Findings and Recommendations

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
October 31, 2025	January 28, 2026	February 6, 2026	2024-0379

Summary of recommendations:

The Child Advocate recommends strengthening MDHHS oversight, policy compliance, and staff preparedness by requiring managerial review and approval of Category II cases lacking cooperation or service benefit; ensuring petitions are filed when closures do not meet statutory and policy requirements; providing regular staff training on MCL 722.628d(1)(e)(iii) and effective case management; gathering candid feedback through an anonymous survey of CWTI‑trained case managers; and engaging staff directly on this report’s findings to identify improvements in training, supervision, and overall practice.

Case background:

Child's Date of Birth: July 5, 2007. This case came to the attention of the OCA after a complaint was received, and the OCA preliminary investigation found problems with the CPS ongoing services case. A full OCA investigation was opened on September 26, 2024, to review Wayne County DHHS’ involvement with the family and to determine what services were provided to address issues that led to the ongoing services case.

Case Objective: 

The objective of this review is to identify areas for improvement in the child welfare system by looking at how the case involving The Child and her siblings was handled by Wayne County MDHHS and the involvement of MDHHS staff. This report is not intended to place blame, but to highlight areas of concern regarding the case; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children.

This case came to the attention of the OCA after a complaint was received, and the OCA preliminary investigation found problems with the CPS ongoing services case. A full OCA investigation was opened on September 26, 2024, to review Wayne County DHHS’ involvement with the family and to determine what services were provided to address issues that led to the ongoing services case.

Family History and Case Background:

Mother and Father are The Child’s parents (17). Mother is also the mother of Sibling One and Sibling Two (2); Siblings Father is their father. The focus of the OCA’s investigation was on CPS’ investigation from September 2023 and the subsequent ongoing case.

On September 2, 2023, Centralized Intake received a complaint with concerns Mother placed Sibling One and Sibling Two at unreasonable risk of harm. The complaint expressed concerns Mother was observed in a parking lot on September 1, 2023, actively inhaling nitrous oxide with both children in the car. The complaint was accepted and assigned to Wayne County for investigation (MiSACWIS ID: 150123186).

Mother and the children were staying at a shelter at the onset of the CPS investigation. CPS staff interviewed Mother on September 3, 2023. CPS documented Mother appeared sober, alert, and articulate. Mother told CPS she was battling depression and dealing with a domestic violence situation involving The Child’s father. She told CPS the family went to the shelter about a month ago to escape an additional partner (not The Child’s father).  Mother denied inhaling the can of nitrous oxide on September 2, 2023, but admitted to having the nitrous oxide can with her in the car. Mother told CPS she first used nitrous oxide in 2012 and that her last use was in 2022. Mother also told CPS she used marijuana and her experience at the shelter was triggering her to use it again. CPS completed a verbal safety plan with Mother around substance use where she agreed to refrain from substance use while driving and CPS suggested she use her support persons when feeling depressed. CPS noted the children were observed in their car seats, free of any visible signs of neglect. Mother completed a drug screen for CPS during this interaction.

On September 5, 2023, CPS spoke with staff at the shelter where Mother and her children were staying. CPS was advised that Mother is a great mother, is employed and doing well. The shelter staff were working with Mother to find permanent housing. The OCA investigator observed this contact was the same contact made in a previous investigation (CAT IV closed August 30, 2023; MiSACWIS ID: 148533197) and was not entered into this investigation until October 2, 2023.

The next social work contact in the investigation was from October 2, 2023, which documents the results of Mother’s drug screen. The drug screen results were negative for all substances; however, the sample comments indicate the device leaked in transit and was not sealed properly. CPS attempted to reach Mother to schedule a Family Team Meeting (FTM) and provide her with an update on the investigation status. Mother’s phone was not accepting calls, and their contact was not successful.

On October 17, 2023, CPS was informed by staff at the shelter that Mother had left the shelter about two weeks prior due to her behavior and being combative with others. CPS was also informed Mother was not on a list for the support group.

On October 18, 2023, CPS completed a home visit with The Child and her father at The Child’s father’s home. The Child was interviewed privately by CPS. The Child informed CPS she had not resided with her mother in about two years due to her current living situation. The Child said she sees her mom from time to time but that her mom did not have a house and was “kind of all over the place right now.” She told CPS her mom “drives like an idiot and unnecessarily fast.” The Child told CPS her mom used to smoke marijuana and cigarettes, but she stopped. The Child advised her mom does “whipped cream can[s]” but she did not know what they were. She explained she saw her mom use them a few times, inhaling from the cans. The Child told CPS there were a bunch of cans in the trash before they were kicked out of their previous home. CPS asked how her mom’s behavior was after she would inhale from the cans. The Child advised her mom would “just seem out of it.” CPS spoke with Father following the interview with The Child. Father expressed concern for the twins in Mother’s care. Father’s concern was because of Mother’s living situation as she was reportedly living in her car while continuing to use nitrous oxide.

On October 19, 2023, CPS spoke with Mother who advised she was staying at a hotel but would soon be moving in with a friend. A FTM was held (by phone) and Mother was informed the case would be opened for services as a Category II with a referral to Families First. At this point CPS had not physically observed or made contact with Sibling Two and Sibling One since September 3, 2023, a period of 46 days. ^[1]

On November 20, 2023, a request from the on-call support team was made to complete a home visit with Mother and the children for both the ongoing case and the CPS investigation. A scheduled home visit occurred at Mother’s new home. The home had minimal furnishings, and Mother advised the on-call support team that she needed beds for the children. The home was otherwise observed to be appropriate. The investigation was concluded as a Category II with a preponderance of evidence supporting placing a child at unreasonable risk by Mother concerning Sibling One and Sibling Two. The investigation closed on December 15, 2023, noting a referral to Families First for services would be made and the family would be monitored by CPS ongoing.

In review of the CPS ongoing services case (MiSACWIS ID: 131045286), no services were referred to Mother when the ongoing case was opened. There was no referral made to Families First. The family had two additional CPS investigations while the ongoing case was opened. One investigation involved concerns for The Child at Father’s home; this investigation was closed as a Category IV on March 4, 2024 (MiSACWIS ID: 158583350). The second investigation (MiSACWIS ID: 178873514) began on July 5, 2024, following concerns Mother had grabbed The Child by the arms and forcibly pulled her onto a bus. This incident occurred after The Child tried to run away, as she did not want to purchase inhalants for Mother. Additional concerns were expressed Mother was doing inhalants from June 8, 2024, to June 10, 2024, which caused her to be in a daze for hours. The complaint also alleged The Child was responsible for caring for her twin sisters.

During the investigation, CPS spoke with Mother by phone on July 5, 2024, and documented that Mother had expressed her frustration with false reports and felt CPS was harassing her. She allowed CPS to verify the well-being of Sibling One and Sibling Two during a home visit on July 8, 2024. Mother denied doing anything to harm The Child and denied asking The Child to purchase inhalants for her. Mother admitted to using inhalants in the past but denied using them currently. She further advised inhalants were “laughing gas that last for minutes, and it did not affect her in any way.” CPS observed the home to be “untidy and cluttered” but sleeping arrangements were appropriate, utilities were in working order, and there was an adequate amount of food observed.

CPS interviewed The Child on July 8, 2024, at her father’s home. The Child told CPS she felt unsafe with her mother due to her mother’s behavior, her mother using inhalants, and making The Child clean constantly. She shared that her mother’s home is always in “horrible condition.” The Child told CPS her mom will spend $50 a day on inhalants and will sit in a daze for hours, leaving The Child to care for her twin sisters. She also shared that her mother is aggressive, and they argue a lot.

The investigation was closed on August 16, 2024, after determining that there was insufficient evidence to support claims of physical injury to The Child or that Mother had placed The Child, Sibling Two, or Sibling One at unreasonable risk. At that time, the ongoing services case (MiSACWIS ID: 131045286) remained open with no services being provided to Mother.

The first three Updated Services Plans (USPs), (report dates: October 3, 2023-December 1, 2023, December 2, 2023-February 29, 2024, and March 1, 2024- May 29, 2024), contained no social work contacts from the ongoing services case manager. All the USP contacts made were linked through the original Category II investigation, and the two subsequent CPS investigations. These USPs were not completed until June 15, 2024, and June 16, 2024, with supervisory approval occurring on June 17, 2024.

