LANSING, Mich. (WOOD) — Michigan’s child welfare agency failed to immediately report several dozen child deaths to a state-mandated watchdog agency, as required by law.
“I was surprised, definitely surprised,” Seth Persky told Target 8 in an interview at the Lansing headquarters of the Michigan Department of Health and Human Services, which is the division that includes CPS. “These are child deaths. We don’t want to miss any child deaths, of course.”
But while cross-checking computer systems this summer, Persky discovered CPS hadn’t issued the required “child death alerts” in 37 cases statewide in 2016. That’s roughly ten percent of the approximately 300 alerts the child welfare agency issues yearly.
It’s those alerts that trigger reviews by the Office of Children’s Ombudsman, an independent state agency that acts as a watchdog in cases that involve CPS, foster care, and juvenile justice.
In Michigan, when a child who’s had recent contact with the state dies, the ombudsman is required to conduct a review.
CPS: “We all get into this business to help families, to protect children”
The watchdog, established by the legislature in 1994, examines whether CPS caseworkers followed policy and law, or could have done something more to protect the child before it was too late.
“They serve an important purpose,” acknowledged Perky. “So we want to get them accurate information so they can do their job well… we all get into to this business to help families, to protect children.”
You need only to look at the faces of children we’ve lost to understand why it’s critical that CPS report deaths promptly.
In several high-profile child death cases, the ombudsman’s review found CPS caseworkers failed to follow policy in their contacts with the families prior to the fatalities.
Those findings often prompt additional training for workers and, in some instances, system-wide CPS policy changes that could save future children.
In 2005, Ricky Holland was murdered by his adoptive parents, who then dumped the 7-year-old’s body in a state game area south of Williamston, east of Lansing.
The ombudsman determined CPS caseworkers failed to thoroughly investigate prior complaints that Ricky was being abused.
In 2007, Nicholas Braman was killed in a murder-suicide orchestrated by his father, Oliver Braman.
The ombudsman found that CPS should have removed the 9-year-old from his father’s Stanton home after the elder Braman admitted to using an electric cattle prod on his other children.
In 2008, Calista Springer died when fire swept through her home in the Village of Centreville in southwest Michigan’s St. Joseph County. The 16-year-old’s parents had tethered her to the upper bunk of her bed.
The ombudsman reported CPS had received complaints that Calista’s parents were restraining her, but caseworkers failed to thoroughly investigate the allegations.
CPS: This case will prompt us to look at how that error was made
It was a call from Target 8 that prompted the Office of Children’s Ombudsman to question CPS about one particular missed death alert.
Chance Powell, who was 10 months old, died in October 2015 after accidentally swallowing one of his grandma’s morphine pills at the family’s Sparta apartment.
Target 8 learned of Chance’s fatal overdose while investigating the opioid epidemic in West Michigan.
Chance’s grandmother told Kent County deputies that she kept her morphine bottle in her bra to keep her adult children from stealing the pills.
Instead, baby Chance somehow got a hold of one.
Target 8 called the ombudsman to find out if the agency had conducted a review of Chance’s death, as is required in cases where families have had contact with CPS.
But CPS had never issued an alert in Chance’s death and, thus, the ombudsman was unaware of it.
“This case will prompt us to look at how that error was made,” Seth Perksy told Target 8.
It’s Perksy’s unit, the Office of the Family Advocate within the Michigan Department of Health and Human Services, that’s responsible for getting those alerts and passing them on to the ombudsman’s office.
In fact, OFA uses the alerts itself to conduct reviews of child deaths from inside CPS.
But Persky’s office never got an alert in Chance Powell’s death.
CPS: Someone has to alert centralized intake after the child dies
After investigating what’s going wrong, Perksy blamed missed death alerts on two failures.
Alerts are triggered by intake workers at CPS’s complaint hotline.
The call takers have to click a box on their computer screen indicating a death, which automatically sends an alert to Persky, who then passes it on to the ombudsman and at least one other public health entity.
But sometimes, intake workers either forget to click the box or the box somehow becomes unclicked, perhaps when a caseworker accesses the file to enter new information.
The second reason for missed alerts involves the way calls first come into the complaint hotline.
In some instances, cases are initially reported as near deaths, but when the child actually dies, the caseworker fails to circle back to notify intake and trigger an alert.
“Someone has to alert centralized intake after the child dies that there’s been a child death and then we get the alert,” explained Persky.
CPS: Doing checks very frequently will definitely fix this problem
Around the same the ombudsman learned about Chance Powell’s death, Persky says he conducted a “routine” cross-check of computer systems and discovered CPS had failed to issue alerts on a total of 37 child deaths statewide in 2016.
So far in 2017, CPS has discovered twelve deaths in which it failed to send alerts.
Persky is still reviewing the child death alert system, looking for ways to improve its accuracy and timeliness.
For now, he’s cross-checking computer systems monthly, comparing his list of death alerts against the state’s child welfare database – known as MiSACWIS – to ensure he’s not missing any fatalities.
In the past, Perksy says he conducted those cross-checks quarterly and yearly.
“Doing checks very frequently will definitely fix this problem” he said.
Additionally, Perksy pointed out that failing to issue a “child death alert” does not mean that CPS is unaware of the death internally.
In fact, managers at the county level should already be reviewing death cases to look for potential errors.
“It’s a really challenging time for our workers,” said Persky, referring to child death cases. “[Caseworkers] are dealing with surviving siblings. They’re talking to parents who just lost a child. They’re talking to law enforcement. But they do need to call that back in to centralized intake. That’s how we find out that the child died.”
Jared Verkerke: CPS should have no control over what they report
Another high-profile case that illustrates the important role of the Office of Children’s Ombudsman was the fatal stabbing of Connor Verkerke on a Kentwood playground in August 2014.
Verkerke’s killer, 12-year-old Jamarion Lawhorn, had previously had multiple contacts with the child welfare system.
The ombudsman’s office examined the Lawhorn family’s prior involvement with CPS after Target 8 contacted the watchdog about Jamarion’s case.
It was the 12-year-old himself who reported the stabbing to 911, telling the dispatcher he was “fed up with life.”
The ombudmsan determined that CPS should have tried to remove Jamarion from his mom’s custody because she’d admitted to abusing him and had already lost parental rights to two other children in another state.
“It seemed like every person and system in place failed at one level or another,” reflected Connor’s dad, Jared Verkerke, in a recent interview with Target 8. “[CPS] just kicked the can down the road until the can exploded and we happened to be right in front of it when it exploded.”
Now, Jared Verkerke and his wife, Dani, speak out whenever they can in hopes of improving the system designed to help protect Michigan’s children.
“When you have several cases that should have been passed on to the ombudsman that weren’t, obviously something is going wrong there,” Dani Verkerke said. “Somebody needs to look at that and try to come up with a solution.”
Jared Verkerke wants the state to find a way to take CPS out of the equation when it comes to issuing the child death alerts that trigger ombudsman reviews.
“CPS should have no control over what they do or do not report because nobody wants to report things where they may or may not have screwed up,” he said. “We have a bad habit in our society of ‘x happens’ and three years later, something is implemented to prevent ‘x’ from happening again. But how many people are lost between ‘x’ and three years later?”