Keeping Families Together in Washington: At What Cost to children?

Born in 2022, “B.B.” died of fentanyl poisoning in March 2023. During the ten years before B.B.’s death, the Department of Children, Youth and Families had received 30 reports about B.B.’s family (many before B.B. was born) for issues including use of heroin, marijuana and alcohol in the home; lack of supervision of the children; domestic violence; an unsafe caregiver living with the family; an unsafe and unclean living environment; unsecured guns in the home; “out-of-control” behaviors by B.B.’s older siblings at school, with the mother described as “out-of-it” and unresponsive to school concerns; concerns about the children’s hygiene; and the mother driving under the influence of marijuana. A Family Voluntary Services case that had been open since January 2023 was closed just days before B.B.’s death. 

How did this happen? Who decided this child was safe at home? And why?

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On August 24, 2024, DCYF announced that it had reduced the number of children in out-of-home care by nearly half since 2018. “Outcomes like this demonstrate our agency’s commitment to keeping families together and children and youth safe,” then DCYF Secretary Ross Hunter said. DCYF is seeing “fewer children and youth in out-of-home care as families are being referred to support services rather than having children removed from their homes.” But the press release did not mention an increase in child fatalities and near fatalities in Washington State. Children like B.B. seem to be barely an afterthought. 

Explaining how it had shrunk the foster care population, a DCYF spokesperson told the Seattle Times that instead of placing children in foster care, it was using “services” to avoid removing children or to reunite families sooner, citing efforts to connect parents to substance use or mental health treatment programs or bring a social worker into the home to solve problems and offer needed items. Although DCYF had already signaled it was committed to keeping families together (as all child welfare agencies are),the Washington legislature decided to go one step further when it passed the Keeping Families Together Act, which took effect on July 1, 2023. Among other provisions, KFTA raised the threshold for the court to order removal of a child from the home. The law now requires the agency to demonstrate “that removal is necessary to prevent imminent physical harm to the child due to child abuse or neglect.”¹ Other provisions further increase the barriers to removing a child who is at risk.²

A troubling increase in child fatalities and near fatalities

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But there may be costs to Washington’s emphasis on keeping families together. DCYF conducts reviews of the deaths of minors that had been in DCYF custody or received services within a year of the death that were suspected to be caused by child abuse or neglect. Also reviewed are near-fatality cases in which the child has been in the care of or received services from DCYF, or was the subject of an investigation for possible abuse or neglect within three months preceding the near fatality. In January 2025, DCYF reported that the number of cases it reviewed increased from 23 in 2019 to 51 in 2023. In 2024, the number of incidents that qualified for review was again 51.

The growth of the opioid crisis in Washington, including the expanding use of fentanyl, almost certainly contributed to the increase in child deaths.  Opioid overdose deaths increased dramatically in Washington between 2019 and 2023, driven increasingly by deaths due to fentanyl.  Fentanyl is particularly dangerous to young children because it takes only a tiny quantity to kill a baby or toddler, who can mistake the pills for candy or put straws or foil meant for smoking the drug in their mouths. The number of fatalities and near fatalities reviewed by DCYF that involved fentanyl climbed from four in 2019 to 34 in 2023 but fell to 27 in 2024–a sign that the fentanyl overdose deaths in Washington may have peaked, consistent with what has been observed nationally. This may also help explain why the total number of deaths reviewed did not rise in 2024. 

Regardless of the causes of the increase in critical incidents, case reviews suggest that a staffing crisis combined with policies and practices that downplay child safety are leading to a disturbing number of preventable deaths. A survey of executive reviews of 2023 and 2024 child maltreatment fatalities with recent DCYF involvement provides examples of problems with screening, investigations, and case management.

Screening Errors

• Reviews documented multiple calls that were screened out despite their apparent gravity. A report that four-year-old Ariel Garcia’s mother pulled Ariel’s older sibling off the bed by the legs and took the sibling to a bar without shoes or a jacket was screened out, perhaps because the Spanish interpreter that the intake worker relied on did not do a good job of relaying the urgency of the grandmother’s concern. Three days later, after two more calls, Ariel was dead, stabbed 40 times by his mother. In another tragic example, a relative of six-month-old “F.A.” called DCYF to report that F.A.’s mother was using drugs and the caller was worried the child was in danger. The intake was closed at screening because “it did not contain any new allegations of abuse or neglect.” Four days later, the infant was in critical condition (and later died) after a car accident in which the mother was believed to be under the influence of substances. The infant had been tested positive for methamphetamine at birth.