The USP dated May 30, 2024, to August 27, 2024, notes the risk scored as intensive. During this reporting period, the ongoing case includes documentation of a home visit that occurred on August 15, 2024. CPS met with Mother and attempted to engage her in services with Families First. Mother refused services.

A closing USP was completed dated August 28, 2024, to September 24, 2024. This USP documents a closing FTM was completed with Mother by phone on September 13, 2024. CPS attempted to engage Mother in services, but she again declined. She continued to deny current inhalant use. CPS documented advising Mother that if another complaint was received and substantiated, a petition could be filed due to her non-compliance with services.

The closing USP documents an email was received from CPS Centralized Intake on September 23, 2024, noting a new complaint (MiSACWIS Intake ID: 147640593) was received with concerns Mother had mental health issues, is unable to provide basic needs for her children and that her home was unsanitary with feces on the floors. Additionally, there were concerns Mother was diagnosed with schizophrenia and was prescribed medication but not taking it.

CPS made an unannounced home visit on September 23, 2024. CPS verified the well-being of Sibling One and Sibling Two. Mother denied the allegations about her mental health and told CPS she was potty training the twins and they remove their own diapers, but denied feces being spread on the floor. CPS documented they did not observe any feces in the home and documented the home to be “junky” but no visible safety hazards were observed.

The ongoing case closed on September 24, 2024, noting Mother refused to participate in services. The risk re-assessment continued to score at an intensive risk level.

During the ongoing case, monthly visits were not completed or documented with Mother and the children in February 2024, April 2024, and May 2024. CPS documented observing Sibling Two and Sibling One on March 28, 2024, and not again until June 28, 2024. At least monthly contact is required during open services cases with the primary caregiver, victim, and non-victim children in the family. Additionally, the ongoing case was opened from December 2023 to September 2024, approximately ten months, with no services being provided to the family.

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_{[1] PSM 713-01 Extension and Overdue Investigation Requirements Case managers requesting an investigation extension, or for investigations going overdue (without an extension request), must complete all the following within 30-calendar days from the date of the referral, and within every 30-days thereafter: Face-to face contact with each alleged child victim(s). Safety assessment. Contact with parent/caregiver(s) of each victim.} 

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Additional Information:

The OCA conducted interviews with MDHHS staff. The OCA was informed this case presented difficulties due to Mother’s refusal to participate in services, and her being difficult to deal with. MDHHS staff voiced further concerns regarding Mother’s choice of substance, specifically her use of inhalants. Inhalants do not appear on drug tests, and this posed difficulty capturing whether Mother was continuing to use inhalants during their involvement.

The OCA was advised MDHHS consulted with the assistant attorney general (AAG) the night before the ongoing case was closed. MDHHS advised the OCA that because of the length of time that had passed since the case was opened, there was not enough to file a petition for removal. This decision also weighed on the belief by MDHHS staff that they did not have evidence Mother was still using inhalants. When asked if MDHHS considered filing a petition to order Mother to comply with services, some MDHHS staff advised they were not aware this was possible, while others were aware this could happen but explained that Wayne County does not do this. MDHHS staff said it is a difficult process to get petitions filed in Wayne County, including urgent matters. MDHHS staff advised the OCA investigator that Wayne County courts do not accept petitions without an AAG signature. Due to the challenges in processing necessary petitions, cases in Wayne County are not being escalated to the court for instances of caretaker non-cooperation.

MDHHS staff informed the OCA there was a delay in the case transferring from the investigative case manager to an ongoing case manager. This was a reason the case was not properly serviced in the beginning and the assigned case manager at the time was overwhelmed with a large number of investigations. Additionally, MDHHS staff expressed an overall feeling of not having supportive supervisors which “make or break” staff. The OCA was told supervisors need to provide more support and guidance to case managers to retain staff and prevent further staffing issues. The OCA was advised that most case managers need about two years to really learn the job and feel comfortable in the role, with a supportive supervisor involved. MDHHS staff also expressed feeling the training received through the Child Welfare Training Institute (CWTI) is not adequate and does not prepare case managers for the work. MDHHS staff advised the information presented in CWTI felt removed from what happens in the community during these investigations. MDHHS staff expressed they believe part of the current staffing problem at MDHHS is due to the lack of proper training. It was explained that it felt as though they were “being pushed into the water and hope you figure out how to swim.”

During the OCA’s investigation, the OCA obtained caseload count reports for Wayne County MDHHS and reviewed the caseload data for the case manager assigned to the CPS ongoing services case. The caseload count data was reviewed from October 2023 to September 2024. During this time period, the assigned case manager held between 27 and 33 cases. Caseloads of this size make it difficult, if not impossible, to meet all policy requirements in each case while ensuring the safety of each child.

Law & Policy:

As part of the OCA investigation, the OCA reviewed law and the protective services manual (PSM) surrounding the department’s requirement for cases to be escalated when parents are non-compliant with services, in addition to the reasons a petition can be filed with the court.

MCL 722.628d Categories and departmental response: Sec. 8d.- outlines the department’s response and category classifications for investigations.

(1) For the department's determination required by section 8, the categories, and the departmental response required for each category, are the following:

(d) Category II - child protective services required. The department determines that there is evidence of child abuse or child neglect, and the
structured decision-making tool indicates a high or intensive risk of future harm to the child. The department must open a protective
services case and provide the services necessary under this act.

(e) Category I - court petition required. The department determines that there is evidence of child abuse or child neglect and 1 or more of the
following are true:

(i) A court petition is required under another provision of this act.
(ii) The child is not safe and a petition for removal is needed.
(iii) The department previously classified the case as category II and the child's family does not voluntarily participate in
services.
(iv) There is a violation, involving the child, of a crime listed or described in section 8a(1)(b), (c), (d), or (f) or of child abuse in the first or
second degree as prescribed by section 136b of the Michigan penal code, 1931 PA 328, MCL 750.136b.

(2) In response to a category I classification, the department must do both of the following:

(a) If a court petition is not required under another provision of this act, submit a petition for authorization by the court under section 2(b) of
chapter XIIA of the probate code of 1939, 1939 PA 288, MCL 712A.2.
(b) Open a protective services case and provide the services necessary under this act.

PSM 713-01 CPS Investigation-General Instructions provides case managers with directions on when to reclassify Category III and Category II cases. For a Category II case, policy states a case must be escalated to a Category I when “the family refuses services or has not made any progress with services and there is continued and/or heightened risk of harm to the child.”

PSM 714-1 Court Involvement states, “every effort must be made to keep families together whenever safely possible. When engagement efforts and service provision are insufficient to achieve and maintain child(ren) safety, a petition seeking court intervention may be necessary.” The case managers are then referred to PSM 715-3 Family Court Petitions, Hearings and Court Orders. PSM 714-1 continues on to explain “a request for removal is not necessary in all situations. Relief requested should be the least intrusive necessary to protect the child(ren) or resolve the emergency.”

OCA Analysis:

In this case, CPS substantiated Mother for placing her children at unreasonable risk of harm. An ongoing CPS services case was opened and Mother initially agreed to participate in services. CPS failed to complete a referral for Families First for Mother. In August 2024, CPS attempted to engage Mother in Families First, however, she refused. This resulted in the CPS ongoing services case to close with an intensive risk level. This was in violation of the law (MCL 722.628d(1)(e)(iii)) and PSM 713-01 as both require a Category II case to be reclassified as a Category I, with a court petition, if the family does not voluntarily participate in services.

