recovery was poor.
During the CPS investigation, a new CPS referral was made about the family. An anonymous
caller stated that the father was heard yelling, slamming doors, and “screaming obscenities,”
particularly at the oldest child. The investigator asked the mother to submit to a urinalysis for
drug use, but she refused. The parents refused to attend parenting classes, but the father did
complete 26 weeks of domestic violence counseling. After four months of working with the
family and offering services, the case was closed. Although the family’s engagement in services
was minimal, the department believed there was not sufficient basis to file a dependency petition.
The findings of the investigation were Unfounded.
The department heard nothing about the family until the spring of 2005. By that time the family
had three sons. The youngest son was born in 2001. The daycare provider expressed concern to
CPS about the oldest boy. He was reported to have been seen “slapping himself” and stated that
his parents “slapped him all the time.” He told the teacher that his parents “hate me and they hit
me.” The center had never seen evidence of physical abuse. The referral was screened as
Information Only.
The next referral was in October of 2005, when the department learned of the fatality.
Issues and Recommendations
Exceptional Social Work Practice
Most of the work on this case prior to the fatality was performed by the Bremerton DCFS
office in 2000. In a very comprehensive investigation that included many collateral
contacts, the social worker identified the risk factors the family presented and began the
process of establishing the children’s tribal identity once their Native American ancestry
was revealed. It turned out to be a lengthy process, not reaching completion until well
after the case was closed. Despite extensive efforts to engage the family, the social
worker was only partially successful in connecting the reluctant parents with services,
and the case was closed per policy. The active efforts made on this case, however, were

Civil Rights 0

Child Fatality Review #05-25
Region 1
Spokane Office
Case Overview
This seven-year-old Caucasian male died in the home of his adoptive mother on January 13,
2005 due to “severe dehydration” as reported by the medical examiner. He weighed 28 pounds,
significantly below the fifth percentile for children his age at the time of his death.
The decedent was born on January 13, 1998. He was placed in foster care on April 5, 1998 due
to concerns of neglect by his biological mother. His biological father is a registered sex
offender. Although the department had concerns about the decedent’s biological mother’s drug
use, the decedent’s birth records indicate that he did not have drugs in his system at birth. He
was placed in his adoptive mother’s home on May 29, 1998, after a brief stay in another foster
The decedent’s medical records indicate that he weighed 16 pounds on July 7, 1998, in the 50th
percentile for children his age. His biological mother relinquished her parental rights on
December 3, 1998. She agreed to an open adoption with his adoptive mother. He was adopted
on April 10, 2000.
Children’s Administration Division of Licensed Resources Child Abuse and Neglect Section
(DLR/CPS) investigated the circumstances surrounding the decedent’s death in conjunction with
Stevens County Sheriff’s office.
In the eleven months since the decedent’s death, there have been six new referrals alleging
physical abuse, negligent or maltreatment of other children who were placed in the adoptive
home prior to the decedent’s death. Several of the decedent’s adopted and foster siblings have
reported that the adoptive mother and her daughter physically abused them and withheld food
and water from them. These referrals were generated both by Department of Social and Health
Services (DSHS) staff and providers upon learning of new allegations of abuse and neglect in the
course of the investigation following the decedent’s death.
For a copy of the full report and case history please review the fatality report at:

Foster Care 0