Maine’s child welfare system has frequently come under fire in recent months for its failure to protect the state’s most vulnerable children. The Child Welfare Ombudsman’s 2023 Annual Report describes these continued shortcomings and offers recommendations for improvement.
The results of this report were shared with the state legislature’s Health and Human Services Committee Tuesday and are scheduled to be presented to the Government Oversight Committee this coming Friday.
Contracted with the Governor’s Office and overseen by the Department of Administrative and Financial Services, the Child Welfare Ombudsman is responsible for assisting Mainers in resolving “concerns and complaints” with Maine’s Child Protective Services Department of the Department of Health and Human Services (DHHS).
The Ombudsman also publishes an annual report that details the findings of their investigations, as well as any specific recommendations they may have to offer the Department.
The most recent annual report revealed that there was a continued “decline in child welfare practice” in the 2023 fiscal year.
“As has been true in previous annual reports, this year shows continued struggles with decision-making around child safety,” the report stated. “Primarily, the Department has had difficulty in two areas: 1) during initial investigations into child safety and decision-making around where a child is safe during an investigation, and 2) during reunification when making safety decisions about whether to send a child home.”
The report then went into greater detail concerning the shortcoming of DHHS and OCFS as identified by the dozens of case-specific reviews conducted by the Ombudsman throughout the year.
“In order to make safety decisions correctly during an investigation, 1) enough facts and evidence must be collected, and 2) the facts and evidence need to be interpreted correction,” the report explained. “This year a survey of case-specific ombudsman reviews found challenges in both areas.”
“In some instances, not enough information was gathered to make an informed decisions about safety, and in others, enough information was gathered but the appropriate action was not taken to protect the child,” the report states.
“Decision-making around reunification of children with parents, including trial placements, continues to be a challenge for the Department,” the report continues.
“This includes effective monitoring of trial placements for child safety,” the Ombudsman wrote. “Reunification issues this year have included delays in filing petitions to terminate parents’ rights; lack of monitoring for trial home placements especially when children were placed out of state; lack of contact with providers; inconsistent random drug screening; court petitions dismissed by the Department before issues causing children to be unsafe are resolved; regular monthly contacts not held with parents; and service cases opened for lengthy periods without court petitions filed.”
The report also made reference to ongoing issues with Katahdin, the software used by the Department to upload and access case data, as well as to assess the risk a child in the system is facing and make decisions about whether or not a child should stay in, or be returned to, their biological home.
Caseworkers have recently reported that overriding recommendations made by the program has been “discouraged” by management at DHHS.
“Katahdin has been in use for over a year. In any transition to such a complex database, there will be setbacks and training issues, and cultural adjustment to the change,” the report said. “However, Katahdin’s issues go deeper than this.”
“Katahdin is negatively affecting the ability of child welfare staff to effectively do their work, and therefore keep children safe,” the Ombudsman states. “The Department has been working to address amultiple issues within Katahdin, and has already implemented many fixes, but Katahdin continues to be a complex problem without an easy solution.”
Among the recommendations for improvement offered by the Ombdusman in the report is the provision of continued support for the “use of safety science in order to effect positive systemic change.”
“Maine has contracted with Collaborative Safety LLC and begun to use Safety Science to review critical incidents, to improve practice, and determine the systemic and root causes of oversights and erroneous practice decisions,” the report explains. “The results of the first year of these types of critical incident reviews have been released by the Department in the Maine Safety Science Model 2022 Report.”
“The Department must take the findings in this, and in future safety science reports, and implement changes based on the outcomes of the safety science reviews,” the report said. “The Department must focus on child welfare practice issues within their own districts that are within their control, such as the need for increased staff training, time pressures affecting decision-making, and difficulties with safety planning.”
The Ombudsman also suggests in the report that “continued support and funding” be provided to increase the “availability of services” for those involved with the Department.
“Essentially every case specific review completed this year by the Ombudsman detailed a case and a family that were negatively affected by a lack of services for both children and adults,” the report said. “Mental health services, substance use treatment services, trauma informed services, domestic violence services, housing, and transportation, are all examples of services that are necessary for the safety and well-being of children.”
The report also suggests that “the Department should explore all possible methods, including statute changes, to provide increased transparency to the legislature and to the public about struggles within and progress toward addressing the complex problems that arise within the child welfare system.”
The Ombudsman further suggested that “the Department must consider the opinions of outside stakeholders, in both assessing and naming the primary issues in child welfare, but also in providing solutions for those issues.”
“Finally, it is crucial that frontline staff’s experiences and opinions are given the utmost consideration and their recommendations are implemented when possible,” the report states.
Covering the period from October 1, 2022 through September 30, 2023, the report was completed prior to the resignation of the Office of Child and Family Services (OCFS) Director Todd Landry in late November of last year.
Mid-January, DHHS announced that it would be making “structural changes” to OCFS, including the appointment of Bobbi Johnson — who had served as the Acting Director of OCFS following Landry’s resignation — as the office’s permanent Director and the launch of a “rapid management audit” of the Child Welfare Division of OCFS.
This audit will be conducted by “an outside organization with expertise in Maine’s Child Welfare Division,” but the press release announcing these changes did not specify the name of the group tasked with completing this review.
As a result of this audit, a report is expected to be released by the end of March 2024 containing both short and long term recommendations for the office.
At the end of last year, Walk a Mile in Their Shoes (WAMITS) — a non-profit founded by former Democratic state senator Bill Diamond — released an extensive report detailing how DHHS has fallen short and provided a number of concrete solutions to the problems identified.
Titled Unsupported: Key Lessons for Improving Maine’s Child Welfare System by Supporting All Stakeholders, the report from WAMITS is broken down into several sections, one for each of the key constituencies involved in and affected by the DHHS’ recent failures: caseworkers, foster parents, children, and other stakeholders.
Each section outlines the “areas of concern” that were noted by stakeholders, explains the consequences that are associated with these problems, and concludes with a number of practical solutions aimed at solving the identified issues.
The number of child fatalities on the watch of DHHS has been increasing for more than a decade now.
In 2007 — the first year for which child fatality data is available — seven children died despite the involvement of child protective services. In 2022, that number rose to twenty-eight, meaning that four times more children died that year compared to 2007 despite DHHS interventions.
Of these twenty-eight, eleven children were determined to have died as a result of “accidents,” including “motor vehicle accidents, drowning, fire, etc.” Six died as a result of “unsafe sleep.” For three others, the cause of death was classified as “sudden unexpected infant death.” Two children died from unspecified causes. One child was murdered. Only five of these children were determined to have died of “natural causes.”
In 2021, four children who had been previously involved with DHHS died within weeks of each other, prompting renewed scrutiny of the Department. Since then, the parents of all four children have been charged with either murder or manslaughter in connection with the children’s deaths.
As pointed out in the Ombudsman’s 2023 report, however, these fatalities are part of a larger problem within DHHS and OCFS.
“Much of the public focus in child welfare has been on child deaths that continue to be reported in the news. These children who have died deserve our full attention and respect,” the report stated. “It is equally important to remember that there are many children who are harmed repeatedly in the care of their parents, but never appear in the news.”
“Children are living in difficult and traumatic circumstances all over the state every day,” the Ombudsman wrote. “We have the responsibility, as a state, to protect those children.”