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

The fatality report mentions inflicted injuries to the half-sibling. The reporting party stated that while the father "was caring for the child and the half-sibling in the past, '[the half-sibling] ended up having a broken femur.'" A second referral also reported that the half-sibling disclosed "'they put rags in [the half-sibling's] mouth, so people did not hear [the half-sibling] crying when they spank[ed] [the half-sibling].'" These mentions pertain to the half-sibling rather than the deceased child, hence implied rather than explicit.

Is there any mention of malnutrition, starvation, or dehydration?

The fatality report states the law enforcement investigation confirmed the child "died of natural causes due to severe protein calorie malnutrition, due to sepsis, [and] due to cardiac arrest." The CHC social worker reported that "the child's medical providers were concerned about the child's weight being too low, as she was about half the weight she should have been for her age and medical condition." A CHC medical provider also reported "concerns for the child's malnutrition." The child's weight had "maintained around 16.75 pounds, when her weight needed 'to be in the high 20's-30 pounds.'"

Is there any mention of medical neglect?

The fatality report explicitly states: "The allegation of fatal, intrafamilial neglect – medical neglect was substantiated." Additionally, a separate open assessment found: "The allegation of medium, intrafamilial neglect – medical neglect was substantiated." The assessment closure summary notes that "[the mother's] failure to seek care for [the child] despite all of her medical needs negatively impacted [the child's] health and more likely than not contributed to her death."

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

The fatality report states that the reporting party indicated "the child was born drug-exposed, which caused all of her health issues, including needing a feeding-tube, being an invalid, and not being able to talk or see." This is a clear reference to prenatal substance exposure.

Is there any mention of an unsafe sleeping environment?

The fatality report mentions the child "had been sleeping on the floor due to the family just recently moving into the maternal relative's home." Additionally, when the child was brought to CHC, doctors found "she had hypothermia." For a medically fragile, non-ambulatory child requiring around-the-clock care, sleeping on the floor could be considered an unsafe or inadequate sleeping environment, though the report does not explicitly characterize it as such, and the hypothermia may have been related to the sepsis rather than the sleeping arrangement.

Was a biological mother involved in the death?

The fatality report explicitly states that "ACHSD… determined that [the mother's] failure to seek care for [the child] despite all of her medical needs negatively impacted [the child's] health and more likely than not contributed to her death." The allegation of fatal medical neglect and fatal deprivation of necessities against the mother were both substantiated. The mother was the child's primary caregiver and the identified perpetrator.

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

The fatality report states the child was "non-verbal" and had multiple developmental needs requiring in-home service providers. The reporting party also stated the child was "not being able to talk or see" and described the child as "being an invalid." The child had "several medical and developmental services in place."

Is there any mention of a physical child disability? (e.g., feeding tube)

The fatality report explicitly describes the child as being "fed through a gastrostomy tube (g-tube)" and "non-ambulatory." The child "required around-the-clock care and attention" and "had several medical and developmental services in place."

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

The fatality report documents multiple prior child protection reports. An open assessment was received on October 28, 2022, regarding medical neglect for the child. A referral was received on August 13, 2020, concerning a fire and conditions at the family's home. The report notes: "Within the last three years, the family had prior involvement with Adams County Human Services Department consisting of one open assessment and one prior referral." The RP also stated having "made several reports to child welfare in the past."

Is there any mention that the death occurred in a temporary shelter or while homeless?

The fatality report notes significant housing instability. The CHC social worker "believed the mother had been staying in motels" around the time of the assessment. The family had "recently moved in with a maternal relative" only about two weeks before the child's death due to financial stress. After the child's death, in February 2023, "It appeared that the mother and the half-sibling were living out of their car." The CDHS CFRT also identified "History of housing instability" as a contributing risk factor. While the child was technically living at the maternal relative's home at the time of death, the broader context of homelessness and motel stays is closely tied to the incident period.

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

The fatality report states: "The mother's criminal history included charges in 2002 for '[c]onspiracy to [m]anufacture,' for which she served one year in jail." This is a prior criminal charge predating the child's death and unrelated to the current incident.

Is substance use by the parent/caregiver referenced?

The fatality report contains extensive references to substance use by the mother. It states: "The mother reported a prior history of methamphetamine use, but had not used it in 13 years. The mother also reported a prior history of alcohol use, but had reportedly been sober for one month." The RP reported "the mother was an alcoholic, who sought medical treatment multiple times a week, due to her alcohol abuse." The maternal relative "reported a history of substance use for the mother." The mother's alcohol use was identified by the CFRT as a contributing risk factor.

The fatality report describes several significant systemic issues. First, no autopsy was performed because the coroner was not aware of neglect concerns and the child's pediatrician "said [the child's death] was expected and [the child's pediatrician] would sign off on it being ruled a natural death." Second, the CFRT explicitly "did not identify any strengths during the review of this fatal incident" — an unusual finding. Third, a second referral containing serious allegations — including that the half-sibling reported "'they put rags in [the half-sibling's] mouth, so people did not hear [the half-sibling] crying when they spank[ed] [the half-sibling]'" and that drugs were being left around the home — was screened out as a "Duplicate referral." Fourth, multiple professionals failed to report their concerns: the child's in-home service providers stated "'they didn't know how to make a report,'" and a CHC medical provider reported feeling "devastated and wishe[d] [the CHC medical provider] had done something [for the child] sooner." Fifth, the caseworker made only two unsuccessful attempts to locate the family (November 4 and November 9, 2022) over 12 days after receiving the medical neglect referral on October 28, 2022 — and the child died the very next day, November 10, 2022. Finally, law enforcement closed their investigation after the coroner confirmed natural causes, and the CFRT made no formal recommendations despite all these systemic failures.