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Observer Investigation: Deaths point to crisis in NC's child welfare system

Fayetteville Observer - 10/11/2017

Oct. 10--Twice in the weeks before Bryan Nathaniel Mathews died, someone tried to warn child protective services.

The mobile home in Fayetteville where the infant lived with his two young brothers was filthy and unsafe, according to whoever reported the family to the Department of Social Services. The source also said the children's parents weren't supervising them.

Little was done.

Within three days after the second report to DSS, the infant was found dead in his crib. He was 12 weeks old when he died on June 23, 2015.

The police officers who arrived to investigate would later describe the home's condition as "deplorable at best." Trash everywhere. Dog feces and urine on the floors and walls. A rotten apple core, a bottle with crusted milk and dirty clothes in a Pack-N-Play. The two other children were immediately placed in foster care.

Had a social worker seen the same "deplorable" conditions?

Would Bryan be alive today if DSS had removed the children earlier?

The social worker assigned to investigate the family hadn't been to the home in "quite some time" before the death and had misrepresented the poor conditions, said Brenda Jackson, the DSS director. That social worker was fired after Bryan died, and the supervisors were disciplined. DSS put in place several improvement strategies in response to the handling of the case, including increased oversight, she said.

Bryan's death isn't an isolated tragedy in North Carolina. A Fayetteville Observer investigation found more than 120 children have died in the state within a year of their parents or caregivers being referred to a DSS agency. Some of those deaths, which go back nearly a decade, were from undetermined causes or accidents. But 31 of the children were killed -- beaten to death, shot, drowned, smothered or poisoned by drugs.

[Fatal Flaws: About this series]

The deaths of children are the most disturbing evidence of a state child welfare system that has been in crisis for years. Through public records and interviews over several months, the Observer found dozens of examples across North Carolina where children connected to DSS died because social workers failed to fully investigate parents or properly assess safety risks.

The numbers may be even higher. The only way for the public to know about these normally confidential DSS cases is when the state conducts a review of a suspicious child death, a process meant to identify any cracks in the system.

These reviews become public records and serve as an accountability tool for DSS, local law enforcement, medical providers and others. But for years now, the state's Child Fatality Review Team has been woefully behind, the Observer found. Some reviews weren't done for four or five years after a child died. An additional 112 child deaths, on top of the 120 that the Observer examined, have yet to be reviewed by the state team, including Bryan's death in 2015.

North Carolina has taken some steps to address failures in its child welfare system, including reforms adopted this year called Rylan's Law after a Moore County toddler.

And on Friday, a senior official at the N.C. Department of Health and Human Services said the agency is making it a priority to clear the backlog of child death reviews by July.

But child advocates say the problems run deep. Among the Observer's findings:

--The state spends relatively little on prevention programs aimed at keeping struggling families together, before abuse occurs. Though the programs have proved effective, North Carolina spends only about $3 million a year on them. The N.C Justice Center estimates that child abuse and neglect cost this state about $2 billion annually.

--People accused in the death of a child often face little punishment. Parents or guardians are typically the only witnesses, and a weapon is rarely used. Most sentences in the cases reviewed by the Observer were probation to a few years in prison.

--The number of children in foster care has skyrocketed more than 25 percent in five years. More than 11,000 children in North Carolina are now living in the foster system -- something a leading child advocate calls a crisis. Cumberland County ranks at the top: The number of foster children from this county would fill a middle school.

Michelle Hughes, executive director of the advocacy organization NC Child, said the entire child welfare system needs a "radical transformation." The answers lie not only in the need for more money and better oversight, Hughes said, but in widespread use of programs proven to stop abuse.

But Hughes isn't optimistic that will happen anytime soon in North Carolina.

"The legislature recognizes it is in crisis, and I think they are committed to trying to strengthen that system and solve what is a range of problems and challenges in that system," she said. "I think we have a ways to go when you are looking at prevention. It's a harder case to make when you have a crisis."

[ MAP: Child deaths in North Carolina. ]

----North Carolina's child welfare system has undergone intense scrutiny for years with little substantive change until last year, when the General Assembly began putting more money into it. That change was driven largely by a federal evaluation in 2015 that found the state failed all 14 child-welfare outcome and performance measures.

Among the findings were that DSS cases had been closed prematurely while safety concerns remained, and parents and children in the system lacked access to health services.

The review forced the N.C. Department of Health and Human Services to make and follow an improvement plan or face a $1.7 million fine.

Partly in response to the damning federal report, the state began conducting child welfare evaluations of all DSS agencies in 2015. An evaluation of Cumberland's DSS last year found significant deficiencies, including one area in which child welfare workers failed in 72 percent of the cases evaluated to visit a family within seven days of when abuse or neglect is substantiated. Sometimes, those visits weren't done until months later, when the process was supposed to have moved from investigation to providing in-home services.