Additionally, PSM 714-1 outlines that MDHHS should make every effort to keep families together, and removal is not necessary in all situations. In this case, a petition to the court asking for in-home jurisdiction and orders for Mother to comply with services was needed initially to attempt to alleviate the risk of harm to the children.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The child advocate finds Wayne County MDHHS did not comply with MCL 722.628d(1)(e)(iii), PSM 713-01 and PSM 714-1 when the 2023 ongoing CPS case closed after Mother did not participate in services.	Agree
The child advocate finds MDHHS closing Category II cases when families are uncooperative with services leaves children at risk of further harm.	Agree
The child advocate finds a petition should have been filed during the 2023 ongoing case as court authority was needed to order the parent to participate in services and secure the safety of the children involved.	Agree
The child advocate finds there was a delay in the case transferring from the investigative case manager to an ongoing services case manager.	MDHHS disagrees. In Wayne County North Central MDHHS, certain cases are retained by the investigator for continued case management as part of standard practice. All CPS specialists have been trained and have access to all PSM policies as it relates to investigation and ongoing policy. There is no policy that requires a transfer of the case from CPS investigation to CPS ongoing.
The child advocate finds the assigned case manager had 23-33 cases assigned to them during the time the ongoing case remained on their caseload.	Agree
The child advocate finds some Wayne County MDHHS staff do not believe they are adequately trained and lack supervisory support.	Agree, MDHHS recognizes the importance of ongoing training and support

 

Recommendations:

Recommendation	MDHHS Response to Recommendation
The child advocate recommends MDHHS require a CPS program or section manager review and approve all Category II cases when there is no cooperation or benefit from services. The review should be completed before closure to determine compliance with MCL 722.628d(1)(e)(iii) and PSM 713-01.	MDHHS agrees in part. MDHHS recognizes there may be an opportunity to enhance practice in Category II cases and is actively working with CSA leadership and Evident Change to assess; however, it is unclear at this time if requiring CPS program or section manager review and approval on all Category II cases when there is no cooperation or benefit from services before closure is the best approach or whether it will have the intended impact. The department is currently exploring a shift from the Structured Decision Making (SDM) Risk Reassessment to an SDM Progress to Case Closure Tool which may help mitigate the identified concern. This tool has been utilized in other jurisdictions and can be customized to meet the unique needs of Michigan children, families, and staff: The tool emphasizes observable behavior change and the use of support networks, rather than mere service compliance. This allows staff to assess meaningful progress toward child safety and family stability. The tool integrates safety with family service plan progress, using a clear decision tree to guide case closure recommendations. This structure supports decisions and reduces ambiguity. Standardized criteria will help ensure all staff apply the same benchmarks, promoting equity and reducing subjectivity in case closure decisions. The tool will prompt detailed documentation of safety interventions and behavior change, improving decision making and supervisory review. The tool can be used at regular intervals or when new information arises, allowing staff to respond promptly to changing circumstances. The tool encourages the use of team meetings and other engagement strategies to assess progress collaboratively with families. CSA is interested in exploring this tool further before making any changes to CPS policy or practice.
The child advocate recommends if closure does not comply with policy, MDHHS require staff to comply with the cited law and policy above by submitting a petition to the court.	MDHHS agrees. This requirement is outlined in Child Protection Law and CPS policy, PSM 714-1.
The child advocate recommends Wayne County MDHHS hold regular trainings with their staff regarding MCL 722.628d(1)(e)(iii) and relevant policies to ensure future compliance. MDHHS should also hold regular training on how to handle ongoing cases and the provision of services to families.	Agree
The child advocate recommends MDHHS conduct an anonymous survey for case managers who participated in CWTI training between 2020 and 2024 to gather their genuine thoughts and feelings about CWTI training and its effectiveness in preparing them for their job responsibilities.	MDHHS disagrees. The pre-service institute (PSI) for child welfare case managers recently went through a lengthy redesign process and the new enhanced curriculum just launched in September 2025. Feedback has been, and continues to be, collected from case managers who attend initial training. All PSI trainees receive a level 1 evaluation after completing training. Additionally, level 2 evaluations (tests) are administered during training. All trainees also receive a level 3 evaluation, which measures training effectiveness and how trainees have applied their learning in practice, three months after completion of PSI, and again after nine months. This feedback, along with an in-depth needs assessments completed by Wayne State University, which included staff surveys and focus groups, informed the PSI curriculum redesign.
The child advocate recommends MDHHS discuss this Findings and Recommendations report with staff and ask what they think could help improve training and supervision.	MDHHS agrees. Wayne County North Central MDHHS will review the findings and recommendations at the local office level.

PDF Version of Report:  Case No. 2024-0513

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
October 31, 2025	January 26, 2026	February 6, 2026	2023-0859

Summary of recommendations:

The Child Advocate recommends strengthening oversight and legal compliance in Category II cases by requiring CPS program or section manager review prior to closure and ensuring petitions are filed when cases do not meet the requirements of MCL 722.628d and related policies. The Advocate further recommends amending PSM 715‑3 to require local offices to notify MDHHS legal when prosecutors decline to file petitions, with MDHHS legal tracking these instances for potential systemic issues. Additional recommendations include providing staff training in Jackson County on applicable laws, policies, and this report; requiring case managers to verify and assess the homes of individuals assisting families living on their property; and documenting housing conditions through photographs at the beginning and end of investigations involving homelessness or poor home conditions to ensure accurate, consistent evidence collection.

Summary:

For the purposes of this example, the names of the individuals involved have been replaced with the stand in identifiers like “Dad” and “Mom.” The term “The Child” refers to the subject child in this case.

The Office of the Child Advocate (OCA) is tasked with making recommendations to positively effect change in policy, procedure, and legislation by investigating and reviewing actions of the Michigan Department of Health and Human Services (MDHHS), child placing agencies, child caring institutions or residential facilities providing juvenile justice services. The Child Advocate’s Act, Public Act 204 of 1994, also requires the OCA to ensure laws, rules, and policies pertaining to Children’s Protective Services (CPS), Foster Care, Juvenile Justice and Adoption are being followed. The OCA is an autonomous entity, separate from MDHHS. 

This OCA review included reading confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), service reports, medical records, social work contacts, and law enforcement reports. The OCA also interviewed MDHHS staff, medical professionals, and law enforcement personnel. Due to the confidentiality of OCA investigations, the OCA cannot disclose the identity of witnesses or complainants or sources of statements and evidence. 

The objective of this review is to identify areas for improvement in the child welfare system by looking at how CPS investigations involving The Child were handled by Jackson County MDHHS, and the involvement of MDHHS staff, medical professionals, and law enforcement. This review reinforces the idea that the safety and well-being of a child is a shared responsibility of the family, community, MDHHS, law enforcement, and medical professionals aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of the investigations; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children.

Given the nature of our responsibilities, the OCA review is inherently prompted by a worst-case scenario. The investigation and review aim to give a voice to the child, or children involved. It is important for readers to understand the majority of cases investigated and managed by CPS, Foster Care, Juvenile Justice, and Adoption, do not lead to the 'worst-case scenario.'

The OCA has undertaken a comprehensive review of various cases where MDHHS has successfully implemented child welfare programs, demonstrating the dedication of professionals who support families in maintaining their resilience and unity during difficult periods. While the OCA's analysis centers on specific cases, the insights presented in this document highlight common areas for improvement that have been consistently observed. The OCA respectfully suggests that by addressing these recurring issues, MDHHS could significantly contribute to preventing potential harm in the future.

The Child was five years old when he died on December 25, 2023. Pursuant to MCL 722.627k, MDHHS notified the OCA of the child fatality. On January 24, 2024, the OCA opened an investigation into the administrative actions of MDHHS prior to The Child’s death. The following report summarizes the information and evidence found during the OCA investigation.

Background and History: 

Date of Birth: December 1, 2018

Date of Death: December 25, 2023

Mother is the mother of six children with four fathers: The Child (5 at TOD), Sibling One (5), Sibling Two (4), Sibling Three (9), Sibling Four (15), and Sibling Five (16 at TOD). Father is The Child and Sibling Three’s father. Siblings Father 1 is Sibling Two and Sibling One’s father. Sibling Five’s father is Siblings Father 2 and Sibling Four’s father is Siblings Father 3.  

Mother has an extensive history of alleged and confirmed child abuse and neglect, dating back to 2008, with 57 complaints, 32 investigations and 25 rejected and/or transferred complaints. There have been two prior Category III investigations, two Category II investigations, and one Category I. The scope of this report highlights the family history starting in January of 2022.

At the time of the January 2022 CPS investigation, CPS was investigating a complaint concerning The Child, Sibling Three, Sibling One, and Sibling Two being found home alone by law enforcement (MiSACWIS ID: 122032899). There were concerns about the home conditions being dirty, knives being accessible to the children, electrical outlets missing covers, and drug paraphernalia in reach of the children. Mother responded by cleaning the home, storing away drug paraphernalia, and covering the electrical outlets. Mother informed CPS the children being left home alone was an honest mistake and she returned home as soon as she became aware they were accidentally left home alone. During this investigation, Mother became uncooperative and was unable to be located. This investigation was closed as a Category IV on February 3, 2022, with an intensive risk assessment score, explaining further attempts to conduct interviews would be made through a new complaint that was received and assigned for investigation on January 14, 2022 (MiSACWIS ID: 122393963). 

