What if you took the same science-based scrutiny that industries have used to improve the safety of airplane passengers, hospital patients and nuclear power plant workers — and applied it to protecting children?
That’s the approach taken in a 39-page review of child protection in New Hampshire, released Wednesday by the Office of the Child Advocate (OCA). “We believe the lives and healthy development of children are equally as important as those of power plant employees or airplane passengers,” the review states.
Under state law, the Division for Children, Youth and Families has to report to the OCA all incidents regarding children who experience physical injury or significant risk of harm, as well as other incidents that may affect the children’s safety and well-being. Between February 2018 and September of this year, 26 deaths of children up to age 18 were reported to the OCA, according to the OCA’s first System Learning Review (SLR) Summary Report.
Forty percent of those deaths involved children under a year old, which the report notes aligns with national statistics. Most of the children died from natural causes or accidents (eight each); three children died by suicide and two died by homicide.
Fifteen of the children or their families had had contact with DCYF.
The new report is based on a review of six critical incidents involving families involved with DCYF: five child deaths and one death of a parent.
The report calls for a shift “from a culture of blame to a culture of accountability.” When a child dies, blame typically falls on individuals or specific agencies, but cases can be more complex, according to the OCA report. “Rather, tragic and usually unforeseeable events emerge from a complex social system comprised of influences from relationships, roles, and interactions within environments, communities, cultures, health services, public agencies and families.”
And it will take an equally complex response to improve the system, the report concludes. “We now understand the approach to tragedy that calls out and fires employees leaves behind an imperfect system in which tragedy will re-occur until the system itself improves,” it states.
The OCA recommends next steps for DCYF, the Department of Health and Human Services, the Legislature and the governor’s office. Among them: improvements in communication and access to case reports and other data for case workers; better cooperation and trust among agencies such as DCYF, law enforcement and health care providers; and additional training, both for case workers and the broader community.
For instance, the OCA recommends that all state employees and contractors participate in training regarding the state’s mandatory reporting requirement for suspected child abuse and neglect.
Child protection service workers (CPSWs) have to be experts in child development who are trained to recognize domestic violence, substance use and psychological mistreatment, according to the OCA report, but they are chronically overworked and underpaid; New Hampshire salaries for these positions are lower than for their counterparts in Maine, Massachusetts and Vermont.
Meanwhile, pressure to complete and close cases in a timely manner is adversely affecting how case workers do their jobs, the report indicates.
“Child protection work is complex,” it states. “It can be heartbreaking, traumatic and dangerous. Training, supervisory support, and manageable workloads all contribute to the CPSW’s well-being and capacity to perform.”
The OCA notes that some of this pressure should be relieved as the state hires new social workers and supervisors, as provided in the new state budget. But that can’t be the sole answer, the report concludes.
“Functioning for more than a decade with inadequate staffing appears to have established a culture of inadequacy that will need deep training, supervision and support to shift to a higher quality of service,” the report states.
In a statement, DCYF and DHHS responded to the new report, noting the agency has been revamping its own critical incident review process. It also said DCYF has filled 21 of the 27 CPSW positions authorized in the new budget, and that hiring time has been streamlined.
“Every child death is a tragedy and deserves our attention so we as a State can learn how to prevent this outcome in the future,” the statement reads. “As a learning organization, we appreciate the review of past traumatic events and recommendations to improve the child well-being and family strengthening system and prevent these tragedies from occurring whenever possible.”
DHHS said it agrees that child safety is a collective responsibility. But the statement went on, “While the OCA drew broad conclusions after speaking to about a dozen DCYF staff, representing a small sample of the broader workforce, we encourage the OCA to consider broadening its work to include more voices from within DCYF and from outside the agency.”