Is there any mention of inappropriate supervision (e.g., child wandered off and drowned)?

The fatality report states: "the MA heard the SC crying around 5:00 AM but did not check the SC." The allegations of Inadequate Guardianship were substantiated against both the MA and MC. ACS documented that the SC was placed in an unsafe sleep position (on her stomach) and the caregivers were aware of the unsafe sleep position. The child's activity at time of incident was listed as "Sleeping" and the supervisor was listed as "Asleep."

Is there any mention of inflicted injury? (e.g. slapped, punched, kicked, choked)

The fatality report documents that the child had extensive prior injuries: "the SC was brought to the hospital with 16 rib fractures with multiple fractures in six ribs. The SC also had a fractured right humerus." The allegations of Fractures and Internal Injuries were substantiated against both the mother and father, and an Article Ten Abuse petition was filed. ACS found "The child was diagnosed with multiple fractures and the parents had no plausible explanations for the injuries. ACS attributed the injuries to parents actions or inactions given the age of the child." While the report does not describe a specific mechanism of infliction, the substantiation of abuse allegations for fractures in a 1-month-old strongly implies inflicted injury.

Is there any mention of an unsafe sleeping environment?

The fatality report explicitly states: "ACS documented the SC was placed on her stomach to sleep" and "the ME opined that the way the SC was placed to sleep was the cause of death." Furthermore, "ACS documented the MA and MC were aware of the unsafe sleep position for the infant." The FASP also noted "safe sleep had been discussed multiple times with all caregivers," confirming the caregivers were educated on safe sleep but did not follow the guidance.

Was a foster parent involved in the death?

The household composition table in the fatality report lists the MA's relationship as "Foster Parent" (Female, 50 Year(s)) and her role as "Alleged Perpetrator." Allegations of DOA/Fatality and Inadequate Guardianship were substantiated against her. However, the narrative also states: "The MA, MGGM, and MC did not want foster care for the SC as the SC's status was changed to a release to relative." This creates ambiguity about whether the MA was technically a foster parent or a kinship relative caretaker, though the official household composition table labels her as "Foster Parent."

Was another adult relative involved in the death? (e.g., grandfather, aunt)

The fatality report documents that the child was in the care of her maternal aunt (MA), maternal cousin (MC), and maternal great-grandmother (MGGM) at the time of death. Allegations of DOA/Fatality and Inadequate Guardianship were substantiated against the MA and MC. The MA placed the child to sleep on her stomach and heard the child crying at 5:00 AM but did not check on her. All three are adult relatives of the deceased child.

Was the child in foster care at the time of the incident?

The fatality report's household composition table labels the MA as "Foster Parent," suggesting the child may have been in a foster care placement at the time of death. However, the narrative states: "Family Court approved the SC's discharge from foster care on 12/1/21" and "the SC's status was changed to a release to relative," indicating the child was officially discharged from foster care before her death on 2/3/22. The conflicting information between the household composition label and the narrative description creates genuine ambiguity about the child's formal placement status at the time of the incident.

Was the child living with relatives at the time of the incident (but not parents)?

The fatality report clearly states: "At the time of the fatality, the SC was residing with her adult MC, MA, and MGGM." These are the maternal cousin, maternal aunt, and maternal great-grandmother — all relatives, not the child's parents. The BM and BF were listed as having "no role" and resided in a different household ("Other Household 1"). The child's placement with these relatives followed her removal from her parents due to substantiated abuse.

Is there a history of child protection reports prior to death (for this child or siblings)?

The fatality report documents a prior CPS report dated 10/16/2021: "The 10/16/21 report alleged that the SC had a fractured right humerus with no explanation for the injury." This report was indicated/substantiated against both the mother and father for Fractures, Inadequate Guardianship, and Internal Injuries. The child was diagnosed with 16 rib fractures and a fractured right humerus, leading to her removal and placement with relatives.

Does the child have a history of foster care (but not in care at time of incident)?

The fatality report states: "Was the child ever placed outside of the home prior to the death? Yes." It further states: "The FSPN reflected that the Family Court approved the SC's discharge from foster care on 12/1/21. The SC was directly placed with the MA with ACS supervision." The child was initially placed with paternal relatives (PGGM and PA) after removal, and was later placed with the MA. The child's status was changed from foster care to "release to relative," indicating the child had been in foster care but was discharged prior to death.

The fatality report contains several substantive details that materially affect understanding of this case. First, the child had an extensive prior abuse history: at just one month old, she was diagnosed with "16 rib fractures with multiple fractures in six ribs" and "a fractured right humerus," with the injuries substantiated against both biological parents. Despite this severe abuse history leading to removal and placement with relatives, the child died from unsafe sleep practices in the relatives' care — even though the report documents that "safe sleep had been discussed multiple times with all caregivers" during home visits on 12/7/21, 12/20/21, and subsequent visits. Additionally, the report identifies a compliance failure: "The documentation did not reflect the MA, MC, or the MGGM were offered services related to the fatality" — specifically, bereavement counseling and funeral arrangement assistance were not offered. The Article Ten Abuse petition filed against the biological parents on 10/21/21 was "withdrawn and dismissed on 2/3/22 due to the SC's death" — the same day the child died. The ME also noted "old fractures to the ribs and arm" on the child at the time of the fatality examination, but opined they "had nothing to do with the SC's death."