On December 13, 2023, a 6-month-old boy was found deceased by his father at 11:42 a.m. in the queen-sized bed they shared, which also contained pillows and loose blankets. The child was found face down and not breathing. The father had woken at approximately 6:30 a.m. and left the child in bed face down — which he said was the child's preferred sleeping position — without checking on the child. The father showered, made breakfast for the 2-year-old sibling, and later left the home to renew food benefits, asking a friend to keep an eye on the children. The friend remained on the front porch and did not check on the child. Upon returning, the father cleaned up a mess before realizing he had not heard the child, at which point he discovered the child was not breathing. The child had no marks, bruises, or injuries. The child was born substance-exposed (positive for amphetamines and fentanyl at birth) and had experienced withdrawal symptoms requiring NICU care. At the time of death, there was already an open CPS assessment on the family regarding the mother's substance use in the home. The family had an extensive history of CPS involvement related to parental substance use, domestic violence concerns, and unsafe living conditions.
Contexts/Conditions
Is there any mention of child drug ingestion or overdose?
The fatality report documents the 2-year-old sibling's urinalysis from December 14, 2023, which "came back positive for amphetamine/methamphetamine and presumptive positive for fentanyl/norfentanyl." Additionally, the sibling's earlier hair follicle test from July 2023 "were positive for amphetamines, methamphetamine, fentanyl and cannabis." These represent post-birth drug exposure in a child in this case.
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 explicitly documents inappropriate supervision. The father left the 6-month-old child unattended for hours: "The father had not checked on the child between the time the father woke up at 6:30 a.m. and the time the child was found deceased" at 11:42 a.m. The father left the home to run an errand and asked a friend on the front porch to "keep an eye out for the child." The neglect allegation was "founded due to the father leaving the child unattended for several hours without checking on him and concerns regarding the father's decision making leading up to the child's passing." Additionally, a separate report "indicated concern for the sibling's supervision and noted a time the sibling was almost hit by a car while outside alone without the father's knowledge."
Is there any mention of inflicted injury? (e.g. slapped, punched, kicked, choked)
Is there any mention of malnutrition, starvation, or dehydration?
The fatality report documents the 2-year-old sibling was noted to be "underweight and petite for their age" and "small for their age." The sibling's weight was at 1 percent on the growth chart. It was further noted that "the sibling had been drinking formula from the deceased child's bottles and therefore was not eating enough solids." The deceased child was "noted to be high risk for failure to thrive" at birth.
Is there any mention of medical neglect?
The fatality report documents several indicators consistent with medical neglect. The mother received late prenatal care: "She began receiving prenatal care around five and a half to six months into her pregnancy" for the deceased child. The sibling "missed an appointment on December 12, 2023, for a weight check" and "Their last well child visit was in May 2023." The deceased child "was noted to be high risk for failure to thrive and all routine care was recommended to be maintained." The mother "had not made any attempts to visit and bond with the child" while in NICU, and "the lack of bonding for the child was acutely impacting their health and negatively affecting their withdrawal symptoms." The mother was also "offered treatment but declined" multiple times during pregnancy.
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 documents the deceased child's prenatal substance exposure: "The child's drug screen was positive for amphetamines and fentanyl and considered a substance exposed infant." The child "was experiencing withdrawal symptoms" and "was fitted with a feeding tube due to concerns with his symptoms of possible withdrawal." The mother "tested positive for amphetamines and fentanyl upon admission for delivery" and "reportedly tested positive for meth, amphetamines and fentanyl during previous medical visits while pregnant." The older sibling was also "substance affected due to intrauterine drug exposure" with umbilical cord blood "positive for amphetamine, methamphetamine, opiates, morphine, codeine and cannabinoids."
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 explicitly documents an unsafe sleeping environment. The child was found "face down and not breathing on the queen-sized bed with pillows and loose blankets." The father was bed-sharing with the children: "the bed the father shared with the children the night prior." The room was "about 10'x10', with little room to move around freely" and "There was no mention of a separate sleeping space present in the room." Safe sleep was discussed multiple times with the family throughout the assessments. The CIRT specifically noted: "it does not appear this particular child's increased vulnerabilities were clearly articulated to the family to help inform their decision making about where and how the child was laid to sleep." A safe sleep checklist from October 27, 2023, documented the father reported bedsharing, and the CPS caseworker "discussed the risks of doing so and advised against it."
Individuals Involved
Was an adoptive parent or guardian involved in the death?