The state recognized that Cumberland had experienced significant staff turnover in the prior two years. But the delay in providing in-home services "is an area of significant risk to the agency," the state said.

Cumberland's DSS wasn't unique. Evaluation records from eight other large DSS agencies show problems at all of them. The state ordered each to revise its program development plans to address the findings and recommendations.

[Observer forum: Finding solutions to our child welfare crisis]

Another study, commissioned by the state to examine child protective services, found county DSS offices lacking in oversight and accountability. Social worker burnout and turnover hindered the agencies, as did a lack of resources.

Reacting to both studies, the state DHHS prepared a Child Welfare Strategic Plan and presented it to lawmakers in February. It calls for strengthening the child welfare and foster care systems, and ensuring that families in DSS care receive proper services and assistance.

"It is our hope that this document will, over the next five years, guide our efforts in creating an exemplary child welfare system in North Carolina," the plan says.

Until then, North Carolina continues to operate under a system that Republican Sen. Tamara Barringer, a former foster parent from Wake County, said is failing its children.

----Glaring examples of that failure are found in the state reviews of children's deaths.

Under North Carolina law, county DSS directors are required to report any child death where they suspect neglect or abuse within five business days to the N.C. Division of Social Services. The division then decides whether a State Child Fatality Review Team should investigate.

These review teams don't look to find fault. Their mission is to identify any critical missteps and recommend important policy changes to prevent future deaths. Each team is different, usually composed of people from local DSS, health departments, nonprofits, hospitals and law enforcement. They are headed by a reviewer from the state division.

The Observer requested completed review team reports under North Carolina's public records law. The state responded with 117 cases in which 120 children died of suspected abuse or neglect within a year of the family or caregivers becoming involved with DSS.

In dozens of deaths, review team reports show, social workers failed to fully investigate the mental health, substance abuse and criminal histories of relatives or caregivers. In other deaths, DSS offices failed to properly educate families or provide them services, such as drug or alcohol treatment. The reviews also found police, hospital workers, friends, families and neighbors failed to relay suspicions of abuse or neglect until it was too late.

A case involving Ashley Tiara Fraiter of Cabarrus County is fraught with such failures. Fraiter, 18 at the time, was accused of killing her 5-month-old son Marcus in August 2008. An autopsy showed that the infant died from a blow to the head. Both of his arms had been broken, one an earlier break that had begun to heal. Fraiter was charged with murder and felony child abuse; she later was found guilty of involuntary manslaughter and sentenced to three years of probation.

The review team's report shows that hospital staff failed to notify DSS social workers about their concerns of abuse when they saw Marcus earlier.

[Explained: Child Fatality Review Team]

And a DSS safety assessment "was not updated with case changes and did not sufficiently take into consideration all relevant information such as past history, domestic violence, substance use, and effectiveness of parenting skills."

The review team's recommendations included that DSS would work with the hospital on identifying and reporting signs of abuse. DSS would make sure it spends enough time with families to thoroughly complete safety assessments, and DSS would reinforce with supervisors their responsibility to meet regularly with their social workers.

The review team report also cited how the parents had evaded social services by moving between counties. DSS agencies have a hard time sharing information with one another, because most still log reports on paper rather than using a computer system.

State officials say they expect to convert the DSS agencies to a computerized system called NC FAST, but they've been saying that since at least 2002. The electronic system is to be in place for all counties by next year.

"We have to have a way to measure outcomes. Until we have NC FAST we can't hold groups accountable because we have no way of measuring it," said Barringer, the Wake County senator.

DSS offices have been using NC FAST since 2013 to determine Medicaid eligibility, but a state audit of 10 agencies released this year found serious problems in their ability to make the determinations accurately and timely. Staff turnover and training were leading causes.

----If the Child Fatality Review Team's work is important for ensuring children don't die while in DSS care, why does it take so long for the state to review a case?

Staffing is one reason. Five years ago, the team had two employees and a temporary worker to cover the entire state. The team had a backlog of 38 child deaths awaiting review, according to a 2012 report by The Associated Press.

And for the last two years, the team had only one full-time employee and a temporary worker, DHHS spokeswoman Kelly Haight said.

Teams conducted only six reviews in 2016, according to records provided to the Observer. And the backlog has grown to 112 child deaths as of August.

With limited staffing, it has routinely taken two years -- and sometimes as many as four or five years -- for a review team to examine a case after a child dies. The reviews typically take two days to complete.

The state blames some of the delays on difficulties in getting health records under federal privacy laws, and on law enforcement asking review teams to wait until their criminal investigations are complete.

