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

The fatality report states the child was "diagnosed with non-life threatening Spina Bifida, requiring constant direct supervision." Despite this, the parents left the children with a 29-year-old unrelated home member who subsequently "left both children alone and unattended, in a separate room." The presenting information describes this lack of supervision, and a Lack of Supervision allegation was formally made against the 29yo UHM (though ultimately unsubstantiated). The incident information also notes the supervisor was "In Another Room" at the time of the incident.

Is there any mention of medical neglect?

The fatality report contains multiple references to medical neglect. In the fatality investigation, "The SM and SF denied seeking medical attention for the SC regarding those concerns and stated they planned on taking the SC to urgent care the following day if symptoms worsened." The pediatrician "confirmed the SM and SF had not reached out about the SC's condition." Additionally, in the May 2021 investigation (substantiated), WCDSS found "the subject child had not been seen by a pediatrician since 2020, or by specialists since 2018 and 2019, which were necessary since he was diagnosed with Spina Bifida." Lack of Medical Care was an explicit allegation in both the fatality report and prior reports.

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

The fatality report documents a prior SCR report (06/05/2020) that alleged "the mother gave birth to the 1-year-old sibling and had a positive toxicology for marijuana at the time of delivery. The sibling's toxicology was still pending." The basis for determination states: "The mother tested positive for marijuana at the time of the sibling's birth; however, the sibling tested negative for all substances." The mother's marijuana use during pregnancy constitutes prenatal substance exposure, even though the sibling ultimately tested negative.

Is there any mention of an unsafe sleeping environment?

The fatality report states WCDSS "did not observe appropriate sleeping accommodations" and found "there were not appropriate sleeping accommodations for the children." The deceased child was sleeping on the parents' queen-sized bed: "The SF reported the SC had been lying on top of pillows on the parents' bed in just a diaper without any blankets covering him, and the 1yo SS had been asleep on the opposite corner of the bed." The home was also described as "unsafe and unsanitary."

Was a biological father involved in the death?

The father is listed as an "Alleged Perpetrator" in the fatality report and had allegations of Inadequate Guardianship and Inadequate Food/Clothing/Shelter substantiated against him. The report notes the father knew the child had been constipated for a week and a half and appeared weaker over 3 weeks but denied seeking medical attention. However, the DOA/Fatality allegation against the father was unsubstantiated, and the official cause and manner of death remain pending, making direct causal involvement implied rather than explicit.

Was a biological mother involved in the death?

The mother is listed as an "Alleged Perpetrator" in the fatality report and had allegations of Inadequate Guardianship and Inadequate Food/Clothing/Shelter substantiated against her. The mother also denied seeking medical attention for the child's worsening condition. However, the DOA/Fatality allegation against the mother was unsubstantiated, and the official cause and manner of death remain pending, making direct causal involvement implied rather than explicit.

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

The fatality report explicitly states: "The four-year-old subject child was diagnosed with non-life threatening Spina Bifida, requiring constant direct supervision." The report also mentions "another medical diagnosis that resulted in chronic constipation." The child's pediatrician noted "the SC had a life expectancy of 30 to 40 years old," indicating the physical condition was significant enough to affect overall health and longevity.

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

The fatality report documents four prior SCR reports within three years before the fatality: 06/05/2020 (Parents Drug/Alcohol Misuse, unfounded), 05/13/2021 (Inadequate Food/Clothing/Shelter, Inadequate Guardianship, Lack of Medical Care, indicated), 09/28/2021 (Inadequate Food/Clothing/Shelter, Inadequate Guardianship, unfounded), and 12/28/2021 (Inadequate Guardianship, Lacerations/Bruises/Welts, Lack of Medical Care, unfounded). There was also one unfounded report from 2016 regarding the 61yo UHM.

Is substance use by the parent/caregiver referenced?

The fatality report references multiple instances of substance use by the parents. In the 06/05/2020 report: "The mother tested positive for marijuana at the time of the sibling's birth" and "she smoked marijuana to help with her nausea throughout her pregnancy." In the 12/28/2021 investigation, "WCDSS observed drug paraphernalia on the unrelated home member's desk and that a service provider had observed the father smoking marijuana in the kitchen of the residence while the children were home." The 09/28/2021 report alleged "the mother and father smoked cigarettes and marijuana in the small room with the subject child and 1-year-old sibling." Alcohol/Substance abuse services were also offered but refused.

The fatality report reveals a significant pattern of systemic casework failures by WCDSS across all four prior CPS investigations. In every prior report, WCDSS failed to add the unrelated home members to the investigation despite the family residing in their home—a compliance issue cited repeatedly. During the May 2021 indicated investigation, the child had not seen a pediatrician since 2020 or Spina Bifida specialists since 2018/2019, and Lack of Medical Care was substantiated; yet "services were terminated due to lack of contact with the family." Drug paraphernalia was observed and the father was seen smoking marijuana in the kitchen with children present, but "the record does not reflect this being addressed with the parents or any household members." Additionally, the official cause and manner of death were still pending at the time of CPS investigation closure, with the final autopsy pending a micro exam and toxicology. The child was found with white foam coming from his mouth and hot skin, which remain unexplained by the pending determination.