Although the focus of the OCA investigation is concerning The Child’s death in December 2023, it is important to note the family experienced an additional child death in April 2023 when Sibling Five died in an automobile accident. Sibling Five had been drinking and driving with his friends, fled from law enforcement, and an accident occurred causing his death. Sibling Five’s death, though a part of the history reviewed, was not a focus of this investigation. 

At the time of The Child’s death, (December 2023) Mother lived in a RV/camper with four of her children, Sibling Three, Sibling Two, Sibling One, and The Child; three of these children were five years old or younger. Sibling Four was in a guardianship placement in Indiana through his probation. 

Review of the January 2022 CPS Investigation (MiSACWIS ID: 122393963) and ongoing case (MiSACWIS ID: 142509):

On January 14, 2022, a complaint was made to MDHHS Centralized Intake (CI) with concerns of improper supervision and physical neglect of three-year-old The Child. The complaint stated a housefire began in The Child’s bedroom (on January 14, 2022). There were concerns Mother was unaware a fire had started in her home and was called by an unknown individual who told her the house was on fire. The complaint continued to explain Mother was able to get The Child out of the home and he was taken to the hospital for medical attention. At the hospital, the complaint documented, The Child was observed covered from head to toe in soot, was very dirty underneath the soot, and a lot of effort was needed to clean him off. Additionally, The Child was observed with sores on his feet and hands and had been wearing the same diaper for a long period of time which resulted in genital irritation. At the time of the complaint, it was unknown how the fire started, but there were concerns with Mother’s account of the housefire. This complaint was accepted and assigned to Jackson County MDHHS for investigation. 

CPS began their investigation by attempting multiple home visits and face to face contacts with Mother and the children from January 14, 2022, to January 21, 2022. During an attempted visit at a former address for Mother, CPS was informed Mother had been evicted due to her substance use. CPS was told of “an area” where Mother may be living. The children’s aunt, Aunt, informed CPS the family may be at a hotel paid for by the Red Cross. Aunt told CPS she was concerned Mother and Siblings Father 1 abused drugs and she suspected they would continue to hide from CPS. Aunt advised CPS she was supposed to pick up the children from Mother the next day and that she would notify CPS when she located Mother, and the children, so face to face contact could be made. 

CPS documented reviewing The Child’s medical records dated January 14, 2022. According to the CPS report, The Child’s medical records state it was unclear when the fire started, how long The Child was exposed to the smoke and if he lost consciousness at any point. The records further explain according to EMS when they arrived, the patient was alert, oriented, breathing without difficulty and did not appear to have any prolonged exposure. It was documented The Child had significant erythema to the groin, with caked on hard stool present in his diaper but there were no burns present. 

On January 21, 2022, CPS spoke with a prior case manager of Mother’s from Early Head Start. CPS was advised Mother’s case closed on December 13, 2021, due to lack of contact, but Mother called the Early Head Start case manager on January 16, 2022, and informed them of the fire that occurred. The Early Head Start case manager told CPS Mother said The Child got a lighter and caught the home on fire. Mother reached out to re-enroll the children in Head Start. The Early Head Start case manager explained they created a safety plan with Mother about lighters and locking them up along with other objects. Concerns were expressed about Mother being methadone dependent, and Mother and the children having been through multiple traumatic experiences due to homelessness, evictions, drug raids, etc. There were additional concerns because Sibling Two and Sibling One showed signs of “delays” that could have been caused by trauma or cognitive impairments.

On January 22, 2022, CPS was informed by Mother’s aunt that Mother and Siblings Father 1 were living in an RV/camper in Grass Lake, Michigan with Sibling One and Sibling Two, the RV had no heat which caused the family to start sleeping in their car. On January 22, 2022, the CPS on call supervisor informed the assigned CPS specialist that the family was found to be living in the camper. The children’s well-being was verified and CPS on call documented they got the family into the Travel Lodge Hotel for a week. 

On January 24, 2022, CPS conducted an unannounced visit at the RV/camper where contact was made with Mother, Sibling One, Sibling Two and Siblings Father 1. Mother advised they were living in the RV/camper until they could determine what to do next since their house burned down. She denied CPS on-call had gotten her into the Travel Lodge Hotel. The CPS report documents “Mother advised CPS that two of her children were with a friend and another one of her children was with a cousin.” She refused to provide CPS with the address or the names of where the boys were but said she would have them come to the RV/camper so CPS could see them. CPS obtained approval to pay for one week at the Travel Lodge in Jackson for the family. The Child and Sibling Three were brought to the RV and were observed by CPS. They were both documented to be free of any visible marks or bruises. Mother advised CPS all the children would stay with her at the hotel, but Sibling Five would not be there until later. She provided Sibling Five’s cell phone number and gave CPS permission to call him. 

On January 25, 2022, CPS and Families First went to the Travelodge to see Mother and the children, however, only Sibling Five (14) and The Child (3) were present. Sibling Five told CPS Mother was taking Sibling Three to school and was expected to return soon. CPS documented Mother called and agreed to meet in the afternoon after getting Sibling Three from school. Due to Mother not participating in a meeting with CPS and Families First, Families First was unable to begin services with Mother, resulting in the opening for Families First services being given to another family.

On January 26, 2022, CPS completed a visit with Mother at the Travelodge where she advised she was having trouble getting her insurance company to pay for the fire due to a conflict in payment. Mother advised CPS she was unsure how it happened, but The Child started the fire in his bedroom. She told CPS The Child was supposed to be sleeping in his bedroom while she and Siblings Father 1 were downstairs. Mother explained one of Sibling Five’s friends yelled that the house was on fire and Siblings Father 1 ran upstairs and pulled The Child out of his room. CPS advised Mother the case would be opened and explained the ongoing CPS process to her. Mother told CPS she would need additional time at the hotel due to not having housing available. 

On January 27, 2022, CPS verified the well-being of Sibling Five, Sibling One, Sibling Three, The Child and Sibling Two. The Child, Sibling Two, and Sibling One were not interviewed due to their lack of verbal development. Mother refused to allow CPS to interview Sibling Five and Sibling Three. This was the last time CPS was able to see all the children together with Mother during this case (investigation 122393963 and ongoing services case 142509).

CPS found a preponderance of evidence for improper supervision of The Child by Mother and Siblings Father 1. The investigation was closed as a Category II with a high-risk level on February 8, 2022, and an ongoing services case was opened. 

According to the Updated Services Plan (USP) for the reporting period of February 9, 2022, to April 9, 2022, CPS made a referral for Mother to participate in services through Families First of Michigan on February 15, 2022. According to case records, Families First closed services on March 1, 2022, due to non-compliance. MDHHS documented Families First advised CPS that Mother had only met with the assigned case manger a few times and they were seven hours behind in the total required service hours. Additionally, it is documented Mother cancelled approximately two appointments each week, was a no show, or was an hour late. It is further documented when visits between Families First and Mother did occur; the meetings would be cut short because Mother would state she had something else going on. Following Families First closing, CPS made a referral to the Homebuilders Program on March 8, 2022. The Homebuilders case manager was able to meet with Mother and the family on March 8, 2022, and four additional visits from March 10, 2022, to March 14, 2022. The Homebuilders service then closed due to Mother’s lack of cooperation on March 15, 2022. 

The last Face-to-Face visit CPS was able to complete with the family was on March 10, 2022, with only Mother and Sibling Two. CPS was not able to verify the wellbeing of Sibling Five, Sibling Three, and The Child. CPS documented in the USP having concerns Sibling Five and Sibling Three were not attending school, with Sibling Three having over 120 absences. The risk reassessment scored as Intensive risk, and the USP documents the case was going to remain open to verify the well-being of the children. 

The OCA reviewed the closing USP for the reporting period ending May 31, 2022. According to the USP, on April 13, 2022, CPS completed a visit with Mother, Sibling One, and Sibling Two at the RV/camper the family was residing in on someone else’s property. Mother asked CPS for documentation she was homeless, and CPS said they could discuss this at a subsequent home visit; however, a text message was sent to Mother on April 19, 2022, advising her the open case would be closing.

