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

The fatality report describes the mother being heavily intoxicated (8 to 18-20 beers) while bed-sharing with a five-week-old infant. Additionally, the father reported the mother "was left alone with the children" when she "chases him out of the apartment." The mother's extreme intoxication while being the caretaker during sleep constitutes inappropriate supervision of the infant.

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

The fatality report states that the father reported the mother "had been physically rough with" J.S.R.'s older sibling. While this inflicted injury was directed at the sibling rather than J.S.R. specifically, it is an affirmative mention of inflicted injury within the case documents pertaining to this family.

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

The fatality report states the father reported the mother "had drank throughout the pregnancy," which constitutes affirmative evidence of prenatal substance (alcohol) exposure for J.S.R. Additionally, the father reported the mother "was drinking to intoxication and breastfeeding J.S.R."

Is there any mention of an unsafe sleeping environment?

The fatality report extensively documents an unsafe sleeping environment. It states: "the mother was intoxicated and bed sharing with five-week-old J.S.R." The father reported the mother "was bedsharing with the newborn and refused to use the crib or swing." Safe Sleep was discussed with the parents multiple times, and DCYF provided a pack and play. Despite these efforts, J.S.R. died while bed-sharing with the intoxicated mother.

Was a biological father involved in the death?

The fatality report states the father was present in the home and was aware the mother was heavily intoxicated and bed-sharing with J.S.R. He reported at 4:00 a.m. that J.S.R. was asleep on the child's back (while bed-sharing with the intoxicated mother), yet did not move J.S.R. to the pack and play. The Committee itself "wondered about his capacity to be protective" and "speculated that the father may have felt powerless to change the situation." While the father attempted to seek help by calling DCYF, his awareness of the unsafe situation and failure to intervene that night constitutes involvement through omission.

Was a biological mother involved in the death?

The fatality report clearly states: "the mother was intoxicated and bed sharing with five-week-old J.S.R." The mother admitted to drinking alcohol before going to sleep. When she woke at 9:45 a.m., J.S.R. was on the child's stomach and was not breathing. The mother's intoxication and bed-sharing directly contributed to J.S.R.'s death.

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

The fatality report extensively documents prior child protection history. "Prior to J.S.R.'s birth, DCYF received three intakes reporting concerns for the welfare of J.S.R.'s older sibling... The concerns alleged the mother was using alcohol to the point of intoxication, DV in the home, and neglect of the [child]. In October 2021, DCYF assigned a CPS investigation." The mother received "a founded finding of negligent treatment" of the older sibling in February 2022. Additionally, on December 30, 2022, a new CPS investigation was opened regarding the mother's treatment of both the sibling and J.S.R. prior to J.S.R.'s death.

Is domestic violence by the parent/caregiver referenced?

The fatality report references domestic violence (DV) multiple times. The initial intakes alleged "DV in the home." The father reported "one altercation three weeks ago when she was intoxicated." The mother denied DV. "The father said the mother was physical with him one time before." A DV expert was planned to participate in the review but had an unexpected conflict. The Committee discussed DV as a concern throughout the case.

Is the mental health of the parent/caregiver referenced?

The fatality report states: "The Committee believed that both the mother and father had unaddressed behavioral health needs that may have warranted further intervention." While "behavioral health" is a broad term that can encompass both mental health and substance use disorders, it references the overall behavioral health status of the parents/caregivers. The Committee's SUD expert specifically identified the mother's potential alcohol use disorder, but the broader "behavioral health needs" language for both parents implies mental health concerns beyond just substance use.

Is substance use by the parent/caregiver referenced?

The fatality report extensively documents the mother's alcohol use. The father reported "the mother would drink throughout the day and usually drank 18 beers daily." On the night of J.S.R.'s death, "the mother said she drank eight beers before going to sleep, while the father said she drank more like 18 to 20 beers." The father also reported the mother "was drinking to intoxication and breastfeeding J.S.R., and had drank throughout the pregnancy." The Committee's SUD expert "identified that the mother may have had an undiagnosed alcohol use disorder." Both parents were also noted to have used alcohol in earlier reports.

The fatality report describes significant systemic issues that materially affect understanding of this case. The CPS program was "operating with an approximately 50% vacancy rate" and "vacancies remain challenging to fill due to a lack of applicants and/or qualified candidates." New employees were "not being afforded a capped or limited caseload following regional core training" and instead were "being assigned full caseloads immediately due to need." The caseworker assigned to J.S.R.'s family "did not review the case history prior to their initial contact with the family." The Committee identified this as "a potential disconnect in completing a thorough assessment of the family's current needs and in assessing child safety." Additionally, the Committee discussed potential bias regarding alcohol as a legal substance versus illegal substances, wondering "if bias may have impacted critical thinking about the mother's substance use." The Committee recommended systemic changes to intake reporting systems and noted that the mother declined a SUD assessment and urinalysis, with no apparent mechanism to compel participation.