Published in The Atlanta Journal-Constitution, March 9, 2014:
BY ALAN JUDD – THE ATLANTA JOURNAL-CONSTITUTION
By the time the local child fatality review committee took up her case, Marnee Kay Downey had been dead one day longer than she lived.
The committee, as mandated by state law, compiled the details of the 8-month-old’s life and death: Chronically malnourished, she weighed less than 10 pounds. Child-protection workers had removed her siblings from their home. And her death, on Oct. 10, 2012, was a homicide: an intentionally administered overdose of a potent painkiller intended for terminally ill cancer patients.
But the committee remained silent on perhaps the most pertinent question: Why was Marnee even with her parents? Her mother took illicit drugs during pregnancy, the child was born with drugs in her system, and her parents celebrated the conclusion of a child-neglect investigation by getting high.
The review committee’s report mentioned none of that. Nor did it suggest anything the state Division of Family and Children Services or other agencies might have to done to protect Marnee. In fact, it recommended nothing at all.
What happened after Marnee Downey died illustrates the breakdown in a critical component of Georgia’s child-protection system: the review process that is supposed to dig deep into why a child died and search for ways to prevent more deaths.
Marnee Kay Downey
Almost a quarter-century ago, Georgia became the first state to create committees for each county to examine every death of a child. Today, all other states follow a similar practice.
But Georgia’s review process, an investigation by The Atlanta Journal-Constitution found, has become an empty exercise.
The newspaper examined reports on 464 deaths that county committees submitted in 2012 to the state Child Fatality Review Panel, which oversees their work. Officials redacted significant portions of the reports: the names of deceased children and their parents, dates of birth and death, even the time of day a child died.
Still, enough data remained to show that, in most cases, the county committees’ work was superficial and slow.
The committees have a broad mandate to study failures by government agencies and to seek changes that would correct mistakes.
But not a single report among the 464 delved into mistakes by DFCS or other agencies. Just two reports requested additional investigation by police or other authorities.
In cases for which the Journal-Constitution could establish a complete timeline, the committees took more than twice as long to complete reviews as the law allows. A few counties, such as DeKalb, left some cases unreviewed for a year and a half or longer and didn’t complete reports on 2012 deaths until November or December 2013. In a recent publication, the statewide panel said timely reviews “build momentum from the tragic event to effect change in the community.” But one-fourth of reviews took longer than the child’s lifetime.
Almost 500 deaths — slightly more than half of the 940 recorded among Georgia children age 17 or younger in 2012 — received no review. Many were attributed to causes that rarely raise suspicions, such as disease or premature birth. But the Journal-Constitution identified 56 deaths in 38 counties that seemed to warrant investigation. Among them were 10 homicides, eight suicides, and seven drownings. Twelve of the 56 children came from families that DFCS had previously investigated.
Perhaps most significant, almost three-fourths of all reports contained no recommendations for preventing other deaths — one of the primary purposes for the reviews. Even when reports included suggestions, they usually offered what amounted to after-the-fact, self-evident parenting advice.
When an unsupervised 2-year-old wandered away and drowned in a pond, the Atkinson County review committee said parents should “watch kids at all times near open water.” When a woman ran over her 4-year-old granddaughter in the driveway, Muscogee County’s committee suggested “buying cars with back-up cameras.” When a baby died from a methadone overdose, the Fulton County committee advised simply, “Parent education.”
Jones County’s committee reviewed the death of an 8-month-old whose family already was the subject of a DFCS investigation. His mother, an unemployed high-school dropout, had a history of marijuana and cocaine abuse, according to state records. Three times DFCS had substantiated abuse or neglect allegations against her. On Oct. 25, 2012, she handed the baby a whole hot dog and left him alone. He choked to death.
The committee’s recommendation: “not to feed an infant-toddler a whole hot dog.”
Melanie Ann Prichard
“When a child dies, we have an obligation to ask ourselves, was there something that we — as caregivers, as a community, and as a society — could have done to prevent this tragic consequence?” the panel wrote. “Did we fail this child in some way?”
The chairman of the statewide panel acknowledges a gap exists between rhetoric and reality. Cobb County Superior Court Judge Tain Kell, who has led the panel since 2012, supports a bill in the General Assembly that would transfer the panel’s operations from the Office of the Child Advocate, a division of the governor’s office, to the Georgia Bureau of Investigation.
“What we do,” he said, “is only as good as the data we get.”
Marnee Downey died in Haralson County, an hour’s drive west of Atlanta. Her death, like hundreds of others, was allowed to go by with little notice, even in the small community that failed to prevent it.
Read the rest of the story here.