R.G. was born in 2022 to parents who were both active Fentanyl users. The mother had used narcotics during pregnancy, and R.G. tested positive for methadone and Fentanyl at birth. A CPS risk-only case was opened, a safety plan involving a relative providing supervision was established, and the family was connected with SUD treatment services. The case was closed in September 2022 after a safety assessment. On October 28, 2022, R.G. was found unresponsive and not breathing at approximately 2:30 a.m. while the family — both parents, R.G., and an older sibling — were sharing a bed. R.G.'s post-mortem toxicology was positive for Fentanyl. The medical examiner ruled the manner of death as undetermined. Both parents were assigned founded findings for negligent treatment of R.G.
Contexts/Conditions
Is there any mention of child drug ingestion or overdose?
The fatality report states: "R.G.'s initial toxicology returned positive for Fentanyl" in reference to the child's death. This is direct evidence of drug exposure/ingestion by the child.
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)?
Both parents were active Fentanyl users and were the sole supervisors of R.G. at the time of death (the CPS case with relative-supervised safety plan had been closed in September 2022). The CPS investigation concluded with both parents receiving "founded findings for negligent treatment of R.G." The safety plan had previously required a relative to provide monitoring and supervision, but by the time of death, that oversight was no longer in place. The parents' active substance use while serving as the only caregivers to the infant constitutes inappropriate supervision.
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?
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 states: "the mother reported she actively used narcotics during her pregnancy and while participating in a Medication Assisted Treatment (MAT) program. The mother said her last Fentanyl use was two weeks prior to R.G.'s birth. R.G.'s toxicology was positive for methadone and Fentanyl." This is clear evidence of 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?
The fatality report explicitly describes bed-sharing involving both parents, R.G., and the older sibling: "According to the father, the family shares a bed (both parents, R.G., and older sibling)." Safe Sleep was discussed with the family on multiple occasions, indicating the caseworker recognized the risk. The fact that R.G. was found "on stomach and not breathing" while bed-sharing constitutes an unsafe sleeping environment.
Individuals Involved
Was an adoptive parent or guardian involved in the death?
Was a biological father involved in the death?
The fatality report states that the father was bed-sharing with R.G. at the time of death. The father was an active Fentanyl user who "said he was using Fentanyl to maintain until he could get involved with a methadone clinic." Both the mother and father were assigned "founded findings for negligent treatment of R.G." following the CPS investigation into R.G.'s death.
Was a biological mother involved in the death?
The fatality report states the mother was bed-sharing with R.G. at the time of death. The mother was an active substance user who had relapsed on Fentanyl. Both parents were assigned "founded findings for negligent treatment of R.G." following the CPS investigation.
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?
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 multiple prior CPS contacts: In January 2022, a referral was made about the father's relapse. In July 2022, a CPS risk-only case was assigned at R.G.'s birth due to the mother's active narcotics use during pregnancy and R.G.'s positive toxicology. This case was closed in September 2022 before R.G.'s death in October 2022. The report states: "R.G. and family had a prior Child Protective Services (CPS) case with DCYF in the last 12 months."
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?
Is a history of arrests or criminal charges for the parent/caregiver referenced?
Is substance use by the parent/caregiver referenced?
The fatality report extensively documents parental substance use. "The parents told the caseworker that their drug of choice is Fentanyl." The mother was on a methadone MAT program but relapsed. "The father said he was using Fentanyl to maintain until he could get involved with a methadone clinic." The mother admitted to using four days prior during an August check-in. The report discusses the parents' ongoing SUD treatment throughout the case.
Notable Details
The fatality report identifies several significant systemic issues. First, the Committee found there is no agency protocol for how to case and safety plan for individuals using Fentanyl, noting "the increased risk Fentanyl presents due to the lethality of this substance compared to other illicit and harmful substances." Second, there is no protocol for how field staff should prepare and respond to Fentanyl exposure in the field. Third, staffing challenges were significant: "this particular CPS unit had had a vacant CPS investigator position for a year that the office has not been able to fill" and "one supervisor covering two CPS units for periods of time." Fourth, the Committee noted the safety assessment transitioned from "unsafe" to "safe" prior to case closure without adequate documentation explaining the change. Fifth, despite identifying all of these systemic concerns, the Committee "did not develop any recommendations," which is itself a notable outcome. The Committee also highlighted concerns about the weighting of Indian Child Welfare cases and the need for medical consultation when parents are actively using Fentanyl.
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