The 2-month-old male child was born at approximately 25 weeks gestation on June 15, 2023, after the mother, who was unaware of her pregnancy, delivered him at home. Due to his extreme prematurity, the child was immediately admitted to a neonatal intensive care unit (NICU) where he remained from birth until death. His lungs were severely underdeveloped and he required continuous mechanical ventilation. Despite medical interventions, the child's body could not develop new lung tissue, and the procedures and medications were causing him pain. On August 22, 2023, the hospital's medical team met with the mother and OCDSS and recommended that assisted living devices be gradually removed to allow the child to pass naturally. The mother consented, and on August 24, 2023, the ventilator was removed; the child died later that day in his mother's arms. The official manner of death was natural, caused by lung disease from premature birth resulting in respiratory failure.
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 includes a substantiated allegation of "Lack of Supervision" against the mother regarding the surviving sibling in the 8/9/23 SCR report. It further describes that the grandparent was not ensuring appropriate supervision of the sibling and was allowing the sibling to visit with the mother at inappropriate locations. The report states: "Upon learning that the grandparent was not ensuring appropriate supervision of the sibling and was allowing the sibling to visit with the mother at inappropriate locations, OCDSS planned with the family for the sibling to temporarily reside with an alternative approved family resource." While this pertains to the sibling rather than the deceased child's direct cause of death, inappropriate supervision is clearly documented in this case.
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?
While no allegation of "Lack of Medical Care" (LMC) was formally charged, the fatality report describes behavior consistent with medical neglect. The report states the mother "had not returned to the hospital since 6/24/23 and had not been responsive to the hospital's outreaches to plan for the child's care" and that "The mother failed to visit the subject child in the hospital following his birth and was unresponsive to hospital outreach to discuss his care." The 8/9/23 SCR report also noted "There had been multiple attempts to reach the mother to give her instruction on what was needed for the child's care." These descriptions describe a failure to participate in the medical care planning for a critically ill premature infant, which constitutes medical neglect in substance, even though the formal allegation was Inadequate Guardianship rather than LMC.
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 checks that during pregnancy, the mother "Used marijuana" under the "During pregnancy, mother" checklist for the subject child. While the infant was noted as born "With none of the issues listed noted in case record" (no positive toxicology, no FAS, no withdrawal), the mother's marijuana use during pregnancy constitutes prenatal substance exposure.
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?
Individuals Involved
Was an adoptive parent or guardian involved in the death?
Was a biological father involved in the death?
Was a biological mother involved in the death?
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)
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?
The fatality report states: "The deceased child(ren) were in foster care at the time of the fatality? Yes" with a date of placement of 08/15/2023 via court order. The report also states: "OCDSS filed a Neglect Petition on 8/11/23 and requested the removal of the subject child and sibling. The removals were granted on 8/15/23. The subject child was placed in the custody of OCDSS and remained hospitalized until his death."
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)
The fatality report describes the child as having severely underdeveloped lungs due to extreme prematurity (25 weeks gestation). The report states: "He had been on a ventilator since birth and his lungs were dangerously fragile" and "his lungs had not fully developed." The child's underdeveloped respiratory system required continuous mechanical ventilation from birth until death, constituting a significant physical disability.
Is there any mention of prematurity or low birthweight?
The fatality report extensively documents the child's prematurity. The Executive Summary states: "The mother was unaware of her pregnancy with the subject child until she delivered him at home, at approximately 25 weeks gestation on 6/15/23." The report further notes: "Due to the child's prematurity, his lungs were underdeveloped" and "The child was prematurely born, which caused a lack of lung development and subsequent respiratory failure."
Is there a history of child protection reports prior to death (for this child or siblings)?
The fatality report documents multiple prior CPS reports for the sibling, including reports dated 07/17/2022 (alleging mother's drug use and inadequate provisions), 12/15/2022 (alleging mother under influence while caring for sibling), and 04/28/2023 (court ordered investigation plus allegations of drug use, lack of supervision). The 8/9/23 report also included allegations about the deceased child and sibling prior to the child's death.
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 references mental health services as part of the mother's service plan. The report states the mother was provided "relevant referrals in response to the fatality, as well as to address the service needs identified in the services case, including supervised visitation, parenting, mental health, and substance use treatment." The initial FASP also "indicated a service plan that included maintaining stable housing, and that the mother engage in mental health and substance use treatment." The mother was also referred for a psychological evaluation. These references indicate the mother's mental health was identified as a service need.
Is a history of arrests or criminal charges for the parent/caregiver referenced?
Is substance use by the parent/caregiver referenced?
Substance use by the mother is a major theme throughout the report. The 04/28/2023 report summary states: "the mother was actively using drugs to the point of impairment while caring for the sibling. The mother was taking the sibling out as late as 3:00AM to purchase drugs." The 12/15/2022 report alleges "the mother was under the influence of drugs while caring for the sibling." Substance use treatment was part of the service plan, and the 8/9/23 report included a substantiated allegation of "Parents Drug / Alcohol Misuse." The mother's service plan included substance use treatment.
Notable Details
The fatality report identifies several systemic compliance issues that materially affect understanding of this case. First, OCDSS failed to attempt contact with the mother after receiving an Additional Information report on 7/19/23 about the child's premature birth and NICU admission, not acting until a new SCR report was registered on 8/9/23 — a gap of approximately three weeks. The report states: "The record did not reflect OCDSS attempted to contact the mother following receipt of the Additional Information report until an SCR report was registered with similar concerns on 8/9/23, prompting a new CPS investigation." Second, the child was born during an open CPS investigation (4/28/23) but was never added to that report. Third, over 74% of progress notes in the 4/28/23 investigation were entered untimely, "between one and seven months after their event dates." Fourth, the 4/28/23 investigation had remained open over seven months at the time of review without determination. Fifth, the mother was unaware of her pregnancy and delivered the child on a toilet at home at approximately 25 weeks gestation, and the child never left the hospital from birth to death.
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