Is there any mention of child drug ingestion or overdose?

The fatality report states: "The child's toxicology revealed norbuprenorphine in the urine which was most likely from the mother's breastmilk." While not a traditional ingestion or overdose, the child did ingest a drug substance through breastmilk, and this was noted as a relevant finding in the autopsy.

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

The fatality report notes that the child's supervisor was "Asleep" at the time of the incident and the child was last seen by the caretaker 4 hours before the incident. The autopsy report stated "a co-sleeping adult on buprenorphine may not exhibit a level of vigilance necessary to avoid an accidental rollover onto newborn," suggesting the mother's medication use may have impaired her ability to supervise the infant. The mother was prescribed Suboxone and had "ran herself short" taking it only twice instead of three times that day.

Is there any mention of prenatal substance exposure (including fetal alcohol syndrome or neonatal abstinence syndrome)?

The fatality report explicitly states under "Infants Under One Year Old" that during pregnancy, the mother "Misused over-the-counter or prescription drugs" and "Used illicit drugs." Additionally, the infant was listed as born "Drug exposed."

Is there any mention of an unsafe sleeping environment?

The fatality report extensively documents an unsafe sleeping environment. The mother co-slept with the 30-day-old subject child and 3-year-old sibling in a queen-sized bed. The report states: "MCDSS found there to be a fair preponderance of evidence to support that the mother was aware of safe sleep practices and had multiple safe sleep provisions for the subject child; however, she regularly co-slept with the subject child, and the autopsy suggested the subject child's death was a result of co-sleeping." The autopsy noted findings "suggestive of a possible object, including a bedmate's body part on the lower face at time of death." Multiple safe sleep provisions (bassinet and Pack n' Play) were available but not used.

Was a biological mother involved in the death?

The fatality report identifies the mother as an "Alleged Perpetrator" and the allegations of DOA/Fatality and Inadequate Guardianship were "Substantiated" against her. The report states: "MCDSS found there to be a fair preponderance of evidence to support that the mother was aware of safe sleep practices and had multiple safe sleep provisions for the subject child; however, she regularly co-slept with the subject child, and the autopsy suggested the subject child's death was a result of co-sleeping."

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

The fatality report documents multiple prior CPS reports. A 06/10/2021 report alleged the father pushed the mother while she was holding the sibling (Indicated). A 03/23/2019 report alleged Parents Drug/Alcohol Misuse when the sibling's meconium tested positive for marijuana (Indicated). Additionally, there was an open CPS investigation at the time of the fatality "regarding domestic violence by the father toward the mother."

Is domestic violence by the parent/caregiver referenced?

The fatality report states: "There was an open CPS investigation at the time of the fatality regarding domestic violence by the father toward the mother." The prior 2021 SCR report alleged "the mother and father of the subject child got into a verbal argument on 6/8/21. The mother was holding the sibling when the father pushed them against a wall." The mother also "had previously been engaged with a domestic violence advocate." Additionally, during pregnancy, the mother "Experienced domestic violence."

Is a history of arrests or criminal charges for the parent/caregiver referenced?

The fatality report states: "The father of the subject child had a warrant out for his arrest at the time of the death for charges unrelated to the fatality and was unable to be located during the investigation." The warrant for charges unrelated to the fatality implies prior criminal history for the father, a parent/caregiver.

Is substance use by the parent/caregiver referenced?

The fatality report extensively references substance use by the mother. She was prescribed Suboxone, and "In the mother's statement to law enforcement, she reported she is prescribed Suboxone and is supposed to take it three times a day; however, on 3/31/22, she 'ran herself short' and only took it twice." The report also notes "The mother and maternal grandmother were also engaged with substance misuse counseling prior to the fatality, due to a history of substance misuse." During her pregnancy with the sibling, the sibling's meconium tested positive for marijuana. During pregnancy with the deceased child, the mother "Used illicit drugs" and "Misused over-the-counter or prescription drugs."

The fatality report reveals several notable systemic and policy issues. First, the autopsy noted that "a co-sleeping adult on buprenorphine may not exhibit a level of vigilance necessary to avoid an accidental rollover onto newborn," establishing a direct link between the mother's Suboxone use and the unsafe sleep death. Second, MCDSS failed to question the mother about her Suboxone use during the fatality investigation despite being aware she was prescribed it: "The record reflected that MCDSS was aware the mother was prescribed Suboxone; however, does not reflect that MCDSS had further discussion with the mother regarding medication use." Third, there was an 8-month gap in casework activity (7/26/21 to 3/31/22) on the open DV investigation during which the subject child was born. Fourth, MCDSS had failed to provide safe sleep education during the prior open investigation despite the mother being pregnant, and an existing PIP was already in place for this exact issue from a prior OCFS finding. Multiple PIPs were already in place for issues cited again in this case, indicating recurring systemic failures.