Is there any mention of child drug ingestion or overdose?

The fatality report documents multiple instances of child drug exposure. In the June 7, 2021 assessment, "The child tested positive for methamphetamine." Additionally, regarding the critical incident: "the siblings tested positive for substances immediately after the critical incident." Drug paraphernalia (a fentanyl pipe and a broken methamphetamine pipe) were also found in the home where the children lived.

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

The fatality report indicates the mother admitted she "had smoked fentanyl earlier that day around 8 a.m." on the day of the critical incident. Hospital staff had previously "voiced concern regarding the mother's presentation in the NICU and cited several examples of the mother struggling to be sufficiently alert, coherent, or safe to hold, feed or respond to the newborn sibling's needs." Despite a safety plan requiring 24/7 supervision by safety service providers, "None of her roommates were at the home during the critical incident, and the last one who was home left right before the child took a bath." Additionally, "the mother acknowledged concerns of drug use by her roommates and allowed them to care for the children." The child was left without adequate supervision by a substance-impaired mother.

Is there any mention of medical neglect?

The fatality report describes the mother noticing the child had been sick in the days leading up to the death: "About a week prior the child was burning up with a fever," the child had a cough potentially caused by black mold, and changes in sleeping patterns. Despite these symptoms, the mother did not seek medical care: "She stated she would have taken the child to the doctor if she thought it was warranted, but she did not feel the symptoms were out of the ordinary." Additionally, the mother's prenatal care for the deceased child "consisted of two appointments," and for the younger sibling, "prenatal care was limited." While not explicitly labeled as medical neglect, the pattern of failing to seek medical care for a symptomatic child implies it.

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

The fatality report documents prenatal substance exposure for the younger sibling in the August 7, 2023 assessment: "both the newborn sibling and the mother tested positive for fentanyl" and the newborn had "significant withdrawals" and "would remain there for at least a week due to concerns of withdrawal." For the deceased child, the February 23, 2022 report notes the child was "presumptively positive for amphetamines and THC at birth," although confirmation testing was negative.

Is there any mention of an unsafe sleeping environment?

The fatality report describes the sleeping environment where the child was found unresponsive: "Observations of the sleeping surfaces in the room described a bed with two pillows, a blanket, a flat and fitted sheet, and a Pack n' Play at the foot of the bed." The child was placed on the mother's adult bed rather than in the Pack n' Play. The mother "would typically bed share with her children." The bedroom also had "black mold." These details describe an unsafe sleeping environment, and safe sleep practices were a noted concern in prior assessments (e.g., "A discussion about safe sleep occurred" in the August 2023 assessment). The child was found with "blue lips and the blanket, just below the child's belly."

Was a biological mother involved in the death?

The fatality report states the critical incident CPS assessment was coded as "Neglect by the mother" with a disposition of "Founded." The report explains: "The children were exposed to an unsafe environment due to drug use in the home by the mother." The mother admitted to using fentanyl the morning of the child's death and placed the child on an unsafe sleeping surface in a home with black mold, cockroaches, and drug paraphernalia.

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. Reports were made on May 24, 2021 (neglect by parents), June 7, 2021 (neglect by parents), July 10, 2021 (physical abuse by mother), August 5, 2021 (threat of harm by parents), February 4, 2022 (threat of harm by father), February 23, 2022 (threat of harm by mother regarding the deceased child at birth), April 2, 2022 (threat of harm by maternal relative), and August 7, 2023 (threat of harm by mother regarding the younger sibling). These cover the deceased child and their siblings.

Is domestic violence by the parent/caregiver referenced?

The fatality report documents domestic violence in the February 4, 2022 assessment: "the father was domestically violent to the mother in the presence of the 1-year-old child. This violence happened over the course of the night and into the morning. The father did not want the mother to go to her motel room, so he physically assaulted her and kept her phone from her. She had bruising and marks from the physical violence." Additionally, the maternal relative "expressed concern for the father's influence on the mother's recovery and violent behavior toward her." Collateral contacts also "reported throughout the CPS assessment the parents were often observed fighting and arguing."

Is the mental health of the parent/caregiver referenced?

The fatality report states: "The staff at the shelter stated the mother had self-reported having mental health concerns but declined supports and services." Additionally, "The father reported untreated mental health and reported a history of substance use."

Is substance use by the parent/caregiver referenced?

Substance use by the mother and father is referenced extensively throughout the fatality report. The mother admitted her "drug of choice was fentanyl, with use of methamphetamine for energy." She "admitted she had smoked fentanyl earlier that day around 8 a.m." on the day of the critical incident. A fentanyl pipe and broken methamphetamine pipe were found in the home. The mother also "disclosed she was struggling with opioid use and used fentanyl during her pregnancy" with the younger sibling. The father was also reported to be "struggling with fentanyl use" and had a history of methamphetamine use. Both parents had histories of marijuana use.

The fatality report identifies multiple systemic and practice failures by ODHS that are substantive to understanding this case. The CIRT found that prior CPS assessments (May 24, 2021 and June 7, 2021) "had incorrect dispositions that were coded as unfounded and unable to determine, respectively; however, both met definitions for founded allegations under Oregon Administrative Rule." A protective action plan was prematurely lifted when the mother claimed to have separated from the father, but "in a subsequent CPS assessment, it was learned that the relationship between the mother and the father did not end." In the August 7, 2023 assessment (weeks before the death), "the mother and father were not referred to supportive services through the local ART (Addiction & Recovery Team)," a safety plan was not implemented for the deceased child and older sibling for 10 days after the safety threat was identified, and safety service providers "did not appear to be fully assessed for that role." The CIRT also noted "the parents were young and this detail highlighted the lack of services for young parents, and specific services for young people who struggle with substance use disorder as they transition to adulthood." These systemic failures represent significant missed opportunities to intervene before the child's death.