The Department of Children and Family Services is heartbroken over the death of 2-year-old Mitchell Robinson. This death has shaken our staff to the core. We said from the outset we were committed to determining what went wrong and to finding solutions. We have been engaged in an internal review and are now at the point where we can release additional information about the case and the actions we have taken in response.
As I review the facts, it’s apparent our staff did talk to the mother. Although no one was there when we went to the house, our staff did reach the mother by phone. She knew we were concerned. She expected us to return to the house, yet she did not do what was necessary to ensure the safety of her child. We failed to get back to the house in time. I deeply regret not doing so.
I want to update the public on steps we’re taking to lessen the likelihood of similar tragedies occurring in the future.
In response to this case, we changed our policy regarding children age 3 and younger. Under the new policy, all cases of abuse/neglect involving a child age 3 and under made by a medical provider to DCFS will be accepted for investigation. The priority response will be set in accordance with the danger posed to the child. However, all caseswhere there is concern regarding a child’s consumption or ingestion of a controlled dangerous substance will automatically be assigned a P1 priority (24-hour response). In addition, we took immediate steps to shore up our staff, with a special focus on the Baton Rouge region. We work constantly to improve our approaches for keeping children safe and improving children’s well-being.
Ard Case Update
Because the Department of Children and Family Services (DCFS) substantiated the allegations of abuse/neglect regarding the death of Mitchell Robinson, the law allows for the release of limited information.
DCFS received three reports from hospital staff involving Mitchell prior to his death. DCFS did not receive any reports involving this family prior to April 12, 2022, nor did we receive reports alleging abuse or neglect from Law Enforcement or any other concerned individual prior to June 26, 2022.
Information concerning Mitchell was first reported to DCFS on April 12, 2022 from a hospital staff member. Mitchell presented to the hospital as unresponsive, Narcan was administered due to concern about substance exposure, but drug testing did not reveal any presence of substances in his system. DCFS did not initiate an investigation based on the information provided.
DCFS received another report concerning Mitchell on June 4, 2022, from a hospital staff member. Mitchell was brought to the hospital unresponsive. Narcan was administered and he was responsive to this medication. Drug tests did not indicate the presence of substances in his system. Hospital staff shared the physician’s concern that Mitchell was exposed to a substance that standard drug testing would not detect, but also indicated the possibility of neurological issues. DCFS assigned this report for investigation. Attempts were made to visit the family, but these were unsuccessful.
On June 17, 2022, a hospital physician contacted the child abuse hotline to share additional information regarding Mitchell. She informed the hotline that additional testing was ordered on June 4th to determine substance exposure. These results were received on June 16, 2022 and were positive for Fentanyl exposure. The physician informed DCFS that an individual would not medically respond to Narcan unless exposed to an Opioid. Although there was suspicion of Mitchell having seizures, this was ruled out. The physician further reported concern due to learning of the parent’s involvement in a major drug bust that occurred in May. This information was provided to the responsible DCFS staff handling the open investigation. The worker was on sick leave from June 21-27, 2022.
Upon learning of Mitchell’s death, DCFS Administrators initiated an immediate internal investigation. The assigned Supervisor was removed from having supervisory responsibilities pending further investigation. During the course of the investigation, the Supervisor resigned. The assigned worker is suspended pending further investigation. All cases assigned to the involved worker and supervisor were reviewed to determine immediate safety needs. A social worker in the state office with a Master’s degree assumed supervisory responsibility for staff previously reporting to the assigned supervisor. DCFS is actively planning and implementing both short-term and long-term strategies to improve safety planning and service delivery both within the Baton Rouge area and statewide. Internal investigations and planning efforts highlight the need for strengthened collaboration with Law Enforcement, Medical providers and other community stakeholders.
Steps Underway to Stabilize Baton Rouge Region
· Increasing staffing to provide additional workforce capacity and oversight of current decision making through temporary reassignments; emergency contracts
· Solidifying procedures/protocols with key system partners, including law enforcement, district attorney, CASA, medical providers, and Children’s Advocacy Center.
· Strengthening community based response to high risk children and families
Statewide Strategies and Needs
· Recruit, retain and support staff to fully meet the responsibilities of the department. Increase frontline staff, as well as other key positions to increase efficiency, competency, and overall operations, and incorporate policies and services to mitigate secondary traumatic stress.
· Ensure coordinated multi-disciplinary response with key system partners from intake throughout the life of the case, including law enforcement, district attorneys, CASA, medical providers, Children’s Advocacy Centers.*
· Prioritize assessment and services for high-risk infants and toddlers, including by expanding capacity of community partners for targeted intervention with families reported to DCFS with children age 3 and under.*
· Coordinate assessment and referrals with Managed Care Organizations, to provide 24/7 consultation with medical/behavioral health providers for access by all staff from intake throughout the life of the case, as well as for caregivers of foster children.*
· Robust training and coaching of staff,following independent evaluation to validate curriculum contents, safety model, and policies, previously developed with Administration for Children and Families Technical Assistance Center.
· Statewide implementation of Central Consult Decision Making (CCDM), nationally recognized as an effective strategy to streamline safe/invalid investigations, thereby allowing more focus by supervisors on case decision making of unsafe children.
· Enhance research and monitoring of critical incidents, ensuring specialized Continuous Quality Improvement process. Includes retrospective review of child abuse/neglect fatalities as well as evidence-based Critical Incident Review process.*
*Based upon recommendations of the U.S. Commission to Eliminate Child Abuse and Neglect Fatalities