M.L., a newborn girl born in 2022, was critically injured in a car accident on September 19, 2022, that also involved her sister, their mother, and the mother's brother. The mother died at the scene, the uncle was uninjured, and M.L.'s sister was injured but not hospitalized. On October 13, 2022, M.L. succumbed to infections related to the injuries sustained in the car accident. At the time of the accident, there was an open CPS case involving the family, with a history of prior CPS intakes dating back to 2018 and documented concerns about parental substance use.
Contexts/Conditions
Is there any mention of child drug ingestion or overdose?
Is there any mention of a drowning incident (either intentional or accidental)?
Is there any mention of a firearm incident?
Is there any mention of inappropriate supervision (e.g., child wandered off and drowned)?
Is there any mention of inflicted injury? (e.g. slapped, punched, kicked, choked)
Is there any mention of malnutrition, starvation, or dehydration?
Is there any mention of medical neglect?
Is there any mention of a motor vehicle crash or incident?
The fatality report explicitly states: "On September 19, 2022, DCYF was notified that M.L., sister, the children's mother, and the mother's brother were involved in a car accident. M.L. was critically injured." It further states: "On October 13, 2022, M.L. succumbed to infections related to the car accident."
Is there any mention of a murder-suicide incident?
Is there any mention of outdoor elements (including hot car deaths)?
Is there any mention of prenatal substance exposure (including fetal alcohol syndrome or neonatal abstinence syndrome)?
The fatality report states that on September 12, 2022, the caseworker "created a Plan of Safe Care with the mother." Per DCYF policy (footnote links to 'infant safety education and intervention'), Plans of Safe Care are specifically created for substance-affected infants. Combined with the recommendation that "DCYF should work with the Substance Use Program Manager to discuss a way to help support staff in creating plans for families experiencing substance use... a harm reduction plan for parents who are continuing to use while caring for their children," prenatal substance exposure is strongly implied though not explicitly named.
Is there any mention of sexual abuse?
Is there any specific mention of shaken baby or abusive head trauma?
Is there any mention of prolonged abuse or torture (including restraints, captivity)?
Is there any mention of an unsafe sleeping environment?
The fatality report states: "M.L.'s mother was also very clear that she would not practice safe sleep and planned on bedsharing with her newborn daughter." While this was not the cause of death, there is an explicit mention of an unsafe sleeping environment.
Individuals Involved
Was an adoptive parent or guardian involved in the death?
Was a biological father involved in the death?
Was a biological mother involved in the death?
The fatality report states: "M.L., sister, the children's mother, and the mother's brother were involved in a car accident." The mother was present during and involved in the car accident that ultimately killed M.L. However, the report does not indicate who was driving or what caused the accident. The mother herself also died at the scene. Her role in causing the accident is unclear, making her involvement in the child's death ambiguous.
Was a day care worker, babysitter, or nanny involved in the death?
Was a female paramour or friend involved in the death (e.g., girlfriend, stepmother)?
Was a foster parent involved in the death?
Was a male paramour or friend involved in the death (e.g., boyfriend, stepfather)?
Was another adult relative involved in the death? (e.g., grandfather, aunt)
The fatality report states: "M.L., sister, the children's mother, and the mother's brother were involved in a car accident." The maternal uncle was present in the vehicle during the car accident that killed M.L. He "was uninjured." However, the report does not indicate who was driving or assign fault, making his involvement in the child's death ambiguous.
Was a sibling involved in the death?
Child Characteristics
Was the child adopted?
Was the child homeschooled (including "cyberschooling") or taken out of school?
Was the child in foster care at the time of the incident?
Was the child living with relatives at the time of the incident (but not parents)?
Is there any mention of a neurological developmental child disability? (e.g., autism, intellectual disability, nonverbal)
Is there any mention of a physical child disability? (e.g., feeding tube)
Is there any mention of prematurity or low birthweight?
Is there a history of child protection reports prior to death (for this child or siblings)?
The fatality report documents extensive prior CPS history: "M.L.'s family first came to the attention of DCYF on November 26, 2018. A CPS intake was screened in... regarding allegations of neglect." Additional intakes followed on April 25, 2019, and two more intakes were received on September 8, 2022. There was also an open CPS case at the time of the car accident.
Does the child have a history of foster care (but not in care at time of incident)?
Is there a history of a sibling death (separate incident from this death)?
Parent/Caregiver Factors
Was an adult charged or arrested for the child's death?
Is domestic violence by the parent/caregiver referenced?
Is there any mention that the death occurred in a temporary shelter or while homeless?
Is an intellectual disability of the parent/caregiver referenced?
Is the mental health of the parent/caregiver referenced?
Is a history of arrests or criminal charges for the parent/caregiver referenced?
Is substance use by the parent/caregiver referenced?
The fatality report's recommendation explicitly references parental substance use: "DCYF should work with the Substance Use Program Manager to discuss a way to help support staff in creating plans for families experiencing substance use. This is not a safety plan but rather a harm reduction plan for parents who are continuing to use while caring for their children." Additionally, a Plan of Safe Care (associated with substance-exposed newborns) was created with the mother.
Notable Details
The fatality report describes multiple significant systemic and policy failures by DCYF. The report states: "The Indian Child Welfare Act (ICWA) and the DCYF policies related to ICWA were not adhered to." Additionally, the Committee found that "The documented attempts at contact and information contained in the case notes and other documents related to CPS investigations did not meet the policy requirements. The investigations were closed out as 'unable to locate,' but there was not an explanation to what attempts were made to complete those investigations." Other concerns included "late entry of case notes, investigations not completed in a timely manner, not including the fathers in the investigations, and during the 2022 case the recently screened-out intakes were not incorporated." The Committee also noted that "The most recently assigned caseworker and supervisor were no longer employed by DCYF." The recommendation focused on substance use harm reduction plans rather than safety plans, suggesting a policy gap for addressing parental substance use while caring for children.
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