Most of the deaths reviewed by the Illinois Department of Children and Family Services’ Office of the Inspector General were ruled accidental or natural, but some of them could have been prevented had state workers been more diligent, according the Office of the Inspector General’s annual report.

Inspector General Denise Kane is mandated to review the death of any child whose family had any involvement with DCFS in the previous year. In about a quarter of the cases, the children were victims of homicide. While Kane’s annual reports include short narratives on every death, she provides more comprehensive investigations of about a dozen death or serious injury cases each year. These investigations include both specific recommendations, like calling for an employee to be disciplined or more systematic suggestions, such as implementing specific policies.

The cases outlined below offer a sample of those that Kane describes.


Baby and drug-addicted mother perish in fatal fire

Death and Serious Injury Investigation 3, 2004, annual report

In August of 2001, a one-year-old boy and his mother died of smoke inhalation after a fire broke out in their apartment. Inspector General Denise Kane notes in one of her annual reports that children dying in fires make up an increasing number of cases reviewed by her in which a medical examiner ruled the death was not by natural causes. She also notes that fire is the No. 1 cause of unintentional death for children, ages 5 and under, in Illinois.

In this case, the mother came to DCFS’ attention seven years earlier when her fourth child tested positive for opiates at birth. The records show she went to drug treatment and was discharged. But, according to Kane’s report, there’s no evidence that she was discharged because she had successfully recovered from her drug addition. Still, her case was closed.

Eight months later, the baby that died in the fire was born substance-exposed. Also, a relative told a caseworker that the mother was still using drugs. But, when a new caseworker was assigned to the case, the mother reportedly told her that she had successfully completed a treatment program. Believing the mother and not verifying any other facts, the caseworker closed the case, according to Kane.

One night, two months later, the mother’s children were playing with matches in the home while the mother was asleep. A fire started. Two children were rescued, but the mother and the one-year-old son died on the scene.

The fire department noted that there were no smoke detectors in the home and never in the caseworker’s notes did it state that she had conducted an assessment of the safety of the home, limiting her observations to the physical condition of the children, according to Kane.

The Office of the Inspector General’s report recommended that the department develop a home safety checklist to help prevent similar tragedies from occurring in the future. It also emphasized that mothers who give birth to substance-exposed infants should receive intensive services to protect their children from harm.


Children’s asthma deaths attributed to lack of care plan

Death and Serious Injury Investigation 1, 2002, Annual Report

Two wards of the state died from severe asthma attacks in two separate incidents in July of 2000. In both of these cases, the Office of the Inspector General concluded that DCFS failed to develop comprehensive care plans to manage the children’s medical conditions. The first victim, a 9-year-old boy who died of an attack while attending a wedding with his relative foster family, had a history of acute asthma and his case file listed numerous hospitalizations throughout his life. The child’s records show that although follow-up medical appointments were scheduled, there is no evidence to indicate that they were kept. No mention of the boy’s asthma was made in the initial intake summary when he first became involved with the department. Caseworkers also drew no correlation between his allergies, which can serve as asthma triggers, and his asthma attacks.

A similar lack of information was also noted in the death of a 16-year-old girl. Despite the fact that she suffered from an asthma attack during her initial health screening with the department, the teen’s records, reviewed by Kane, indicate that no one documented the treatment she received or whether her new foster parents were told how to manage her health needs. The Office of the Inspector General report notes that her case record is devoid of information regarding her medical history. While both children had extensive histories of medical treatments for asthma, the Office of the Inspector General notes that neither child had an Asthma Action Plan or received a peak flow meter, a tool that would have gauged their respiratory strength on a regular basis. In its response, the Office of the Inspector General recommended that child welfare workers be educated to notice the risk signs of a child’s asthma condition and that the department identify current and incoming wards with asthma and other serious illnesses.


Foster mother drowns child in bathtub

Death and Serious Injury Investigation 12, 2003, Annual Report

A 6-year-old boy died in February 2001 after his foster mother punished him by holding him in a bathtub of cold water for 45 minutes. This was one of two recent cases where foster parents killed children who were placed with them. The Chicago Reporter’s analysis of the 419 death cases reviewed by Kane during the past four years found that 123 of the children who died were in foster care and more than half of them died from natural cases.

Of the 21 who were murdered, most were killed by gang or domestic violence, according to the Reporter analysis. Still, in this case where a foster child was killed by the woman who was supposed to provide him a safe haven from abuse or neglect, the Office of the Inspector General pointed out several failures.

In May 2002, for instance, the boy’s therapist contacted the state’s hotline to report abuse and neglect, saying the child had told her that his foster mother had punished him by making him stand in a cold shower after he had taken a cupcake without permission.

After investigating this report, child protection workers concluded it was unfounded but staff members reportedly had serious concerns about the foster mother’s ability to care for her children. Over time, she was licensed by three different private child welfare agencies, but the agencies failed to check with each other about their experience with this foster mother, according to Kane.

There were also concerns that the boy was not being adequately supervised. And no attempt was made to address the boy’s poor attendance at school; while the caseworker noted that the child attended school on a regular basis, school records show he missed more than one-third of class days. The Office of the Inspector General recommended that a full school report on the each child should be made and that the licensing supervisor in charge of training review the report on this case.


9-year-old with cerebral palsy beaten to death

Death and Serious Injury Investigation 9, 2003 Annual Report

A 9-year-old child with cerebral palsy died from blunt abdominal trauma after being beaten by her mother and her mother’s boyfriend in October 2000. This case was initially investigated by the Chicago police, who ruled it an accident and closed the criminal investigation without filing charges against the mother or her boyfriend, according to Kane. But after reviewing the case, DCFS substantiated a case of abuse against them and took custody of the five remaining children in the mother’s care, according to Kane.

The mother had a long history of involvement with DCFS and was indicated on seven prior reports involving neglect. According to Kane’s review, the department had received 16 hotline reports of alleged incidents of abuse by the mother, ranging from medical neglect, cuts, welts, and bruises. The deceased child was once taken into custody by DCFS when she was 3 years old, after the mother failed to get her medical treatment for her disability. She was placed with her grandfather but the department, believing the mother had made significant improvement, allowed her to return home in December 1999.

Shortly after being placed back in her mother’s care, the child received burns while taking a bath; nonetheless, the case was closed in July 2000 because child welfare staff felt that the mother received sufficient support from the grandfather and the mother seemed calmer and less prone to bursts of anger. The case was reopened when the mother gave birth to a cocaine-exposed infant four days later. A different agency was assigned to provide services to the mother, however, a lack of funding prevented the agency from providing the mother with the therapy she needed. In reviewing the case, the Office of the Inspector General recommended that the child protection investigator be counseled for her failure to review prior reports against the mother and her failure to assess risk. It also proposed that all professionals providing services to the family meet together and talk about the case before the child is allowed to return home.