The closing USP documents the CPS case manager, and the supervisor held a Family Team Meeting (FTM) on May 31, 2022. Mother, her family, and her supports, were not present for this FTM. According to the closing USP, Mother failed to cooperate with Families First and Homebuilders, she was living in a camper trailer, there was no imminent risk, and the court had not been contacted. The FTM contact documents the recommendation was to close the Category II as “uncooperative.” 

The ongoing case officially closed on May 31, 2022, with an intensive risk level, and the safety assessment scored the children safe with services. No services were currently in place with the family. Additionally, the ongoing case closed without verifying the well-being of all the children in several weeks. Families First had contact with Sibling Five on February 23, 2022. There was not a successful face to face contact with Sibling Five by CPS after this date. The Child was last seen by CPS, 37 days prior, on March 7, 2022. Sibling Three and Sibling One were last seen by CPS on April 13, 2022.

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_{[1] A CPS service plan in Michigan is a personalized roadmap designed to protect and support children in situations where there's a concern about child abuse or neglect. It outlines steps to ensure child safety, enhance their well-being, and involve parents in fulfilling their responsibilities. The plan may include safety assessments, goal setting, parental engagement, access to support services, and regular progress reviews. Recent updates and pilot programs in Michigan are aiming to streamline services and improve outcomes for families involved with CPS, including a more holistic approach to addressing needs beyond just abuse and neglect.}

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OCA Investigation:

During the OCA’s investigation, the OCA asked MDHHS staff why the CPS ongoing case was closed without the family participating in services. The OCA was informed the case was abruptly closed after Mother disappeared. They were unable to locate her and the only time they were able to get Mother to respond was when they had something to provide her with, such as Easter baskets. Mother would not disclose where she was living or where the children were. When discussing why the safety assessment was scored as safe with services, but no services were in place, MDHHS staff said the assessment was answered this way because they were unable to locate the family, making it difficult to say if the children were safe or unsafe. 

The OCA asked MDHHS staff why the case was not escalated to a Category I after Mother did not fully participate in, complete or benefit from services. The OCA was advised MDHHS had conversations with the prosecutor’s office about filing a petition, but MDHHS and the prosecutor did not believe they had imminent risk to file. MDHHS informed the OCA the prosecutor told them they did not have enough to move forward with a petition as required by MCL 722.628d(1)(e)(iii)². MDHHS staff acknowledged they could have consulted with the MDHHS legal department when the prosecutor did not support a statutorily mandated petition.

MDHHS staff expressed concern for MDHHS policies PSM 713-01 and PSM 714-01, stating they contradicted each other in sections. MDHHS staff explained PSM 713-01 talks about Category II cases needing to be escalated to Category I when services are refused or not participated in and there is continued or heightened risk of harm to the child. MDHHS staff explained PSM 714-01 merely states, if the family does not voluntarily participate in services, a petition must be filed, and the case is reclassified as a Category I and does not discuss continued or heightened risk of harm to the child. 

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_{[2] MCL 722.628d(1)(e) Category I - court petition required. The department determines that there is evidence of child abuse or child neglect and 1 or more of the following are true:}

_{(iii) The department previously classified the case as category II and the child's family does not voluntarily participate in services.}

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Overview of CPS history between 2022 Category II and The Child’s Death:

Between the ongoing case closing and The Child’s death (December 2023), CPS was involved with Mother and her family during six additional investigations.

MiSACWIS ID: 132013012 - An investigation began on June 2, 2022, with concerns for improper supervision of The Child and Sibling Three by their father, Father Jr. During this investigation, the family was difficult to contact, and the well-being of The Child and Sibling Three was not verified by CPS until July 8, 2022. At the time, CPS was informed Mother was living in a home without electricity and Mother’s aunt was providing care for Sibling Two and Sibling One. Mother informed CPS she was bouncing from staying with her aunt, to living in a camper or a hotel. This investigation was closed as a Category IV on July 14, 2022. 

MiSACWIS ID: 141533280 - An investigation began on March 27, 2023, with concerns for improper supervision of Sibling Four (Mother’s son, age 13) by Mother. The complaint expressed concern Mother provided Sibling Four with marijuana and smokes marijuana with him when he visits. At the time of this investigation, Sibling Four was under a guardianship with Mother’s aunt. CPS was advised Sibling Four was facing criminal charges and had been kicked out of school. Sibling Four informed CPS when he visits his mother, he often watches his younger siblings, Sibling Two and Sibling One, so his mom can go out. He expressed concern about his mother’s relationship with her boyfriend, Siblings Father 1. Sibling Four advised CPS his mother has told him Siblings Father 1 has beat her up before. Sibling Four denied his mother giving him marijuana or smoking marijuana with him. Sibling Four told CPS his mother smoked marijuana around them and that he has used marijuana before. This investigation was closed on April 21, 2023, as a Category IV, with no documented contacts verifying the well-being of The Child or Sibling Three. 

MiSACWIS ID: 143203171 - An investigation began on April 11, 2023, regarding concerns for improper supervision of Sibling Two and Sibling One by Mother and Siblings Father 1. The complaint stated Sibling One and Sibling Two were left with Sibling Four for extended periods of time and there was concern Malichi was not mature enough to be a caretaker for the children because of his criminal behavior and marijuana use. Additional concerns were expressed about domestic violence between Mother and Siblings Father 1 in the presence of the children. During this investigation, Mother denied allowing Sibling Four to supervise the younger children for extended periods of time. She admitted to using marijuana before going to bed each night and denied providing Sibling Four with marijuana or using marijuana with him. Mother’s home was not observed during this investigation due to Mother being unresponsive to CPS. CPS had difficulty reaching Father Jr. (The Child and Sibling Three’s father) to verify the well-being of The Child and Sibling Three. CPS verified Sibling Two, Sibling One, and The Child’s well-being during a face-to-face contact at the Jackson County MDHHS office on May 5, 2023. This investigation was closed as a Category IV on May 11, 2023, stating the investigation regarding Sibling Five’s death remained open (see below).

MiSACWIS ID: 143773441- An investigation began on May 1, 2023, after the death of Mother’s son, Sibling Five. On April 28, 2023, Sibling Five and his peers were drinking and driving, shot rubber bullets from the car and fled from law enforcement. As a result, the car rolled over while being chased and Sibling Five was ejected from the car. Sibling Five was declared deceased on the scene. Additional concerns were expressed regarding Mother’s living conditions, Mother using heroin and crack, leaving the children for extended periods of time, and Mother’s children appearing malnourished and unbathed. During this investigation, Mother was minimally responsive to CPS. The children were in the care of relatives who had no ability to seek medical attention for the children and had difficulty getting a hold of Mother. Mother was residing at a hotel during this investigation and Sibling Four was reported to have left his guardian’s home to be with Mother. This investigation was closed as a Category IV on June 2, 2023, with no documented contact with Sibling Four or his whereabouts being confirmed after he left his guardian’s home. During this investigation, CPS attempted to contact Siblings Father 1 by phone, but this attempt was unsuccessful. 

MiSACWIS ID: 150433201- An investigation began on September 11, 2023, with concerns Mother was residing in a van with her children, using methamphetamines, and leaving the children with relatives for days without contact. There were additional concerns both fathers, Father Jr. and Siblings Father 1, were producing methamphetamine in their homes. CPS coordinated efforts to locate the family with law enforcement and contact was made on September 13, 2023. Mother denied leaving the children with relatives, denied methamphetamine production, and denied using drugs. Mother informed CPS she was residing between two RV/campers and denied living in her van. Mother refused to drug screen during this investigation. Mother denied knowing the addresses to where she stayed. CPS also spoke with Siblings Father 1 who denied drug use or methamphetamine production, stating he was homeless and did not have a home to produce drugs in. He advised staying in a camper on a friend’s property and provided CPS with his friend’s contact information. CPS was able to verify the camper was located on the property of his friends’ home but because Siblings Father 1 was not present, they were unable to access the camper to properly assess its suitability and safety. CPS made several attempts from September 27, 2023, to October 10, 2023, to locate Mother and observe her housing. CPS located Mother on October 10, 2023, but Mother refused to allow CPS access to her camper. CPS received a voicemail from Mother’s aunt on October 10, 2023, stating that Mother left The Child and Sibling Three in the care of a relative who is unable to reach Mother, and the children are too much for the relative to handle. There is no further documentation that this concern was discussed with Mother or if the children returned to Mother’s care. The CPS investigation was closed as a Category IV on October 12, 2023, with an intensive risk assessment score.

