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April 27, 2013 permalink
When two-year-old Caleb Pacheco was found dead in January 2012 the Colorado Department of Human Services produced a twelve page fatality review. Colorado's child protection ombudsman has found 97 mistakes in the report.
Failed to Death
In Colorado child fatality review, nearly 100 inaccuracies found, watchdog says
A state report reviewing the death of a 2-year-old whose mummified body was found under a Sterling mobile home is riddled with almost 100 inaccuracies and missing details about the decisions that child protection workers made before his death, according to an investigation released Thursday.
The investigation, conducted by the Office of Colorado's Child Protection Ombudsman, listed 97 findings that Ombudsman Becky Miller Updike says raise questions about the accuracy and credibility of the fatality review. The Colorado Department of Human Services, which did the fatality review, did not list all of the policy violations made by county caseworkers responsible for protecting Caleb Pacheco, Updike said.
"I'm concerned about the overall number of inaccuracies and the overall process that allows the state to release a report that had so many inaccuracies," Updike said. "If any good can come from the review of this death, it would be that we improve future child protection. I think the number of errors in this report raises concerns about that."
Updike's investigation found that in writing the 12-page child fatality review, human services repeatedly used incorrect dates, did not include details about ongoing drug use by Caleb's mother, Juanita Kinzie, and failed to note that caseworkers incorrectly completed risk and safety assessments.
The Department of Human Services also routinely omitted details found in caseworker reports, incorrectly summarized contacts with Caleb's family and failed to note policy violations, according to the ombudsman report.
Caleb's report was the first released in a new format that Reggie Bicha, executive director of the Department of Human Services, promoted as an effort to create a more comprehensive and transparent account of child fatalities in Colorado. On Thursday, Bicha said that reviewing the report provided both the ombudsman and child welfare services guidance for how to review child fatalities.
"At the end of the day, each side learned from each other, and we have better facts that will help us find better outcomes for kids," Bicha said. "I think the two reports speak for themselves. ... I think that this is the way the process is supposed to work."
Nonetheless, the state's Division of Child Welfare disagreed with 70 percent of the findings listed in the ombudsman report, according to their responses included in the report.
This is the first ombudsman investigation into a report completed by the Department of Human Services.
Child fatality reviews are completed for kids who entered child welfare services two years before their death from abuse and neglect. The reviews detail previous involvement with the child welfare system, including whether caseworkers and supervisors made mistakes in protecting kids.
Caseworkers received at least three calls from people concerned about Caleb before he disappeared in January 2011 — the same month caseworkers returned Caleb to his mother, who child protection workers knew had a history of drug abuse.
Caleb's body was found Jan. 22, 2012. Kinzie was arrested in Denver the day before, high on methamphetamines. She told officers she had strangled her son and hid his body.
Kinzie pleaded guilty to one count of child abuse and one count of second-degree murder and was sentenced to 32 years in prison.
On Jan. 5, almost a year after Caleb's body was found, the Department of Human Services released its review of his death.
The ombudsman report revealed new details and possible violations made by Logan County caseworkers and supervisors in their decision to return Caleb, who had been cared for by his aunt, back to his mother.
The fatality review noted Kinzie consented to a drug test. The ombudsman report says the review omitted the fact that the drug test showed she was using meth.
By the time the drug test came back, Caleb and Kinzie had disappeared.
In their response, human services admitted to withholding the information, but the department said revealing the test's results would have violated federal privacy laws, as Kinzie was in treatment at the time of the test. Neither the ombudsman report nor the human services report indicate that Kinzie was receiving treatments at the time of the drug test.
In all, the ombudsman found 17 additional policy violations, three instances when human services violated state law, 61 inaccuracies and 16 key details about the case not included in human services report.
Among the findings:
- Human services did not include multiple reports about Kinzie's drug use.
- Douglas County caseworker was incorrectly identified as a Denver County caseworker.
- Outcomes of risk and safety assessments in Caleb's case were not included in the human services report.
- Dates for when child protection workers were contacted or closed cases were incorrect nine times in the report.
- Human services violated state confidentiality laws by releasing information about reporting parties — contentions that human services strongly disagreed with in their response.
"I think we've heard the state on numerous occasions say that they are moving toward a more transparent process. However, our findings call that statement into question," Updike said. "I hope the state really is moving toward this because the public deserves it, the families deserve it and the policymakers deserve it."
Updike is leaving her post as ombudsman at the end of May and will take a position as president of children and family programs for Lutheran Family Services Rocky Mountain.
The ombudsman investigation also included recommendations to improve the child fatality review process. The ombudsman office suggested that human services not summarize information from caseworker reports and include more case-specific information. One recommendation suggested that human services work with an outside entity to review all child fatality reviews released in the last two years.
Human services disagreed, or disagreed in part, with those three recommendations and four others.
Stephanie Villafuerte, executive director of the Rocky Mountain Children's Law Center, said the report about Caleb also raises concerns about the accuracy of other child fatality reports completed by the Department of Human Services.
"It is a terribly sad day in Colorado when a child dies from abuse and neglect. It is an even greater tragedy when the report of this child's death contains over 90 different errors and omissions," Villafuerte said. "How can any of us problem-solve around child abuse deaths if we do not have accurate or full information."
Since 2007, 202 children have died of abuse and neglect in Colorado. Among those, 75 had parents or caregivers who were known to the child welfare system before their deaths, according to data compiled by The Denver Post and 9News as part of the Failed to Death project.
Caleb is one of 11 deaths that human services is reviewing from 2012. As of Thursday afternoon, only four of those reports had been released.
Source: Denver Post