But waiting so long can have serious consequences, said Simmons, the executive director of the Council for Children's Rights in Charlotte. Social workers, witnesses and family members tied to the case may have moved or can't remember the events leading to a death, said Simmons, a member of the review team for Mecklenburg County.

At the urging of Simmons and others, the General Assembly last year approved spending $59,000 to hire three more state workers for the review teams.

On Friday, Haight, the DHHS spokeswoman, said in an email that the N.C. Division of Social Services added federal money to that amount and has hired four child fatality reviewers and a supervisor within the last year. She said the division also is implementing a new policy to schedule an initial child fatality review within 24 hours of receiving a report, and intends to finish each review within three to six months unless law enforcement asks for a delay.

"We are also working with our local partners to further streamline this process to improve our understanding of why these fatalities occur and to develop recommendations for preventing them in the future," said Michael Becketts, assistant DHHS secretary, in an email Friday. "We take the review process seriously and it is a priority for the department. We expect to have the backlog of reviews completed by July 1, 2018."

The five new review team employees will have their work cut out. The 112 child deaths awaiting a review are nearly as many as all of those conducted between 2011 and 2016.

----In North Carolina, the public rarely learns about a child dying in the care of DSS unless those responsible are charged with murder. The only child welfare documents that become public are those from the State Child Fatality Review Team.

But in the case of Bryan Mathews, a Cumberland County Courthouse worker became so incensed about what happened to the infant that she tipped off the Observer.

The tip led to a Fayetteville police document called a warrant information form.

The form, dated the day of Bryan's death, further describes the conditions the infant and his brothers were living in.

The older boys -- then ages 1 and 3 -- slept without sheets or blankets. The mattress was covered in loose plastic, "which they could have easily suffocated on," the form said.

Their mobile home on Crestwood Avenue off Bingham Drive was infested with fleas, and bites covered the older boy's arms and legs. He suffered from anxiety and would hide under the table at daycare and shake.

Bryan's brothers were unable to speak, the police document said, "only making what sounded like animal sounds to each other to communicate. They lacked the basic skills as getting dressed, brushing their teeth, eating with utensils and were often caught eating food out of the trash can. Daycare social worker reported to DSS that (the older boy) came to school daily filthy and smelling so bad, and finding dog hair inside his diaper."

[What to do if you suspect child abuse]

District Attorney Billy West said Fayetteville police considered charging Bryan's parents with murder, but no one was sure what caused his death. The autopsy listed the cause as undetermined, possibly sudden infant death syndrome or unsafe sleeping practices.

Without a specific cause, police didn't think murder charges would stick. A year later, they charged the parents, Joe and Heather Mathews, with three counts each of contributing to the delinquency of a minor. Joe Mathews also was charged with misdemeanor child abuse.

On April 11, Cumberland County District Court Judge David Hasty found the parents guilty on the delinquency charges and sentenced them to 18 months of probation. Their children remain in foster care.

During the trial, Fayetteville Police Officer Devon Miller described the conditions of the home as "deplorable."

"There was trash all throughout the house," Miller testified, saying his shoes stuck to the floor.

The carpeting was soiled and bloodstained in spots, he said. A burgundy couch appeared almost black.

According to testimony, Heather Mathews went to the bedroom to study for college classes the evening before her son was found dead. She told investigators she left her husband to tend to the children.

Miller testified that Joe Mathews told him he had propped up Bryan with a pillow and gave him a bottle, believing the newborn was able to feed himself.

Officer Patrick Strickland testified that Joe Mathews told him that he checked on Bryan about 7:30 a.m. About four hours later, he checked again and found a large blanket over Bryan's face and blood around his nose. The baby was dead.

Heather Mathews also testified. She said a judge was working on a plan that would reunify the family. She said she had a job and was taking courses through the online Phoenix University. She was taking parenting classes as well, she said, adding that the instructor was "so amazed by her progress."

At that remark, a social worker involved in the case stood up and told the judge that DSS had to get a court order to make her comply with the parenting classes and other programs. The social worker said she wasn't pleased with the parents' progress.

Daisy Smith stood outside the courthouse at the trial's conclusion. A foster parent, she said she took the children into her home after Bryan's death but had to give them back to DSS because they had an "unmanageable behavior."

"You could tell the kids had been neglected," Smith said. "They couldn't get along with other kids."

Last week, Heather Mathews agreed to talk to a reporter about the case but didn't return a call. In a private message on social media, she accused DSS of taking children from their parents for years for no reason.

That, she wrote, is the real story.

Staff writer Greg Barnes can be reached at gbarnes@fayobserver.com or 910-486-3525.

MAP: Numbers of deaths reviewed per county. Select it to read the reports.

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(c)2017 The Fayetteville Observer (Fayetteville, N.C.)

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