Alternatives to Investigation

• Too many referrals may be assigned to the Family Assessment Response (FAR) pathway, an alternative to a traditional investigation and designed for lower-risk cases. On a FAR track, a social worker “assesses” (instead of investigating) the family and refers caregivers to voluntary services. There is no finding about whether maltreatment has occurred. Two months before the death of “F.A.,” a caller reported that F.A.’s father slapped F.A.’s mother on the face while she was breastfeeding the baby. He then dragged her out of the trailer by the hair. The mother’s other children were present and observed the assault. The intake was assigned for a FAR assessment.

Inappropriate closure of assessments and investigations

• Reviewers noted instances in which FARs  were closed after parents failed to cooperate, without caseworkers considering a transfer to an investigation track, or when FAR’s were closed before determining that the parent had followed through with services. In the case of “F.A.,” an investigation was even closed as “unable to complete” due to the parents’ lack of cooperation.

Assessment failures

• Reviewers noted multiple failures to adequately assess parents for domestic violence, mental health, and substance abuse; failures to contact collaterals (relatives and friends) and instead relying on parental self-reports; lack of recognition of chronic maltreatment; ignoring evidence of past problems if not included in the current allegation; and failing to anticipate future behavior based on historical patterns. Before Ryleigh Walker, whose parents are pictured above³, died at age four after ingesting fentanyl, an investigation was closed because the children were staying with relatives, despite the mother’s history of repeatedly removing the children from relatives with whom she had left them. A month later the child was found dead at a motel in the custody of the parents. 

Lack of subject matter expertise, particularly in substance abuse

• Reviewers noted the failure to conduct a full assessment of substance abuse including history, behavioral observations, and collateral contacts; disregarding the unique danger to children posed by fentanyl; downplaying the significance of marijuana use, particularly as an indicator of relapse from more lethal illicit drugs; and disregarding alcohol abuse because it is legal. Reviewers also noted the lack of deep knowledge about domestic violence and mental health among staff and the need to provide access to subject matter experts when needed.

Failure to obtain information from treatment and service providers

• The failure to communicate with service providers about clients’ participation in services like drug treatment and relying on clients’ self-reports was noted by more than one review team. Sometimes the providers refused to cooperate.  Staff told the team reviewing the case of six-week old S.N. about a substance abuse treatment provider that routinely refused to cooperate and told clients not to cooperate with DCYF, even when the parent had signed a release form. S.N.’s cause of death was combined toxic effects of fentanyl and methamphetamine with a contributory condition of unsafe sleep environment.

Failure to remove a child despite safety threats

• The team reviewing the case of Ryleigh Walker reported that there were at least two different times where an active safety threat was present that would have justified filing a petition in court to place Ryleigh in foster care. However, the staff believed, based on past experience, that the court would have denied the petition and therefore did not file. 

Questionable Reunifications

• Prince Lewis, a three-year-old allegedly beaten to death by his mother, was in foster care for over three years but his mother’s rights were never terminated. He was on a trial return to his mother for just over five months when he was found dead with bruises and burns all over his body. Seven-year-old “M.T.J.”, who died  of “nonaccidental injuries,” had been returned to his mother after two-and-a-half years in foster care. M.T.J.’s death followed a 2018 death of his infant sibling under suspicious circumstances.

Staff shortages and high turnover were mentioned as contributing to the observed deficiencies in case practice in almost every fatality review. In the case of B.B., whose family had been the subject of 30 calls before he died of fentanyl poisoning, the reviewers noted that the office charged with protecting him had been functioning with a 50 percent vacancy rate for the last several years. They stated that such a vacancy rate leads to high turnover, high caseloads, caseworkers with little experience, and supervisors forced to carry cases rather than support their caseworkers. Even caseloads that comply with state standards may be too high. The standard of 20 families per caseworker for in-home services (Family Voluntary Services in Washington) was noted to be unmanageable by one review panel, which noted that these cases are often high risk cases and require multiple contacts per month with family members, services providers, and safety plan participants. A document with one-paragraph summaries of the reviewed cases is linked below.

Conclusions

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DCYF told King5 that “the increase in child fatalities and near fatalities in Washington is not being driven by the change in removal standards …. or the reduction in the number of children in foster care. It is being driven by the increased availability of a highly addictive and hazardous drug and a lack of substance use disorder treatment in our communities.” And in a recently-posted document, DCYF states that fentanyl is responsible for the increase in child deaths and touts its efforts to distribute “Harm Reduction Kits” to families who struggle with substance use disorders. These kits contain “essential items, such as a lock box, fentanyl testing strips, naloxone, and educational materials to raise awareness about the dangers of synthetic opioids.” 

But is child welfare’s adoption of adult harm reduction strategies an example of sacrificing child safety to keep families together?

Is it really safe for a child to be living with active substance abusers, simply because the child can be revived?