MiSACWIS ID: 15313353- An investigation began on December 12, 2023, with concerns for Sibling Four residing in Indiana with an aunt and uncle who were no longer able to care for him. There were additional concerns Mother was homeless, living out of a camper, and it was unknown who would be able to provide care to Sibling Four. During this investigation, Mother admitted to CPS she was struggling with housing and needed assistance. She advised CPS if they (the aunt and uncle) “did not want Sibling Four, that she had a place for him here in Michigan.” CPS discovered Sibling Four’s prior guardianship ended and he was sent to live with an aunt and uncle in Indiana through his probation. CPS was informed by his probation officer, Sibling Four was staying in Indiana with the aunt and uncle, and things were going well. On December 19, 2023, CPS completed a scheduled visit to a “plot of land observed to have multiple trailers/campers and a home on it.” The CPS report documents the “camper was cluttered but did not present safety concerns.” There were working utilities such as heat, electricity, and water. Mother told CPS she was struggling with food and asked for assistance until her food stamps were issued again. CPS provided Mother with a Meijer gift card and a housing resource list. This investigation was closed as a Category IV on January 25, 2024. A new complaint was received on December 25, 2023, regarding The Child’s death, MiSACWIS ID: 163133404) more information below).

During each of these investigations, Mother was minimally cooperative with CPS, was difficult to get a hold of, and her living arrangements were not properly observed and assessed. CPS was unable to verify the well-being of some of the children during these investigations, making it difficult to properly assess the risk to the children.

Review of CPS’ investigation regarding The Child’s death (MiSACWIS ID: 163133404):

On December 25, 2023, CPS Centralized Intake received a complaint regarding the death of The Child. The complaint stated Mother failed to supervise the children which resulted in them playing in the roadway and The Child being fatally struck by a car. This complaint was accepted and assigned to Jackson County for investigation. 

CPS began their investigation by collecting medical records surrounding The Child’s death. On December 26, 2023, CPS made an unannounced visit to Mother’s Aunt’s home, Mother’s aunt. Mother’s Aunt did not have the children in her care and informed CPS Mother was hospitalized for a psychological evaluation for suicidal statements following The Child’s death. She believed Father Jr. had Sibling Three and that Sibling One and Sibling Two were with their father, Siblings Father 1. 

CPS spoke with Father Jr. by phone and was informed he was at the home where Mother was living about an hour before the accident with The Child occurred. He advised Sibling Three was with a family friend and he would give CPS his contact information. He told CPS Sibling One and Sibling Two were with their father, Siblings Father 1. 

CPS attempted a home visit to Mother’s RV/camper with law enforcement. CPS documented the outside of the camper to include “several piles of garbage, and garbage bags stacked outside. There were broken two-by-fours in the yard with children’s toys, several tarps covering the roof, wet diapers on the ground, a mattress, broken plywood, a lamp, and a refrigerator.” CPS noted no windows were facing the driveway or the road from the camper. CPS observed the scene of the accident and noted the camper would not have a direct line of sight of the driveway where The Child and Sibling Three were riding bikes and where The Child was struck by the car. CPS also conducted a home visit to the family friend who was assisting with caring for Sibling Three. Sibling Three was observed, and his well-being was verified.

CPS was informed by law enforcement that while on scene of the accident, Mother was heard yelling at Sibling Three, making statements such as “if he dies, it is your fault.” It was believed by responding officers that Mother was heavily intoxicated at the time of the incident and an attempt to get a preliminary breath test (PBT) from her was made. CPS was informed it was law enforcement’s intent to seek charges for child neglect causing death for Mother. 

On December 27, 2023, CPS had not been able to see Sibling One and Sibling Two and had concerns Mother may flee the state with the children. CPS determined a petition needed to be filed for removal to safeguard the children. Due to the concern for substance use and criminal history, removal would also be requested from both fathers. A petition was filed on this date, and a removal order was granted for the children. A hearing was scheduled for December 28, 2023. Mother, Father Jr., and Siblings Father 1 were evasive with CPS and did not respond to calls or texts. CPS made several visits and attempts to locate and remove all the children on December 27, 2023, and on December 28, 2023, prior to the court hearing. During their searches, CPS was able to enter the RV/camper where Mother and the children were residing at the time of The Child’s death. The inside of the camper was described to have multiple tarps zip-tied to the roof of the home, a sink full of dishes, garbage throughout the countertops, a mattress on the wall, shoes and toys covering about half of the floor, noting it was challenging to walk through the home. It is further documented the ceiling was actively caving in on itself and did not appear secure, with layers of the ceiling visible. The bed was covered in clothing and parts of the camper were not accessible due to the number of items in the room. A rifle was also noted in the corner of the bedroom. 

The children were eventually brought to the courthouse after the hearing as the judge would not allow anyone to leave until the children were presented to CPS. Sibling Two was observed to have crusted food and dirt on his face and clothing. He was wet through his pull-up and pants. His face and hands were also covered in something sticky. Sibling Two had a deep wet cough. Sibling One had no shoes on, and his pants were saturated with urine or juice. He also had food crusted on his face and a strong urine odor. 

Sibling Two, Sibling One, and Sibling Three were placed in two relative homes. The investigation was concluded as a Category I with a preponderance of evidence supporting physical neglect of The Child, Sibling One, and Sibling Three by Mother, and placing Sibling Two, Sibling One, The Child, and Sibling Three at unreasonable risk by Father Jr., Mother, and Siblings Father 1. The investigation was closed on February 6, 2024.

OCA Investigation: 

The OCA conducted interviews with MDHHS staff regarding Mother’s living conditions during the December 12, 2023, investigation and the CPS investigation concerning The Child’s death. The OCA inquired how the home was considered appropriate for the children during a home visit on December 19, 2023, but less than a week later, the home conditions were unsafe and deplorable. MDHHS staff explained during the December 19, 2023, home visit, Mother knew MDHHS were coming. The trailer was observed to be clean, and no safety concerns were identified. MDHHS staff were unable to recall if the roof was covered with tarps or the condition of the ceiling, noting the ceiling may have been covered with a sheet. MDHHS staff further advised that no pictures were taken due to there being no concerns. It was explained to the OCA that if there are no concerns with the home environment, pictures are not typically taken. Additionally, the OCA asked why the property owner was not interviewed regarding the family’s ability to use the bathroom and shower. MDHHS staff advised they were unaware the property owner needed to be interviewed, and they had never been in a situation before where multiple families were living on the same property. 

Law and Policy Review:

722.628d Categories and departmental response: Sec. 8d. - outlines the department’s response and category classifications for investigations. 

1. Court authority is needed to order the parent to do something to allow the child to remain safely in their own home.
2. Court authority is needed to secure safety of the child.
3. If requesting removal, caseworkers must document through use of social work contacts, and on the petition that reasonable efforts were provided or attempted and that services did not eliminate the need for removal.

This policy also discusses MDHHS offices working with the prosecuting attorney’s office or alternate counsel when submitting petitions to the court. The policy explains that when the prosecuting attorney or alternate legal counsel refuses to file a mandatory petition, the case manager must file the petition directly with the court. If a prosecuting attorney or alternate legal counsel refuses to file a non-mandatory petition with the court, PSM 715-3 states the caseworker may file the petition directly with the court, documenting the attorney’s refusal and any action taken in social work contacts.  

