Maine Child Welfare Agency Reports Systemic, Deadly Failures in 2022


A Maine child was born into a household with parents who neglected him, restrained him for long periods of time, and ignored him.

Despite multiple investigations beginning with the child’s birth, reports of domestic violence and medical neglect, five months passed before the child was rescued into state custody.

The foregoing is just one case of state workers at Maine’s child welfare agency struggling to protect Maine kids born into abusive or harmful situations.

This situation and several others were summarized and analyzed in a heartbreaking report out this week from the Department of Health and Human Services’ Child Welfare Services Ombudsman.

The report, led by Child Welfare Ombudsman Executive Director Christine E. Alberi, examines the work of Maine’s child welfare agency and employees in 2022

Alberi’s report is a clarion call to community leaders and elected officials that Maine’s child welfare agency is failing, and Maine kids are paying the price, sometimes with their lives.

Four child welfare cases received media coverage last year after children died despite interventions by the state. Although the report acknowledges those cases, they cases were not included in the summaries provided by the ombudsman. The new examples brought to light suggest media scrutiny of the agency last year only scratched the surface of the dysfunction in Maine’s child welfare system.

In one instance, the agency failed to take action for more than a year despite a child’s exposure to severe drug-related harm.

“The child was exposed to substance misuse including witnessing an overdose, and a court filing only occurred after the child been present for another frightening drug fueled incident,” the report states.

In another case, the state failed to intervene despite substantiated allegations of “severe” domestic violence perpetrated against a mother and her child, closing an investigation only to reopen a new one months later due to further domestic violence in the presence of the infant. The child remained in the custody of the parents for another eight months.

In yet another instance, the report found morally repugnant behavior on the part of a parent failed to generate prompt actions by the state.

The report states: “A parent had a jeopardy finding and cease reunification for an older child due to treatment that was heinous or abhorrent to society. Despite this and the parent’s significant child protective and criminal history, two child protective investigations were completed that left the younger children in that parent’s care. The children entered state custody four months after the second investigation began. The Department’s actions were not proportionate to the extremely high risk indicated by the history and facts of the case.”

Those are just a few of the sterilized summaries contained within the ombudsman’s report. The full read is a harrowing look at how the state is struggling, and often failing, to navigate the extraordinarily complex challenges surrounding child welfare and state interventions.

Challenging as these issues may be, though, the report points up several concrete deficiencies in the conduct of child welfare investigators that may be contributing to tragic cases like the ones described in the report.

More than half of all child welfare cases handled by the Department of Health and Human Services had “substantial issues,” according to the report. The report defined these “substantial issues” as instances in which state employees did not follow best practices, did not follow state policy, or both, and these deviations had a material effect on the safety of children or the rights of parents.

In other words, a “substantial issue” occurred when a government employee went off books, and in multiple cases such behavior led to rights violations or harm to children.

“Of particular note this fiscal year,” the report states, “there were multiple instances where the Department did not recognize risk to children, both during investigations and reunification cases.”

The report says the review discovered two primary problems with initial investigations. The first is that some cases weren’t investigated enough by state workers. The second was that even when the case was investigated enough by state workers, the risk to a child or children wasn’t recognized and decisive action was not taken.

Investigating child abuse cases and then acting on that information is the core function of the agency, so these are pretty significant — existential, even — problems. The list of issues the ombudsman identified with child welfare investigations is devastating.

Investigators did not call parents who weren’t home, police records and court orders were not reviewed, and there was an over-reliance on previous incomplete investigations. Medical records were not sought, parents were not drug tested, new information was not investigated, and investigations were limited to the scope of a complaint rather than all information obtained during a subsequent probe.

In some instances, the report says the Department decided a complaint against a given individual wasn’t true solely because a previous investigation into that individual turned out to be unsubstantiated, as if one unproven allegation meant every allegation thereafter was false.

Taken together, the ombudsman report paints the picture of state workers who did not live up to the expectations of the job, whether because of a lack of resources, staff, or some other reason. Regardless of the ultimate causes of the deficiencies, the report doesn’t pull punches in assessing the dangerously insufficient work of the state’s child welfare investigators. Both at the individual level and organizationally, there was an utter breakdown in the capacity of the agency to perform its work.

“The importance of child protective history to a current investigation cannot be overstated,” the report states. “There were multiple cases this year where the history alone indicated a high level of risk, but staff did not have the history at the outset of the investigation or during the course of the investigation.”

In addition to flawed investigative practices, the ombudsman also identified weaknesses in the agency’s handling of efforts to reunify children with their parents after the children had been taken into state custody or removed to the care of a close relative.

In these situations, the state will work with parents to develop a reunification plan. Often, this means a substance abuse treatment plan. Ideally, the state will monitor a parent’s progress toward sobriety and allow the child into their custody only when that is achieved and the child’s safety is assured.

In multiple cases, that didn’t happen.

The report said reunification decisions had been made even though it was clear that “the jeopardy to the child has not been alleviated.”

In multiple cases, the ombudsman found state workers failed to recognize that they were reunifying a child into a dangerous situation.

The report found glaring, commonsense issues with the performance of state workers on such cases.

State workers failed to contact medical providers, failed to provide random drug screening, failed to assess new romantic partners in a child’s living arrangement, failed to investigate a parent’s parental capacity before returning a child, and failed to perform mental health evaluations on parents.

The ombudsman also identified severe deficiencies in the handling of children who had been taken into state custody. Although the laws governing such cases were written with the understanding that it is in the best interest of the children to minimize a child’s time in state custody, the report notes multiple cases where children were held in state custody overly long. In some instances, the report attributes these delays to COVID-19 and the delays it caused in court processes.

In two cases assessed by the ombudsman, infants that were removed from their parents after receiving serious injuries in their parents’ care were given back to their parents or the parents were allowed to visit before the state had determined that it would be safe to do so or the parents had acknowledged responsibility for the injuries.

Underlying the report — and the issue of the state’s handling of child welfare generally — is the tension between protecting children and respecting parents’ rights. On the one hand, the goal of the agency is to protect the welfare of Maine kids. But on the other is the legally protected right any parent, even a flawed one, has to raise their children.

The stakes are high: case workers are tasked, ultimately, with deciding when to separate a child from their parents, a decision that could have lasting impacts on the child’s development and later life. But inaction could lead to the death of a child, as was the case for four children in Maine last year.

The report should serve as a frightening moral wakeup call to Maine’s media and the powerful politicians who just celebrated the second inauguration of Democratic Gov. Janet Mills.

“Hope is still alive in Maine,” she declared in her address Wednesday.

But so far, her response to the conclusions of the ombudsman’s report, and the treatment in the broader Maine media, has been muted.

Mills’ office sent out two press releases this week, one touting her inaugural address, the other celebrating a spending bill she signed. But she has not commented publicly on the report.

The Bangor Daily News story cited only one line from the report about a “downward trend” at the agency, but instead focused on the political implications of the documented cases of child abuse and state dysfunction.

By Friday, the report had already disappeared from the Portland newspaper’s homepage, replaced by reports of ski conditions, an analysis of campground attendance in 2022, and an editorial about a congressman from New York.

You can read the full report here:


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