Was a biological father involved in the death?
The fatality report explicitly documents the biological father's involvement in the child's death. "The allegation of neglect to the 6-month-old deceased child by the father was founded due to the father leaving the child unattended for several hours without checking on him and concerns regarding the father's decision making leading up to the child's passing." The father was bed-sharing with the child, left the child face down on a queen-sized bed with pillows and loose blankets, and did not check on the child for approximately 5 hours after waking.
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)?
The fatality report documents that the father's friend was asked to supervise the children while the father left the home: "The father's friend came to the home and was asked to keep an eye out for the child and the child's sibling while the father ran an errand." However, the friend remained on the front porch rather than inside with the children: "The father returned home and found his friend still on the front porch." The friend failed to check on the child during this period. The child likely died during or around the time the friend was supposed to be watching. The paternal grandmother stated "the father's friend used substances but was not sure if they used anything the day he was there," identifying the friend as male.
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?
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 states that at birth, "The child was fitted with a feeding tube due to concerns with his symptoms of possible withdrawal and was being transferred to the NICU." While temporary, this is an explicit mention of a feeding tube used for the child. The child was also described as a "substance exposed infant" who experienced withdrawal symptoms at birth, indicating enhanced physical vulnerabilities.
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 an extensive history of prior CPS reports for both the deceased child and the sibling, dating back to May 4, 2021. Reports were received on May 4, 2021; May 8, 2021; May 15, 2022; November 23, 2022; April 4, 2023; June 29, 2023; June 30, 2023; October 27, 2023. At the time of the child's death on December 13, 2023, there was an active, open CPS assessment: "At the time of the child's death, there was an open CPS assessment concerning the child's father and paternal grandmother allowing the child's mother to use substances in the home and be around the children while under the influence."
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?
The fatality report documents a report received May 15, 2022, "regarding concerns of domestic violence perpetrated by the father in the presence of the 1-year-old sibling. It was believed the mother was assaulted nightly by the father." The report states: "The father was heard screaming and threatening the mother, while signs of a physical altercation could be heard within the family home." Also, "The father was described to be a violent man" who "would yell and sometimes break things when he was irritated." While the mother denied physical violence during interviews, the allegations are explicitly documented.
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 reported being diagnosed with mental health conditions when she was around 14 or 15 years old." Additionally, the mother "reported to struggle with stress management and utilized substance use to cope."
Is a history of arrests or criminal charges for the parent/caregiver referenced?
The fatality report documents prior criminal history for both parents, separate from the child's death. The father "had previous service engagement in 2019 after receiving a DUII where he completed services." The mother was "lodged at the county jail and facing 18 months in prison for theft charges" (referenced on July 24, 2023). The mother was also arrested "at the paternal grandmother's home for a warrant" on January 3, 2024, and "was found under the influence and was detained by her probation officer" on January 24, 2024. These are prior criminal matters separate from the child's death.
Is substance use by the parent/caregiver referenced?
Substance use by parents/caregivers is extensively documented throughout the fatality report. The father reported daily marijuana use and a history of methamphetamine use. His urinalysis from January 8, 2024, "was positive for cannabis, alcohol and methamphetamine." The mother "reported she used methamphetamine and fentanyl daily" and had an extensive history of heroin, methamphetamine, and fentanyl use. The paternal grandmother was reported to smoke marijuana. The paternal aunt had a history of substance use. Allegations of substance selling from the home were also documented.
Notable Details
The fatality report identifies several significant systemic and policy issues. First, at the time of the child's death, there was already an open CPS assessment on the family. The CIRT noted that "the conflicting information about substance use in the household presented a challenge in understanding the day-to-day safety of the children in the home." The CIRT specifically identified bias regarding marijuana: "Safe Systems data has shown bias regarding the risks associated with marijuana use versus other substances has impacted case practice decisions in other cases reviewed by the CIRT. Parent/Caregiver marijuana use must always be factored into overall safety considerations for a highly vulnerable infant when a parent/caregiver indicates a preference for bed sharing." The CIRT also noted that workload pressures due to "high vacancy rates resulting in the need to often respond to multiple reports weekly and sometimes daily" exacerbated challenges in thorough case review. Additionally, the report highlights the importance of developing Plans of Care for substance-exposed infants under the federal Comprehensive Addiction and Recovery Act (CARA) and acknowledges that the father's role as the primary custodial parent "was not acknowledged or supported by upstream community supports."
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