J.C., a 1-year-old boy, died on December 12, 2022, in the Sequim area of Clallam County, Washington, from fentanyl exposure after secondhand fentanyl smoke was inhaled at a residence on Fireweed Road. J.C. was with his mother and an unidentified male at the time. People at the house administered Narcan, but J.C. was found dead when medics arrived. The mother, Crystal Kathleen Coffman, 36, was arrested for investigation of first-degree manslaughter but was released as the investigation continued. DCYF had received multiple intakes regarding concerns about the mother's substance use and care of J.C. since February 2022, including reports of the mother nodding off, appearing impaired while caring for J.C., and smoking fentanyl in the child's presence. A CPS investigation was open at the time of J.C.'s death, but a dependency petition had never been filed.
Contexts/Conditions
Is there any mention of child drug ingestion or overdose?
The fatality report states "J.C. died the previous day due to fentanyl exposure." The news article reports "A 1-year-old baby died Monday afternoon in the Sequim area from suspected second-hand fentanyl smoke" and "The person who called for help said fentanyl was being smoked around the baby." This clearly describes a child's death from drug exposure/ingestion via inhalation.
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)?
Multiple instances of inappropriate supervision are documented. The fatality report describes J.C.'s mother "nodding off" while caring for J.C. On February 15, 2022, the roommate reported "J.C.'s mother to be 'hunched over' in the front seat of the mother's car and appeared to have 'nodded off'" while "J.C. was inside the car screaming." On March 16, 2022, a therapist reported the mother "appeared to be under the influence of a substance" with "J.C.'s head was dangling with no support." At the time of death, "fentanyl was being smoked around the baby" per the news article.
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?
The fatality report states: "Then on February 14, J.C.'s mother told the roommate she had been in a car accident. She did not seek medical attention and law enforcement was not called." While this is not related to the child's death, a motor vehicle crash is mentioned in the case record.
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 "J.C. was faced with multiple challenges at birth that would need follow up as a newborn, infant, and possible toddler" and that "medical records obtained by the initial CPS caseworker supported a report to DCYF at J.C.'s birth." Neither birthing hospital called DCYF despite the records. Additionally, footnote 3 references a "brand name for the medication naloxone or buprenorphine. The medication is used to treat Opioid Use Disorder," appearing in the context of describing the mother's condition when J.C. was two months old. The mother had long-standing substance use issues known to a therapist "for years." Combined, these strongly imply 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 describes the first intake on February 11, 2022: "The caller reported concerns that the mother was 'nodding off' and the caller was concerned the mother would roll on top of the infant." This describes an unsafe sleeping environment with co-sleeping risk while the mother was impaired. Additionally, Safe Sleep was later discussed with the mother as a topic, indicating it was a recognized concern.
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?
The fatality report states "J.C. was with mother and a male when he died" and "the mother was arrested related to her death." The news article confirms "Crystal Kathleen Coffman, 36, of Port Angeles was arrested and booked Monday evening" for "investigation of first-degree manslaughter — domestic violence." The news article also states "The person who called for help said fentanyl was being smoked around the baby," and the mother was present.
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 states "J.C. was with mother and a male when he died." Since J.C.'s biological father was documented as incarcerated ("The mother provided information about the father, that he was incarcerated and where he was incarcerated"), this male was someone other than the father. The news article states "Several others were present at the scene." While the relationship of this male to the mother is not specified, his presence at the scene when fentanyl was being smoked around the baby implies involvement in the death.
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 child protection reports prior to J.C.'s death: an intake on February 11, 2022 (screened out); an intake on February 15, 2022 (screened in for CPS/FAR); an intake on March 16, 2022 (screened in for CPS/FAR); and an intake on November 23, 2022 (screened in for CPS investigation). The report also notes "This case was open for a CPS investigation at the time of J.C.'s death." Additionally, the report references "documentation of the history related to J.C.'s mother as a child and J.C.'s grandparents involved with DCYF," indicating prior DCYF history for the family.
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?
The news article states "Crystal Kathleen Coffman, 36, of Port Angeles was arrested and booked Monday evening" for "investigation of first-degree manslaughter — domestic violence." The fatality report also states "the mother was arrested related to her death." Although she was later released and the investigation was ongoing, she was 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?
The fatality report states on February 11, 2022: "the mother is living in a shelter." The mother and J.C. lived in a shelter during the early months of DCYF involvement. The mother subsequently moved between different units in housing. However, the death itself on December 12, 2022 occurred at "a residence in the 700 block of Fireweed Road" per the news article, the nature of which (permanent housing vs. temporary) is unclear. The family's housing instability is documented throughout the case.
Is an intellectual disability of the parent/caregiver referenced?
Is the mental health of the parent/caregiver referenced?
The fatality report states that "a local therapist called DCYF and reported that she has known J.C.'s mother for years." Having a long-term therapeutic relationship with a therapist implies mental health involvement for the mother, though the specific concerns raised by the therapist in the report pertained to substance use.
Is a history of arrests or criminal charges for the parent/caregiver referenced?
The fatality report states that J.C.'s mother "provided information about the father, that he was incarcerated and where he was incarcerated." Being incarcerated indicates prior criminal history for the father, a parent/caregiver, predating and separate from J.C.'s death.
Is substance use by the parent/caregiver referenced?
Substance use by J.C.'s mother is extensively documented throughout the fatality report. The first intake reported the mother was "nodding off." The roommate observed the mother appeared to have "nodded off." A therapist "has known that the mother experiences substance use." The mother "often smells like cannabis." The November 2022 intake reported the mother was "smoking fentanyl with her [child] present." Needles and tinfoil were found on the floor. The caseworker noted the mother "was sweating and shaking" during conversation. The footnote references medication-assisted treatment for Opioid Use Disorder. The news article states "fentanyl was being smoked around the baby."
Notable Details
The fatality report describes several significant systemic and policy issues. First, the staff discussed that "their court system in Clallam County was already using the standards for dependency court cases for the House Bill 1227" before its effective date, and that "the higher burden for removal of a child from parental care was already effectuated by their court and therefore it has negatively impacted their ability to successfully pursue out of home care for children they assess at imminent danger." Second, the CPS caseworker assigned was "brand new to child welfare and did not receive adequate support or guidance from her then supervisor" and was one of three CPS caseworkers in the office with "three vacancies in the unit." Third, the Committee noted a missed opportunity: "Neither the birthing hospital, and the hospital he was transferred to for his post-birth medical needs, called DCYF. The Committee believes medical records obtained by the initial CPS caseworker supported a report to DCYF at J.C.'s birth." Fourth, law enforcement initially said they would place J.C. in protective custody but "changed their minds when he was found with mother and maternal grandmother even though there is history regarding the maternal grandmother and substance use." Fifth, relationships with community partners were described as "hostile and uncooperative at times."
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