District violates federal law requiring release of child fatality information

On January 18, 2025, two police officers accompanied a worried grandmother to an apartment in a Northwest Washington high-rise. There they found 38-year-old Ebony Washington and her 20-month-old daughter, Kemy, dead. Ebony had overdosed on a mix of MDMA, cocaine, ethanol and the animal sedative xylazine, called “tranc” on the streets. Kemy had died of starvation and dehydration. Mother and daughter had been dead for days or even weeks, as reported in a devastating story by Paul Schwartzman in the Washington Post.

Kemy’s father and grandmother were worried about her for several weeks, ever since Ebony stopped responding to calls and text messages. Ebony had a history of drug abuse and neglect of her older daughter. Now ten, that daughter had been removed from her by the Child and Family Services Agency (CFSA) and was being raised by a cousin. After Kemy’s birth, her father and paternal grandmother became concerned about Ebony’s continued drug abuse and its impact on Kemy. Kemy’s paternal grandmother, Kineta Johnson, told Schwartzman that she had called CFSA’s hotline twice, months before the deaths, and had never heard back. But the agency’s spokesperson, Keena Blackmon, told Schwartzman that they could find “no record of any call reporting allegations of abuse or neglect for the decedent child.”

The meaning of Blackmon’s statement is not as clear as it might seem. CFSA’s hotline screens out all calls that the call screener decides do not involve abuse or neglect. Thus, Blackmon’s words could very well mean that the agency received the grandmother’s calls but that the screener believed they did not concern abuse or neglect. In the aftermath of a child maltreatment fatality, numerous screened out-calls to child protective services are often found, so I naturally asked CFSA to provide a record of the findings of CFSA’s investigation of Kemy’s death. Those findings would have included a record of the calls that were received about this family. But Blackmon informed me that since Kemy’s manner of death had been ruled an accident by the Office of the Chief Medical Examiner (OCME), the agency was not required to provide any information.

When a child dies of abuse or neglect, and the family had prior interaction with child protection services, it is critical for the public to have access to information about how those interactions were handled. Nothing can bring a dead child back, but learning from mistakes can save children in the future from abuse or neglect. That’s why the Child Abuse Prevention and Treatment Act, the nation’s keystone legislation about child abuse and neglect, requires that all states have a policy for public release of “information and findings” about child maltreatment deaths. Like all but four states, the District has a law incorporating this federal requirement. DC Code Section 4-1303.31 defines a “child fatality” (for the purpose of disclosure) as:

(A) The death of a child as a result of child abuse, neglect, or maltreatment, as certified by a physician, or the Chief Medical Examiner of the jurisdiction in which the child died or where the autopsy was performed; or

(B) The death of a child where the Chief Medical Examiner cannot rule out child abuse, neglect, or maltreatment as contributing to the cause of death.

But there is something strange about part (A) of this definition. The Chief Medical Examiner (OCME) does not decide whether a child death was due to abuse or neglect.¹ OCME assigns a cause of death (the illness or injury responsible for the death) and a manner of death (how did the child come to die by that cause), neither of which equates to whether the child’s death was due to abuse or neglect. Keena Blackmon referenced Kemy’s manner of death—accident—as the reason why CFSA did not have to provide information about the case. There are five manners of death—natural, accidental, suicide, homicide, and undetermined, and any of these can be compatible with abuse or neglect. As a matter of fact, Arizona’s excellent Child Fatality Review Team reported that accidental injuries (such as car crashes, suffocation, drowning, poisoning, and fire) were the most common manner of death among neglect or abuse-related deaths in the state in 2024.² Moreover, it is hard to imagine how Kemy Washington’s death did not involve neglect, when her mother had ingested a cocktail of dangerous drugs that would clearly impair her ability to care for her child, even if they did not cause a fatal overdose.

CFSA does release information and findings of child deaths for which OCME ruled the manner was “undetermined” under 4-1303.31(B), which requires release of information and findings when the Chief Medical Examiner “cannot rule out” child abuse or neglect as contributing to the cause of death. But its interpretation of 4-1303.31(A) to require a homicide ruling to demonstrate that a child died as the result of “abuse, neglect, or maltreatment” is simply illogical considering the lack of equivalence between manner of death and the presence of abuse or neglect. Moreover, DC’s use of manner of death to define which fatalities are susceptible to release appears to be unique. I reviewed disclosure statutes in all 50 states and the District for a report, Keeping the Public in the Dark, prepared for the Lives Cut Short project: I did not find another state that defines child maltreatment deaths this way for the purposes of disclosure.

It is not only Kemy Washington’s case for which disclosure is being blocked by the District’s bad law. At least four other child deaths that likely involve neglect were ruled as “accidental” by OCME between 2022 and 2024, according OCME reports provided to Lives Cut Short.³ They included:

• Journey McCoy, age three, died in October 2022 of fentanyl and fluorofentanyl intoxication, according to the OCME, which ruled her death an accident. Journey had ingested her mother’s Percocet, which was laced with multiple drugs. Journey’s mother, Sasha McCoy, was charged with with murder and pleaded guilty to voluntary manslaughter, making it doubly ridiculous that the law bars disclosure of information about the case. Moreover, as the Post reported, McCoy had a history with CFSA. In 2020, she was substantiated for inadequate supervision after allegedly leaving two of her four children to smoke marijuana. In August 2021, she was referred to substance abuse treatment after her new baby was born suffering from withdrawal. DC’s flawed statute prevents the public from finding out whether CFSA did enough to protect Journey and her siblings.
• An infant girl died in October 2023 of “asphyxia due to unsafe sleep environment with cocaine.”
• A one-year-old boy died in March 2024 of fentanyl and fluorofentanyl intoxication.
• An infant boy died in August 2024 of methamphetamine toxicity.

It is worth knowing that another drug poisoning death, that of two-month-old Amiri Royal Bynum of fentanyl intoxication, was ruled a homicide by OCME. It is not clear why this death was ruled a homicide while the other drug poisoning deaths were deemed to be “accidents.” And of course we have no idea how many other “accidental” deaths due to parental neglect were never the subject of autopsies by OCME.

Transparency is a prerequisite for improving child welfare systems to better protect children. Withholding information about child deaths that are the result of parental neglect but not classified as homicides by OCME prevents the public from knowing what went wrong in these tragic cases. I am asking the DC Council’s Committee on Youth Affairs to work with me to draft and pass legislation to fix this problem. I urge my readers to share this post with their networks and with members of the Youth Affairs Committee and urge them to change the law so that we can learn from past errors and hold CFSA accountable as appropriate for the deaths of children that it has touched in the past.

Originally published in Child Welfare Monitor DC