Maine’s child protective system has buckled under the weight of persistent staffing challenges that worsened during the pandemic and also has been hampered by poor communication between families and other stakeholders that collectively put vulnerable children at risk, according to an independent review released Thursday.

However, the 29-page report from Casey Family Programs did not go into detail about specific failures related to the spate of deaths that prompted the state to ask for help, focusing instead on systemic issues.

Casey, the Seattle-based nonprofit that conducted the review for Maine’s Department of Health and Human Services at no cost, also outlined seven recommendations the state can implement.

The DHHS is still reviewing the report and will publicly release actions it plans to take in response to Casey’s recommendations next week, according to Jackie Farwell, the department’s spokesperson.

The review was requested by DHHS in July following a series of child deaths in June. Five children, all 4 years old or younger, died from accidents or serious injuries. In three cases, caregivers have been charged with manslaughter or murder. In at least one case, child protective caseworkers were working with the family.

“The heartbreaking deaths of these children continue to be felt among their families, their communities, our staff, and our state as a whole,” Todd Landry, director of the DHHS Office of Child and Family Services, said in a statement. “Casey’s expert review will help us work with our partners throughout the child welfare system to keep children safe and support Maine families now and into the future.”

Sen. Bill Diamond, D-Windham, a past member of the Health and Human Services Committee who has been a leading voice for reforms to the state’s child welfare system, said the Casey Family Programs’ report left him disappointed. The national organization already has worked with DHHS in the past and one of its senior officials, Dan Despard, is a former Maine child welfare director.

“After reading the recommended steps for OCFS to take in order to improve child safety, I’m disappointed to say that I feel many of the deeper, longstanding issues within the department that have led to numerous child deaths in recent years have been missed,” he said. “Ensuring coordination between all those involved in a child welfare case, following national best practices, and supporting engagement between OCFS and parents are all things that we currently expect from of our child welfare agency. These recommendations appear to take a soft approach to urgent, severe issues.

“Additionally, there does not appear to be a recommendation addressing the department’s inability to place children in safe households, which the Child Welfare Ombudsman has reported over the previous two years.”

OPEGA ALSO INVESTIGATING

In addition to the review by Casey Family Services, the Legislature’s Office of Program Evaluation and Government Accountability has launched its investigation into child welfare practices in Maine. That agency will present initial findings later this year, but the full report won’t be completed until early next year.

The same office conducted a review in 2018 following the high-profile deaths of Marissa Kennedy and Kendall Chick, which led to some reforms but hasn’t solved all of the problems.

The first of the recent five child deaths occurred June 1 in Brewer. Police have since charged Ronald Harding with manslaughter in the death of his 6-week-old son, who police allege was shaken to death.

Five days later, a 3-year-old girl was found dead in Old Town. Police arrested the mother, Hillary Gooding, and charged her with manslaughter. The girl’s cause of death has not been released.

And on June 17, a 4-year-old boy from the Franklin County town of Franklin died from what police believe was an accidental self-inflicted gunshot wound. No one has been charged in connection with that case.

The death of 3-year-old Maddox Williams occurred June 20 in Stockton Springs. His mother, Jessica Williams, was charged with murder and has pleaded not guilty.

A Windham boy, 4-year-old Sulaiman Muhiddin, died on June 24, but police have released no details about how or where he died. The state has asked that his death be included in the review.

STAFFING IS BIGGEST CHALLENGE

According to Casey, staffing remains the biggest challenge, even though lawmakers have approved funding for additional caseworkers on more than one occasion in recent years. Although there are more positions, they aren’t always filled. The jobs see high turnover, although OCFS has made improvements recently, and new hires often require several months of training. The pandemic also made things worse because many workers were forced to quarantine for long stretches.

In addition to staffing, Casey noted that the department could do better communicating with other agencies that provide family supports. Confidentiality concerns often emerged as a barrier to improving communication.

State workers also struggle at times to get families to engage with them and accept supports because the system is largely voluntary for parents, the report found.

Casey’s report echoes many concerns that have been raised by Christine Alberi, the state’s children welfare ombudsman, whose job it is to provide independent oversight of OCFS. This summer, two ombudsman’s office board members resigned in protest because they didn’t feel like state officials were listening to Alberi.

The recent report doesn’t identify specific failures of the system related to the deaths, and cautions against placing blame on individual mistakes. Alberi also has been reluctant to place blame on workers or supervisors.

Casey recommended the state take seven steps to support system child welfare improvements, including establishing joint protocols with law enforcement, hospitals and child welfare staff to clarify their roles when abuse or neglect is suspected, and improving engagement between parents and the child welfare system.

“We remain committed to learning all we can from these tragic deaths and taking action to help Maine children grow up safe, healthy and loved,” DHHS Commissioner Jeanne Lambrew said in a statement. “Casey Family Programs brought a wealth of experience and national perspective to this thorough review and we are comprehensively evaluating their recommendations to identify steps we can take immediately and over the long-term to protect Maine children.”

PROBLEMS ARE NOT NEW

The problems predate the recent deaths.

Last month, DHHS released an updated list of all child deaths dating to 2007 that were either classified as homicides or included signs of abuse, or were preceded by some involvement with the state’s child protective system.

The 143 deaths detailed in the DHHS report included 30 homicides, as determined by the state’s medical examiner; 18 attributed to “sudden unexplained infant death;” 26 determined to be accidental; 35 resulting from co-sleeping, which typically occurs when a sleeping adult inadvertently smothers an infant; and 34 resulting from natural causes, suicide or where the cause was undetermined.

That list did not include the recent deaths.

A Portland Press Herald/Maine Sunday Telegram examination of the cases found that in 21 of the 30 homicides since 2007, children came from families that had been involved with child protective services at DHHS because of suspected abuse or neglect involving the deceased child or a sibling.

In 12 of those cases, DHHS did not conduct an assessment following at least one abuse or neglect report, although assessments may have been conducted following other reports related to that family. And tragedy followed, sometimes quickly.

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