On May 21, 2022, a 3-month-old African American male infant was pronounced deceased in his home in Kenosha County, Wisconsin. The Medical Examiner's preliminary autopsy report noted the cause of death as undetermined with an unsafe sleep environment; the final autopsy report remained pending. The agency's Initial Assessment substantiated neglect of the infant by his mother. The infant resided with his mother, father, and three half-siblings ages 11, 13, and 17. No criminal charges were filed, and the criminal investigation remained open at the time of the report.
Contexts/Conditions
Is there any mention of child drug ingestion or overdose?
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)?
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)?
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 multiple times that "The Medical Examiner's Office preliminary autopsy report noted the cause of death to be undetermined with an unsafe sleep environment."
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: "The Initial Assessment completed by the agency found a preponderance of the evidence to substantiate neglect of the infant by the mother." The mother was determined to have neglected the infant in connection with his death in an unsafe sleep environment.
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 lists nine prior screened-out CPS or Services reports dating from 2009 to 2017, including reports on December 13, 2017; September 10, 2017; April 30, 2014; February 24, 2012; August 15, 2011; May 23, 2011; March 9, 2010; and July 14, 2009. While all were screened out, they constitute a documented history of child protection reports involving the family prior to this death.
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?
Notable Details
The fatality report documents that despite substantiating neglect of the infant by the mother in connection with the child's death, the agency closed the case upon completion of the Initial Assessment. The surviving half-siblings were initially deemed unsafe and a Protective Plan was initiated, but the mother and father were subsequently assessed as protective, and the half-siblings remained in the home. Additionally, the family had nine prior screened-out CPS or Services reports spanning from 2009 to 2017, none of which were screened in for further assessment. The closure of the case after substantiated neglect in a child death, combined with the lengthy history of prior reports, may raise questions about systemic case handling.
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