Is there any mention of a drowning incident (either intentional or accidental)?

The fatality report states: "law enforcement responded to a naked male child found deceased in a body of water." While the word "drowning" is not explicitly used, finding a child deceased in a body of water strongly implies drowning as the cause of death.

Is there any mention of a firearm incident?

The fatality report describes a shooting that occurred at the family home in May 2021: "another intake was received. That intake alleged a shooting occurred at the family home... the mother's ex-boyfriend broke into the home and threatened her current boyfriend, who then shot the intruder. The children were reportedly present but unharmed." While the shooting did not directly cause the child's death, it is a documented firearm incident involving the family.

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

The fatality report extensively documents inappropriate supervision. A prior intake reported the child "was naked and running around his neighborhood" and "a male at the home stated that on multiple occasions, the child 'defeated the security measures' at the home." The mother described the child as an "escape artist" who "always looks for ways to get out of the home." Neighbors told law enforcement the child "would often escape from his home." He was ultimately found deceased in a body of water after escaping from the home, and there was an open CPS intake alleging lack of supervision at the time of death.

Is there any mention of medical neglect?

The fatality report documents that the child "was reportedly behind in speech" but "did not have a PCP" and "had not been to a dentist." The mother reported taking him to an urgent care facility "for medical attention when needed" rather than providing regular preventive medical care. His sister "also did not have a PCP." This constitutes evidence of medical neglect.

Is there any mention of outdoor elements (including hot car deaths)?

The fatality report states: "law enforcement responded to a naked male child found deceased in a body of water." The child was found outdoors, unclothed, in a body of water, indicating exposure to outdoor elements.

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

The fatality report documents prenatal substance exposure for the deceased child's sibling. It states: "the hospital called in another intake. The hospital reportedly received toxicology results indicating the baby and mother tested positive for amphetamines." It further notes: "The hospital called to report that the newborn's meconium tested positive for methamphetamine. The mother's confirmation test was also positive for methamphetamine." This constitutes documented prenatal methamphetamine exposure for the sibling born in September 2019.

Is there any mention of sexual abuse?

The fatality report states: "the Committee learned about the relationship between early childhood sexual assault and the inability to produce urine. There is a history of childhood sexual assault in this case." This refers to childhood sexual abuse suffered by a parent, not the deceased child. The condition (sexual abuse) occurred, though it pertains to a parent's history rather than direct abuse of the children in this case.

Was a biological mother involved in the death?

The biological mother was the primary caregiver of the child. Her failure to adequately supervise the child, who had a known pattern of escaping the home, contributed to the circumstances of his death. The report documents multiple CPS intakes regarding lack of supervision. The mother also had documented substance use issues and repeatedly delayed or avoided caseworker visits and home inspections. She was responsible for the child when he escaped and was found deceased in a body of water.

Is there any mention of a neurological developmental child disability? (e.g., autism, intellectual disability, nonverbal)

The fatality report notes the child "was reportedly behind in speech, but the mother said he was making progress." The Committee discussed the child's "behavioral challenges and needs." The child was repeatedly described as an "escape artist" who on multiple occasions "defeated the security measures" at the home. While no formal diagnosis of a neurological or developmental disability is stated, the combination of speech delay and persistent behavioral challenges may suggest a developmental concern.

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

The fatality report documents an extensive history of child protection reports prior to the child's death. Intakes were received in August 2016, September 2016, September 2019 (two intakes for the sibling's birth), November 2020, April 2021 (two intakes), May 2021, June 2021, August 2021, and June 2022. These involved allegations of neglect, substance use, unsafe living conditions, and lack of supervision.

Is domestic violence by the parent/caregiver referenced?

The fatality report discusses domestic violence (DV) in multiple contexts. The Committee states: "DCYF has a policy about universal domestic violence (DV) screening... The Committee believes this case should have qualified for a specialized DV screening. The first time DV was mentioned involved DV allegations between the mother and her oldest son's father." The mother filed for a protection order. Additionally, a shooting occurred when the mother's ex-boyfriend broke into the home and threatened her current boyfriend.

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

The fatality report states: "Law enforcement also stated the mother's boyfriend had multiple criminal warrants for his arrest." These criminal warrants predate the child's death and represent prior criminal history of a person associated with the caregiver/household.

Is substance use by the parent/caregiver referenced?

The fatality report extensively documents substance use by the parent/caregiver. The oldest child's father alleged "the mother was using methamphetamines and heroin" and was "dating the person who sells her substances." Both the mother and newborn sister tested positive for methamphetamine at the sister's birth. In 2016, an intake alleged the mother and her boyfriend were "shooting up meth." The caseworker observed "cannabis on the bench by the front door" during a May 2021 visit. Multiple substance use assessments were recommended but not completed.

The fatality report identifies several significant systemic and policy failures. First, on June 19, 2022, an after-hours caseworker observed the home was a fire hazard with no clear pathways and exits blocked by large items, but did not enter the case note until 8:30 a.m. on June 21. The report states: "On Monday, June 20, at 8 a.m., the originally assigned caseworker arrived at work, checked the case, and did not see any updated information in the computer system." The caseworker stated "had she known about the case note prepared by the after-hours caseworker, the assigned caseworker may have pushed harder to convince the mother to allow her to enter and observe the home." Second, the positive methamphetamine test results for both the mother and newborn were not incorporated into the case plan: "This information was not incorporated into the case plan or discussed with the parents or service provider." The case closed in December 2019 "without any toxicology samples provided by the mother or her boyfriend." Third, multiple cases were closed prematurely without gaining home access or completing collateral contacts. Fourth, the office experienced significant vacancies and high caseloads. These systemic failures represent critical missed opportunities in the nine days before the child's death and throughout the years of DCYF involvement.