On June 3, 2022, the mother placed her 4-month-old daughter to sleep on the parents' adult bed on a Boppy Pillow and left her unattended while the parents watched television in the living room. When the father went to check on the child approximately thirty minutes later, he could not find her. The mother discovered the child unresponsive among garbage bags filled with clothing, between the bed and the wall. Nearby utility workers called 911 and performed CPR. The child was transported to the hospital in respiratory and cardiac arrest, later airlifted to a second hospital, and placed on a ventilator with very low brain activity. The parents elected to remove life support and the child was pronounced deceased at 12:37 AM on June 5, 2022. Notably, child protective services had delivered two portable cribs and discussed safe sleep guidelines with the family that very morning.
Contexts/Conditions
Is there any mention of child drug ingestion or overdose?
Is there any mention of a drowning incident (either intentional or accidental)?
Is there any mention of a firearm incident?
Is there any mention of inappropriate supervision (e.g., child wandered off and drowned)?
The fatality report states that the mother "left the child on the bed to sleep" while "The parents were watching television in the living room." The child was "left unsupervised for an undetermined amount of time." Allegations of "Lack of Supervision" were substantiated against both the mother and father. CCDHHS found that "The parents had access to safe sleep for the child and they failed to place the child in a safe sleep environment and left the child unsupervised."
Is there any mention of inflicted injury? (e.g. slapped, punched, kicked, choked)
Is there any mention of malnutrition, starvation, or dehydration?
Is there any mention of medical neglect?
The fatality report states regarding the paternal grandmother's CPS history more than three years prior: "the PGM had 31 SCR reports against her. Of the 32, 21 of them were indicated for allegations of EdN, CD/A, IG, LS, LMC, and IF/C/S." LMC refers to "Lack of Medical Care" per the abbreviation key. This indicates substantiated medical neglect by the paternal grandmother in prior investigations, though not directly involving the deceased child.
Is there any mention of a motor vehicle crash or incident?
Is there any mention of a murder-suicide incident?
Is there any mention of outdoor elements (including hot car deaths)?
Is there any mention of prenatal substance exposure (including fetal alcohol syndrome or neonatal abstinence syndrome)?
The fatality report explicitly states under the "Infants Under One Year Old" section that during pregnancy the mother "Used illicit drugs" and the infant was born "Drug exposed." The CPS investigative history from 01/16/2022 further states: "The mother delivered the subject child and both the mother and the child tested positive for marijuana." Additionally, the report notes: "Although the child was born with a positive toxicology there were no concerns regarding the mothers' drug use."
Is there any mention of sexual abuse?
Is there any specific mention of shaken baby or abusive head trauma?
Is there any mention of prolonged abuse or torture (including restraints, captivity)?
Is there any mention of an unsafe sleeping environment?
The fatality report extensively documents an unsafe sleeping environment. The child "was placed to sleep on an adult bed" on a "Boppy Pillow" and "left the child unattended for about thirty minutes." The child was found "amongst several garbage bags that were filled with clothing, between the bed and a wall." Additionally, "the mother stated the child also regularly slept in the bed with her and the father. When co-sleeping, the child was placed in the middle of the parents, elevated with a Boppy Pillow, and covered with a blanket up to her stomach." The medical examiner "reported that unsafe sleep practices may have played a role as an extrinsic factor in the child's death."
Individuals Involved
Was an adoptive parent or guardian involved in the death?
Was a biological father involved in the death?
The fatality report identifies the father (19-year-old male) as an alleged perpetrator. Allegations of DOA/Fatality, Inadequate Guardianship, Inadequate Food/Clothing/Shelter, and Lack of Supervision were all substantiated against him. He was present during the fatal incident and was responsible for the child's care. The household composition identifies him as "Father" — and given the context (no mention of stepfather or non-biological relationship), he is understood to be the biological father.
Was a biological mother involved in the death?
The fatality report identifies the mother (20-year-old female) as an alleged perpetrator. She "placed the child to sleep on the parents' bed, on a Boppy Pillow, and left the child unattended." Allegations of DOA/Fatality, Inadequate Guardianship, Inadequate Food/Clothing/Shelter, and Lack of Supervision were all substantiated against her. She is identified as the biological mother (the report confirms she delivered the child and the pregnancy section refers to her directly).
Was a day care worker, babysitter, or nanny involved in the death?
Was a female paramour or friend involved in the death (e.g., girlfriend, stepmother)?
Was a foster parent involved in the death?
Was a male paramour or friend involved in the death (e.g., boyfriend, stepfather)?
Was another adult relative involved in the death? (e.g., grandfather, aunt)
The paternal grandmother (43-year-old female) was listed as an alleged perpetrator. The allegation of Inadequate Food/Clothing/Shelter was substantiated against her. The report states: "The parents and child resided with the paternal grandmother, she was aware of the living environment and failed to take corrective action." She was also "aware of the condition of the home, specifically the items near the bed which created a safety hazard for the child."
Was a sibling involved in the death?
Child Characteristics
Was the child adopted?
Was the child homeschooled (including "cyberschooling") or taken out of school?
Was the child in foster care at the time of the incident?
Was the child living with relatives at the time of the incident (but not parents)?
Is there any mention of a neurological developmental child disability? (e.g., autism, intellectual disability, nonverbal)
Is there any mention of a physical child disability? (e.g., feeding tube)
Is there any mention of prematurity or low birthweight?
Is there a history of child protection reports prior to death (for this child or siblings)?
The fatality report documents extensive prior CPS history. The deceased child was the subject of an SCR report dated 01/16/2022 regarding both the mother and child testing positive for marijuana at birth. Additionally, the paternal grandmother had an open CPS investigation at the time of the fatal incident (beginning 05/31/2022) and had 31 prior SCR reports between 2002 and 2019, of which 21 were indicated. Multiple other prior reports within three years are detailed.
Does the child have a history of foster care (but not in care at time of incident)?
Is there a history of a sibling death (separate incident from this death)?
Parent/Caregiver Factors
Was an adult charged or arrested for the child's death?
Is domestic violence by the parent/caregiver referenced?
Is there any mention that the death occurred in a temporary shelter or while homeless?
Is an intellectual disability of the parent/caregiver referenced?
Is the mental health of the parent/caregiver referenced?
The fatality report states: "The mother had diagnosed mental health, and reported she was not in any treatment and was not taking any medication."
Is a history of arrests or criminal charges for the parent/caregiver referenced?
Is substance use by the parent/caregiver referenced?
The fatality report states that during pregnancy the mother "Used illicit drugs" and "the child was born with a positive toxicology." The January 2022 SCR report notes: "The mother delivered the subject child and both the mother and the child tested positive for marijuana." Additionally, the paternal grandmother's CPS history includes indicated allegations of "CD/A" (Child's Drug/Alcohol Use) — though that pertains to other children in her care. The mother's drug use during pregnancy constitutes substance use by a parent/caregiver.
Notable Details
Several notable systemic details are present. Most significantly, CCDHHS provided two portable cribs and discussed safe sleep guidelines with the family on the morning of 6/3/22, the same day as the fatal incident that evening — demonstrating that the parents had access to safe sleep resources and yet failed to use them. The report also reveals that CCDHHS failed to complete a Plan of Safe Care for the infant born drug-exposed in January 2022. The paternal grandmother had an extraordinary CPS history: "Between 2002 and 2019, the PGM had 31 SCR reports against her. Of the 32, 21 of them were indicated." Recurring compliance issues were identified across multiple prior investigations, including repeated failures to send notification letters within required timeframes and failure to review CPS history timely. Additionally, Chautauqua County does not have an OCFS-approved Child Fatality Review Team.
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