“Multiple failures” by DCFS blamed on Baton Rouge toddler’s fentanyl death

BATON ROUGE — A report by the Office of State Inspector General’s Office details “multiple failures” by the Department of Children and Family Services, or DCFS, that contributed to the fentanyl overdose death of two-year-old Mitchell Robinson, III.

The scathing report says systemic problems within DCFS led to Robinson slipping through the cracks and points the finger directly at the agency for taking “no action whatsoever” during a nine-day period where DCFS personnel had knowledge that Robinson tested positive for fentanyl.

DCFS fentanyl overdose death of Mitchell Robinson
2-yr-old Mitchell Robinson

“There are serious concerns regarding the safety of the child”

The IG’s report sites that the DCFS caseworker assigned to Robinson’s case was “overburdened” and that her supervisor failed to assist with that caseload. It goes on to say that there was a failure to check on “whether initial in-person contacts were made” in Robinson’s case. The report also claims that the caseworker’s supervisor failed “to manage the caseworker’s assigned cases while she was out on sick leave for an entire week.”

DCFS personnel were not trained on the medical use of Narcan, a drug used to reverse the impacts of opioid overdoses, the report said. The department “did not initially recognize the significance of the child having been revived on two occasions with (Narcan),” according to the report.

Part of the problem was that the toxicology screens used by the hospital did not test for synthetic opioids, which includes fentanyl, leading to initial negative results that “caused confusion among DCFS personnel not familiar with the medical use of Narcan.” However, an email in the IG’s report from an unnamed child welfare manager acknowledged the hospital’s testing and noted “…There are serious concerns regarding the safety of the child.”

The case was assigned as Priority 2, requiring the assigned caseworker make face-to-face contact with a parent and the child within 48 hours per DCFS policy. A caseworker was assigned the next day on June 7, 2022.

‘Perfect storm’ of failures

There were three calls linked to Robinson’s case reported to the DCFS toll-free, statewide hotline within its Child Welfare Division. The first call was on April 12, 2022 by a nurse at OLOL’s North ER after Robinson was brought in “unresponsive” after reportedly eating candy from an Easter egg hunt. The nurse reported that Robinson was not breathing but that he had responded to “four rounds” of Narcan and was on a “Narcan drip.”

A second call was made on June 4 from the same OLOL North ER that Robinson was “unresponsive” once again. The report says, “At least four times during the call, the nurse stated that the child would ‘only respond to narcotic reversal medication.’ She noted that the child responded to his first dose of Narcan, but did not respond well to the second or third doses.

Robinson was in respiratory distress when he was transferred to Children’s Hospital.

The report says that on June 17, nine days before Robinson’s death and 10 days after the case was assigned to a DCFS caseworker, a third call was made to the DCFS hotline by a pediatric emergency physician who had treated him on June 4. She told the hotline that Robinson had “overdosed in his own house twice” and “went home with parents who nearly killed him twice.”

UWK first reported the doctor’s pleas for help after Robinson’s fentanyl overdose in August 2022.

The report says the doctor tried educating the call-taker about Narcan, saying, “…the only thing that Narcan works for is opiates.” The physician also told the call-taker about a May 2022 news report of a drug bust at the child’s residence.

An email with the information provided by the physician, including a positive fentanyl test, was documented and sent to a DCFS supervisor and the caseworker on June 17.

The investigation revealed that, “DCFS administrators believed that the information provided in the hotline calls by the OLOL North ER nurse was not clear, as the caller stated on each occasion that the hospital’s ‘drug screen was negative.’

The IG’s investigation found the lack of training about Narcan, how it works and what it is used for, led to Robinson’s case not initially being accepted by DCFS for investigation.

The report also notes that the caseworker assigned to Robinson’s case was assigned “several other high priority cases” during the same time, and that she became sick after being assigned his case. The report says that in-person contact, as required by the agency, was never made.

The caseworker cooperated with investigators. The DCFS supervisor over this case was demoted before resigning from the agency, and she did not cooperate with the State Inspector General.

Failed by the system

The breakdown goes beyond DCFS. The report says that law enforcement was not contacted by medical personnel, even after Robinson was revived twice following fentanyl exposure.

There are also no records, according to the report, of law enforcement contacting DCFS after Robinson’s parents were arrested in May 2022. EBRSO responded to the IG’s report telling UWK, “Detectives said they were called but unfortunately did not document the specifics. The child was released to a family member that was not involved in the criminal activity. We now require that DCFS give us an intake reference number for our report.”

There was also “poor and vague communication” between medical personnel and DCFS on the first two calls made to the agency’s hotline.

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