The following is the first of my articles on foster children who have been abused or neglected within a system that was supposed to protect them. There will be more to follow. This story can be found linked on the following website:

Link

Melissa’s Story1

Melissa, a blind two-year-old foster child regularly kicked her portable crib “until she tire(d) herself and (fell) asleep,” according to her foster mother.2 Family members said that Melissa spent most of her days in a walker, since she was unable to support herself sitting up, but stayed in a portable crib at naptime and at night.

According to Melissa’s foster mother, when Melissa was younger, she was medically fragile due to CHARGE Syndrome, a rare disorder often resulting in blindness, profound hearing loss, heart malformations, retarded growth, blocked sinuses, lung congestion and physical deformities.3 Since becoming older, the foster mother said Melissa required only basic care, was not medically fragile and did not need surgery for a hole in her heart.

Besides her foster mother and grandmother, Melissa lived with five foster siblings and the foster mother’s two biological children. Her foster brothers’ ages were 2, 1 and 4 months. Her foster sisters’ ages were 9 and 2. The foster mother’s biological children were 14 and 12 years old.

One Saturday evening, as part of a regular routine, her foster mother put Melissa to sleep at 6:30 p.m. The foster mother had a monitor and could hear Melissa’s usual “pattern of noises and kicking.” The foster grandmother said she checked on Melissa about 7 p.m. and found her sleeping. The foster mother said the door to Melissa’s room is always open, and people are always passing by and looking in. About 9 or 9:30 p.m., the foster grandmother decided to wake Melissa and “finish feeding her.” She found Melissa motionless in a collapsed crib.

According to the foster mother, she put Melissa on the kitchen table and began CPR, and when there was no response, they called EMS. When EMS arrived, Melissa was “somewhat stiff” and pronounced dead at the scene. Melissa did not appear to have any trauma, except that there was blood and stool in her diaper.

A detective at the scene reported that he observed the crib and found that the bottom, wooden part of it had been dismantled. He said that the crib appeared to have been assembled incorrectly or that its screws were not tightened. He said “the lower portion of the crib where [Melissa] was supposedly lying was on the ground.” He also noted that the pillow and blanket that the foster mother said the child was using in the crib were in the next bedroom on a double bed.

The foster grandmother said she found Melissa face up with her head sideways at an angle, with part of her body on the floor and part on the crib mattress. The foster mother and grandmother said that the screws had been loose before and that a handy man tightened them. The 12-year-old biological daughter could not remember when she last saw Melissa, but said that she had heard her banging on her crib that morning. That evening, however, no one heard the bed collapse. The foster mother speculated that the child suffocated when the crib fell.

DPRS closed an investigation for neglectful supervision with a finding of “unable to determine.” The licensing investigator had not received the medical examiner’s findings, but reported that the examiner said that no abuse was found. The licensing investigator did not find any violations.

According to the detective involved in the case, the autopsy found the cause of death to be “undetermined,” meaning that the medical examiner could not find a cause and did not find any signs of abuse; he ruled that the blood in the diaper was not caused by abuse. The county medical examiner refers all child deaths to an expert local death review committee, but DPRS did not refer the case to any of its internal or external review personnel or committees. Agency policy requires only that deaths determined to be from abuse or neglect be referred to a death review committee.4

Consequently, no one asked questions that could lead to improvements in DPRS policies, standards and procedures, or that could improve care of children in this foster home. For instance, no one asked why Melissa was “finishing being fed” at 9 p.m., when she already had been fed at 6 p.m. and left in her crib awake. No one asked why the foster mother could not hear a crib collapse over the monitor when she had no problems hearing Melissa’s “noises and kicking” when she was awake. No one asked why the foster mother noticed nothing amiss when she put the younger children to bed earlier.

The foster mother’s use of a portable crib with loose screws was not cited as a violation, though standards require equipment and furniture to be safe for children. CribSafe.net recommends that portable cribs not be used as permanent beds. They are not subject to as many safety requirements, are smaller than regular cribs, are “not suitable to the rigorous wear and tear of daily crib use” and should not be used at all after a child is 18 months old. The organization also cautions that children have suffocated due to extra mattresses placed in cribs; Melissa’s had two.5

No one questioned the appropriateness of placing a medically fragile child in a house with seven other children and only two caretakers. Despite the fact that DPRS’ licensing investigator found “no violations,” the foster home exceeded the number of children allowed according to the agency’s licensing standards. These require that a foster family shall not care for more than six children, nor more than two infants under 18 months old, including biological children.

Melissa’s death file contains a report form, the intake call report, a contact log with summaries of interviews with witnesses, the police report, a letter to the foster parent announcing the findings and a misfiled form belonging to an unrelated case file.

The CCL investigator referenced police photographs but did not include them in the file. The investigator ordered CPS medical records, physician records and a copy of the autopsy and medical examiner’s report, but these were not in the file because DPRS closed the case before the investigator received them.

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Endnotes
1The child’s name has been changed for privacy reasons.
2Except as otherwise noted, all information is from the Texas Department of Protective and Regulatory Services.
3WebMDHealth.com, “CHARGE Syndrome,” http://my.webmd.com/content/healthwise/8/1944.htm?lastselectedguid={5FE84E90-BC77-4056-A91C-9531713CA348. (Last visited February 1, 2004.)
4Texas Department of Protective and Regulatory Services, CPS Handbook (Austin, Texas), Section 2313.
5ChildSafe.net, “Non-Full Size Cribs and Portable Cribs,” http://www.childsafe.net/for_parents/portable.html. (Last visited January 8, 2004.)