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

The fatality report explicitly describes inappropriate supervision as a central factor. It states: "the subject child was outside at a relative's home unsupervised, when he ran into the street, was hit by a car, and died." It further notes: "It was unclear who was supposed to be supervising the child when he ran into the street and was struck by a car. Furthermore, it remained unknown who was supervising the sibling or how long the children had been unsupervised." The open CPS investigation at the time had allegations of "Lack of Supervision" against the mother.

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

The fatality report's CPS investigative history includes a report dated 11/29/2021 which states: "An SCR report received on 11/27/2021, alleged the MGM and adult sister (SC's mother) of the aunt beat the aunt with a broomstick. As a result, the aunt had sustained a bloody right index finger, numerous bruises to the right forearm and shin, a laceration above the left eye and pain to the back." The aunt was 17 years old at the time, making her a minor.

Is there any mention of medical neglect?

The fatality report documents medical neglect in the CPS history. It states: "In 2018, the mother was indicated for inadequate guardianship, lack of medical care and lack of supervision regarding the sibling." The Foster Care Placement History section further describes that "the grandmother did not have the sibling's lifesaving medical equipment with her" and the sibling was removed due to "the Neglect Petition that was filed on 9/5/18 regarding the sibling's medical neglect." Additionally, the 11/29/2021 CPS report included "Lack of Medical Care" allegations regarding the aunt.

Is there any mention of a motor vehicle crash or incident?

The fatality report states: "the subject child was outside at a relative's home unsupervised, when he ran into the street, was hit by a car, and died." The preliminary cause of death was "blunt force trauma." The news article corroborates: "a 4-year-old boy has died at the hospital after being hit by a car on Sunday evening."

Was a biological mother involved in the death?

The fatality report states that the mother was present at the barbeque. "While the mother was inside the home, the child and sibling were outside." The mother claimed the uncle was supposed to supervise, but "The record was unclear if the mother had spoken to the uncle regarding supervision, or if the uncle agreed to supervise the children." Additionally, there was a safety plan in place that the children would reside with the grandmother until the mother engaged in treatment, but the grandmother had returned the children to the mother prematurely. The mother was also the subject of an open CPS investigation with allegations of Lack of Supervision. While the mother did not directly cause the child's death, her failure to ensure adequate supervision implicates her involvement.

Was another adult relative involved in the death? (e.g., grandfather, aunt)

The fatality report states: "The mother reported the child was outside and was supposed to be supervised by the uncle." However, "Despite reasonable efforts made by MCDHS, they were unable to make contact with the uncle; therefore, he was not interviewed regarding the fatal incident or whether he was responsible for supervising the children." The uncle was present at the scene but his actual supervisory role was never confirmed.

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

The fatality report describes the sibling's medical condition in the Foster Care Placement History section: "The sibling had a medical condition that required a higher level of care" and the grandmother "did not have the sibling's lifesaving medical equipment with her." While this pertains to the sibling rather than the deceased child, it constitutes a mention of a physical child disability in the household.

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

The fatality report documents multiple prior CPS reports. An SCR report dated 01/26/2022 alleged Inadequate Guardianship and Lack of Supervision against the mother for both the deceased child and sibling. An SCR report dated 11/29/2021 alleged multiple forms of abuse against the mother and grandmother regarding the aunt. Additionally, "In 2016, there was an SCR report received with allegations of inadequate guardianship against the mother regarding the sibling" and "In 2018, the mother was indicated for inadequate guardianship, lack of medical care and lack of supervision regarding the sibling."

Does the child have a history of foster care (but not in care at time of incident)?

The fatality report answers "Was the child ever placed outside of the home prior to the death? Yes." It then describes: "The subject child went into the care of his father and was returned to the mother's custody on 10/17/19 with an order of supervision in place." This placement occurred during a CPS investigation and was part of an official child welfare action (a Neglect Petition was filed on 9/5/18). While the child was placed with his biological father rather than in traditional foster care, this constitutes a history of out-of-home placement through child protective services.

Is the mental health of the parent/caregiver referenced?

The fatality report extensively references the mother's mental health. It states: "MCDHS learned the mother had a history of untreated mental health concerns." The 01/26/2022 SCR report alleged "the mother had undiagnosed mental health concerns and her behavior was unstable and unpredictable. The mother had blacked out and became angry... The mother was having a mental health breakdown." Additionally, "MDCHS contacted the mother's mental health providers who reported the mother had not actively engaged in treatment, missed several appointments, and was discharged from the program."

Is substance use by the parent/caregiver referenced?

The fatality report states: "MCDHS learned the mother had a history of untreated mental health concerns and a history of substance misuse." It also notes: "The mother recognized she was struggling with her mental health and substance misuse after the death of the child." The services table shows alcohol/substance abuse services were "Offered, but Refused."

The fatality report identifies several systemic and process issues that are substantive. First, a safety plan was in place requiring the children to reside with the grandmother "until the mother was engaged and benefitting from her treatment," but "The grandmother returned the children to the mother in March or April of 2022, because the grandmother believed the mother could adequately care for the children" — despite the mother not having engaged in treatment. Second, MCDHS had multiple compliance issues: a CPS history check was completed untimely, 9 out of 88 progress notes were not entered contemporaneously, and in the prior 11/29/2021 report, "Despite MCDHS observing and documenting the bruises which were alleged in the SCR report, they unsubstantiated the allegations and unfounded the report." Third, the uncle who was allegedly supervising the child was never interviewed despite being present at the time of the fatal incident. Fourth, the mother repeatedly failed to engage in mental health treatment both before and after the child's death, and declined services offered after the fatality.