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The child advocate finds Jackson County MDHHS did not comply with MCL 722.628d(1)(e)(iii), PSM 714-1 and PSM 715-3 when the January 2022 ongoing CPS case (MiSACWIS ID:142509) closed. During the category II open services case, Mother did not participate in services and was not cooperative with CPS.	MDHHS agrees in part. Jackson County MDHHS did consult with the prosecuting attorney, who indicated that the Department did not have enough evidence to support a petition, stating “no imminent risk.” It is unclear, based on the contacts, whether there was a discussion about filing an in-home petition to order the family to participate in services. The Department could have moved forward with securing outside counsel and filing a petition based on PSM 714-1, if the court dismissed/ withdrew the petition, then consulted with Children’s Services Legal Division. However, the Department closed the case in May 2022. It should be noted that since January 2022 (the time of the Updated Service Plan in question), Jackson MDHHS has secured private representation outside of the prosecutor’s office. Since this change, the Department’s legal representative has not disagreed with filing a petition in accordance with policy and law. Since the initial review of this case in 2023, Jackson County has reviewed these policies and procedures with staff and supervisors and has proceeded with filing petitions in accordance with policy. This policy will also be reviewed with staff and supervisors as a reminder of when a petition must be filed on an ongoing case.
The child advocate finds the Jackson County MDHHS staff who were interviewed believe there is contradictory language regarding escalating Category II cases in PSM 713-01 and PSM 714-01.	MDHHS agrees. Jackson County does not disagree that staff reported a discrepancy in PSM 713 - 01 and PSM 714 -01. However, the policies do align regarding the escalation of Category II cases. The policies were reviewed with staff and supervision on 12/04/2025.
The child advocate finds PSM 713-01 and PSM 714-01 do not contradict one another. Both policies direct staff to escalate a Category II case to a Category I case when a family does not voluntarily participate in services, which requires a petition to the court.	MDHHS agrees. The discrepancy between policies appears to relate to PSM 715-3 and PSM 714-01, not PSM 713-01. Please reference response to Findings 1 and 2 above. This policy update has been reviewed with staff and supervisors on 12/04/2025.
The child advocate finds MDHHS closing Category II cases when families are uncooperative and unable to be located, leaves children at risk of further harm.	MDHHS agrees. However, PSM 715-3 has been updated to reflect the same information in PSM 714-14 as of 11/01/2022.
The child advocate finds Jackson County MDHHS closed the January 2022 ongoing case (MiSACWIS ID: 142509) without verifying the well-being of all Mother’s children within 30 days prior to the case clos	MDHHS agrees. PSM 715-3, PSM 713-01, and PSM 714-14 were reviewed with staff and supervisors on 12/04/2025 regarding escalation of cases as well as verification of all children within 30 days of case closure.
The child advocate finds a petition is required to have been filed during the 2022 ongoing case, per MCL 722.628d(1)(e)(iii), as court authority was needed to order the parent to participate in services and secure the safety of the children involved.	MDHHS agrees in part. Jackson County MDHHS did consult with the prosecuting attorney, who indicated that the Department did not have enough evidence to support a petition, stating “no imminent risk.” It is unclear, based on the contacts, whether there was a discussion about filing an in-home petition to order the family to participate in services. The Department could have moved forward with securing outside counsel and filing a petition based on PSM 714-1, if the court dismissed/ withdrew the petition, then consulted with Children’s Services Legal Division. However, the Department closed the case in May 2022. It should be noted that since January 2022 (the time of the Updated Service Plan in question), Jackson MDHHS has secured private representation outside of the prosecutor’s office. Since this change, the Department’s legal representative has not disagreed with filing a petition in accordance with policy and law. Since the initial review of this case in 2023, Jackson County has reviewed these policies and procedures with staff and supervisors and has proceeded with filing petitions in accordance with policy. This policy will also be reviewed with staff and supervisors as a reminder of when a petition must be filed on an ongoing case.
The child advocate finds several additional complaints were made and investigated by CPS following the January 2022 ongoing case closure, with continued concerns of placing a child at unreasonable risk (formerly improper supervision), substance use, and physical neglect. Mother was minimally cooperative with these investigations and CPS was unable to obtain enough evidence to determine if she was abusing substances or not and was not able to fully verify her living conditions for herself and the children. In at least two cases CPS was not able to verify the safety and wellbeing of Mother’s children.	MDHHS agrees.
The child advocate finds that CPS documented Mother’s camper to be suitable for the children during their home visit on December 19, 2023, but less than a week later when The Child died, the home was deplorable, unsafe, and unsuitable for children.	MDHHS agrees. Within the initial investigation, the home conditions were documented as hazard-free, but later, the investigation shows the home was deplorable and photos during this case were not uploaded.

Recommendations:

Recommendation	MDHHS Response to Recommendation
The child advocate recommends MDHHS require a CPS program or section manager review and approve all Category II cases when there is no cooperation or benefit from services before closure to determine compliance with MCL 722.628d, PSM 714-1and PSM 715-3.	MDHHS agrees in part. MDHHS recognizes there may be an opportunity to enhance practice in Category II cases and is actively working with CSA leadership and Evident Change to assess; however, it is unclear at this time if requiring CPS program or section manager review and approval on all Category II cases when there is no cooperation or benefit from services before closure is the best approach or whether it will have the intended impact. The department is currently exploring a shift from the Structured Decision Making (SDM) Risk Reassessment to an SDM Progress to Case Closure Tool which may help mitigate the identified concern. This tool has been utilized in other jurisdictions and can be customized to meet the unique needs of Michigan children, families, and staff: The tool emphasizes observable behavior change and the use of support networks, rather than mere service compliance. This allows staff to assess meaningful progress toward child safety and family stability. The tool integrates safety with family service plan progress, using a clear decision tree to guide case closure recommendations. This structure supports decisions and reduces ambiguity. Standardized criteria will help ensure all staff apply the same benchmarks, promoting equity and reducing subjectivity in case closure decisions. The tool will prompt detailed documentation of safety interventions and behavior change, improving decision making and supervisory review. The tool can be used at regular intervals or when new information arises, allowing staff to respond promptly to changing circumstances. The tool encourages the use of team meetings and other engagement strategies to assess progress collaboratively with families CSA is interested in exploring this tool further before making any changes to CPS policy or practice.
The child advocate recommends if closure does not comply with law and policy, MDHHS require staff to comply with the cited law and policy above by filing a petition.	MDHHS agrees. This requirement is outlined in Child Protection Law and CPS policy, PSM 714-1.
The child advocate recommends MDHHS amend PSM 715-3 to require local county offices to inform MDHHS legal when a prosecuting attorney or alternate legal counsel refuses to file a petition. Additionally, the child advocate recommends MDHHS legal track these instances to determine if there are systemic issues with MDHHS offices or prosecuting attorney’s offices that need to be addressed further.	MDHHS agrees in part. On August 5, 2024, the Children’s Services Legal Division (CSLD) released a Communication Issuance (CI) outlining guidance regarding dismissed and withdrawn petitions in an abuse/neglect case. The CI distribution included all CSA Central Office and county child welfare staff. The CI specifically requires child welfare staff to send an email to the dedicated email box for CSLD any time a petition is dismissed or withdrawn. Many county offices provide daily emails to CSLD where CSLD provides legal guidance in acceptance of the county’s legal representation/court’s decision or to recommend the county seek private representation to pursue the petition. The guidance for private representation is already provided in PSM 715-3. CSA staff are aware of the guidance in the CI; however, it is not currently outlined in policy. This is pending incorporation into PSM as soon as administratively possible. CSLD is already tracking situations related to petition handling to determine trends and issues with CSA’s representation in the state.
The child advocate recommends Jackson County MDHHS hold a training with their staff regarding MCL 722.628d(1)(e)(iii), relevant policies, and this report, to ensure future compliance.	MDHHS agrees. Jackson County MDHHS reviewed the following policies, PSM 713-01, PSM 715-3 and PSM 714-1, with staff and supervision on 12/04/2025.
The child advocate recommends MDHHS require case managers to attempt to verify the home of an individual helping a family when the family resides on the property but outside of the property owner’s home, when the family is using the home to shower, obtain water, eat, etc. This should be verified in person with an assessment of the property owner’s home to ensure it is suitable to meet the needs of the children. MDHHS could also require a written, detailed safety plan, signed by both the parents and the individuals assisting the family.	MDHHS agrees in part. MDHHS recognizes enhanced policy guidance may be needed in relation to cases involving these specific circumstances; however, further internal discussion is prudent to assess for unintended consequences, legal considerations, and other factors that may impact a case manager’s ability to do this safely and effectively. In addition, MDHHS continues to partner with Evident Change to implement an enhanced SDM Safety Assessment, which will include a structured approach to safety planning, guided by factors identified in the assessment. This recommendation will be considered as part of this work.
The child advocate recommends MDHHS require case managers take photographs of a family’s housing situation during investigations involving homelessness, or poor home conditions, whenever possible. Photographic evidence should be gathered during investigations, both proving and disproving allegations. Pictures of a home must be taken at the onset of an investigation and the completion of an investigation to properly document evidence, eliminating questions into an assessment of the home if and/or when a new complaint is received.	MDHHS agrees in part. MDHHS recognizes enhanced policy guidance may be needed around photographs in cases involving physical neglect due to living conditions; however, further internal discussion is needed to determine what specific guidance should be provided.

