M.M. was born in 2021 with prenatal exposure to heroin and methamphetamine and was treated in the NICU. The family had an extensive history with DCYF, including multiple reports and interventions related to the mother's substance use. On April 18, 2022, M.M.'s mother found the child unresponsive at home and called emergency medical services. The mother admitted to smoking fentanyl, and law enforcement found fentanyl and methamphetamine in M.M.'s play area. M.M. suffered a cardiac arrest and was diagnosed with a brain injury secondary to probable fentanyl ingestion. M.M. was placed in protective custody and admitted to a critical care unit. On May 16, 2022, M.M. was taken off life support and passed away. DCYF issued negligent treatment or maltreatment founded findings against both parents, though neither parent was criminally charged at the time of the review.
Contexts/Conditions
Is there any mention of child drug ingestion or overdose?
The fatality report states: "M.M. had a cardiac arrest and was diagnosed with a brain injury secondary to probable Fentanyl ingestion." It also notes that "the officer said they found fentanyl and methamphetamine in M.M.'s play area."
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 states: "The mother admitted to smoking fentanyl, and the officer said they found fentanyl and methamphetamine in M.M.'s play area." Smoking fentanyl while responsible for the child and having drugs accessible in the child's play area constitutes inappropriate supervision, ultimately leading to M.M.'s probable fentanyl ingestion.
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: "A medical professional notified DCYF that due to prenatal exposure to harmful substances, M.M. was receiving care from the neonatal intensive care unit. The mother disclosed that during her pregnancy, she ingested heroin on a daily basis and periodically used methamphetamines."
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 states: "The FVS caseworker spoke with the mother about Safe Sleep and Period of Purple Crying. The FVS caseworker offered advice to the mother about M.M.'s sleep environment and asked that the crib bumpers be removed." Crib bumpers are recognized as an unsafe sleep element. Although this concern was addressed and the bumpers were later removed, the initial presence of an unsafe sleeping environment is documented.
Individuals Involved
Was an adoptive parent or guardian involved in the death?
Was a biological father involved in the death?
The fatality report states: "DCYF issued negligent treatment or maltreatment founded findings against both parents." While the direct description of the fatal incident focuses on the mother's actions (smoking fentanyl, drugs in play area), the father also received founded findings for negligent treatment or maltreatment in connection with M.M.'s death.
Was a biological mother involved in the death?
The fatality report states: "Emergency medical services responded to M.M.'s home after mother found M.M. unresponsive. The mother admitted to smoking fentanyl, and the officer said they found fentanyl and methamphetamine in M.M.'s play area." Additionally, "DCYF issued negligent treatment or maltreatment founded findings against both parents." The mother's drug use in the home directly contributed to M.M.'s probable fentanyl ingestion.
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?
The fatality report states that a Committee subject matter expert "pointed out that the first year of life is a critical time for infants who are born premature and who are affected by harmful substances," referencing M.M. Additionally, M.M. received care in the neonatal intensive care unit at birth, which is consistent with prematurity. While the report does not say "M.M. was premature" in a standalone sentence, the statement clearly applies to M.M. in context.
Is there a history of child protection reports prior to death (for this child or siblings)?
The fatality report documents multiple prior child protection reports: a CPS risk-only investigation in April 2021 after M.M.'s birth, two intake calls in October 2021 (one screened out, one initially screened in then screened out), and a CPS-FAR case opened in February 2022. All of these preceded the April 2022 critical incident.
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 substance use by both parents. It states: "The mother disclosed that during her pregnancy, she ingested heroin on a daily basis and periodically used methamphetamines." The father "also disclosed methamphetamine use." Later, "The mother admitted to smoking fentanyl, and the officer said they found fentanyl and methamphetamine in M.M.'s play area." The mother also participated in SUD treatment and medically-assisted treatment.
Notable Details
The fatality report documents several significant systemic issues. The Committee learned about "high staff vacancies and turnover rates in two of the three involved offices" and that "caseloads were extremely high and that supervisors were re-assigned to carry full caseloads," which left less time for clinical supervision. The Committee identified that multiple case transfers and courtesy supervision arrangements "may have contributed to a lack of follow-through and oversight." The Committee observed that "DCYF has a culture that focuses on identifying which office should be assigned a particular case and that this may detract from focusing on service provision and assessing safety." A caseworker did not complete referrals for early learning programs requested by the mother because the case was transferring, which the Committee "identified as a missed opportunity." The October 2021 intake that initially screened in was transferred to another office and subsequently screened out, which the Committee felt was "a critical time to re-assess the mother's progress." Notably, the Committee did not identify any formal findings, and the sole recommendation was to hire a licensed therapist to support DCYF staff experiencing secondary trauma, along with suggestions about staffing.
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