PDF Version of Report:  Case No. 2023-0859

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
October 31, 2025	January 26, 2026	February 6, 2026	2024-0379

Summary of recommendations:

The Child Advocate recommends strengthening oversight and policy compliance in Category II cases by requiring CPS program or section manager review and approval when there is no cooperation or benefit from services, and ensuring petitions are filed when case closures do not meet the requirements of MCL 722.628d(1)(e)(iii) and PSM 713‑01. The Advocate further recommends that Wayne County MDHHS provide regular training on these policies, as well as on managing ongoing cases and service provision. Additionally, the Advocate recommends that MDHHS conduct an anonymous survey of case managers who completed CWTI training between 2020 and 2024 to assess its effectiveness and engage staff in discussing this report’s findings to identify improvements in training, supervision, and overall practice.

Case Summary:

Date of Birth: July 5, 2007

The Office of the Child Advocate (OCA) is tasked with making recommendations to positively effect change in policy, procedure, and legislation by investigating and reviewing actions of the Michigan Department of Health and Human Services (MDHHS), child placing agencies, child caring institutions, or certain facilities offering Juvenile Justice services. The Child Advocate Act, Public Act 204 of 1994, also requires the OCA to ensure laws, rules, and policies pertaining to Children’s Protective Services (CPS), Foster Care, Adoption and Juvenile Justice are being followed. The OCA is an autonomous entity, separate from the MDHHS.  

This OCA review included reading confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), service reports and social work contacts. The OCA also interviewed MDHHS staff, and reviewed law and policy surrounding CPS ongoing services cases. Due to the confidentiality of OCA investigations, the OCA cannot disclose the identity of witnesses or complainants or sources of statements and evidence.

The objective of this review is to identify areas for improvement in the child welfare system by looking at how the case involving Child and her siblings was handled by Wayne County MDHHS and the involvement of MDHHS staff. This report is not intended to place blame, but to highlight areas of concern regarding the case; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children.

This case came to the attention of the OCA after a complaint was received, and the OCA preliminary investigation found problems with the CPS ongoing services case. A full OCA investigation was opened on September 26, 2024, to review Wayne County DHHS’ involvement with the family and to determine what services were provided to address issues that led to the ongoing services case. 

Family History and Case Background:

Mother and Father are Child’s parents (17). Mother is also the mother of Sibling One and Sibling Two (2); Siblings Father is their father.

The focus of the OCA’s investigation was on CPS’ investigation from September 2023 and the subsequent ongoing case. 

On September 2, 2023, Centralized Intake received a complaint with concerns Mother placed Sibling One and Sibling Two at unreasonable risk of harm. The complaint expressed concerns Mother was observed in a parking lot on September 1, 2023, actively inhaling nitrous oxide with both children in the car. The complaint was accepted and assigned to Wayne County for investigation (MiSACWIS ID: 150123186). 

Mother and the children were staying at a shelter at the onset of the CPS investigation. CPS staff interviewed Mother on September 3, 2023. CPS documented Mother appeared sober, alert, and articulate. Mother told CPS she was battling depression and dealing with a domestic violence situation involving Child’s father. She told CPS the family went to the shelter about a month ago to escape an additional partner (not Child’s father). Mother denied inhaling the can of nitrous oxide on September 2, 2023, but admitted to having the nitrous oxide can with her in the car. Mother told CPS she first used nitrous oxide in 2012 and that her last use was in 2022. Mother also told CPS she used marijuana and her experience at the shelter was triggering her to use it again. CPS completed a verbal safety plan with Mother around substance use where she agreed to refrain from substance use while driving and CPS suggested she use her support persons when feeling depressed. CPS noted the children were observed in their car seats, free of any visible signs of neglect. Mother completed a drug screen for CPS during this interaction. 

On September 5, 2023, CPS spoke with staff at the shelter where Mother and her children were staying. CPS was advised that Mother is a great mother, is employed and doing well. The shelter staff were working with Mother to find permanent housing. The OCA investigator observed this contact was the same contact made in a previous investigation (CAT IV closed August 30, 2023; MiSACWIS ID: 148533197) and was not entered into this investigation until October 2, 2023. 

The next social work contact in the investigation was from October 2, 2023, which documents the results of Mother’s drug screen. The drug screen results were negative for all substances; however, the sample comments indicate the device leaked in transit and was not sealed properly. CPS attempted to reach Mother to schedule a Family Team Meeting (FTM) and provide her with an update on the investigation status. Mother’s phone was not accepting calls, and their contact was not successful. 

On October 17, 2023, CPS was informed by staff at the shelter that Mother had left the shelter about two weeks prior due to her behavior and being combative with others. CPS was also informed Mother was not on a list for the support group. 

On October 18, 2023, CPS completed a home visit with Child and her father at Child’s father’s home. Child was interviewed privately by CPS. Child informed CPS she had not resided with her mother in about two years due to her current living situation. Child said she sees her mom from time to time but that her mom did not have a house and was “kind of all over the place right now.” She told CPS her mom “drives like an idiot and unnecessarily fast.” Child told CPS her mom used to smoke marijuana and cigarettes, but she stopped. Child advised her mom does “whipped cream can[s]” but she did not know what they were. She explained she saw her mom use them a few times, inhaling from the cans. Child told CPS there were a bunch of cans in the trash before they were kicked out of their previous home. CPS asked how her mom’s behavior was after she would inhale from the cans. Child advised her mom would “just seem out of it.” CPS spoke with Father following the interview with Child. Father expressed concern for the twins in Mother’s care. Father’s concern was because of Mother’s living situation as she was reportedly living in her car while continuing to use nitrous oxide. 

On October 19, 2023, CPS spoke with Mother who advised she was staying at a hotel but would soon be moving in with a friend. A FTM was held (by phone) and Mother was informed the case would be opened for services as a Category II with a referral to Families First. At this point CPS had not physically observed or made contact with Sibling Two and Sibling One since September 3, 2023, a period of 46 days.¹ 

On November 20, 2023, a request from the on-call support team was made to complete a home visit with Mother and the children for both the ongoing case and the CPS investigation. A scheduled home visit occurred at Mother’s new home. The home had minimal furnishings, and Mother advised the on-call support team that she needed beds for the children. The home was otherwise observed to be appropriate. 

The investigation was concluded as a Category II with a preponderance of evidence supporting placing a child at unreasonable risk by Mother concerning Sibling One and Sibling Two. The investigation closed on December 15, 2023, noting a referral to Families First for services would be made and the family would be monitored by CPS ongoing. 

In review of the CPS ongoing services case (MiSACWIS ID: 131045286), no services were referred to Mother when the ongoing case was opened. There was no referral made to Families First. The family had two additional CPS investigations while the ongoing case was opened. One investigation involved concerns for Child at Father’s home; this investigation was closed as a Category IV on March 4, 2024 (MiSACWIS ID: 158583350). The second investigation (MiSACWIS ID: 178873514) began on July 5, 2024, following concerns Mother had grabbed Child by the arms and forcibly pulled her onto a bus. This incident occurred after Child tried to run away, as she did not want to purchase inhalants for Mother. Additional concerns were expressed Mother was doing inhalants from June 8, 2024, to June 10, 2024, which caused her to be in a daze for hours. The complaint also alleged Child was responsible for caring for her twin sisters.

During the investigation, CPS spoke with Mother by phone on July 5, 2024, and documented that Mother had expressed her frustration with false reports and felt CPS was harassing her. She allowed CPS to verify the well-being of Sibling One and Sibling Two during a home visit on July 8, 2024. Mother denied doing anything to harm Child and denied asking Child to purchase inhalants for her. Mother admitted to using inhalants in the past but denied using them currently. She further advised inhalants were “laughing gas that last for minutes, and it did not affect her in any way.” CPS observed the home to be “untidy and cluttered” but sleeping arrangements were appropriate, utilities were in working order, and there was an adequate amount of food observed. 

CPS interviewed Child on July 8, 2024, at her father’s home. Child told CPS she felt unsafe with her mother due to her mother’s behavior, her mother using inhalants, and making Child clean constantly. She shared that her mother’s home is always in “horrible condition.” Child told CPS her mom will spend $50 a day on inhalants and will sit in a daze for hours, leaving Child to care for her twin sisters. She also shared that her mother is aggressive, and they argue a lot. 

The investigation was closed on August 16, 2024, after determining that there was insufficient evidence to support claims of physical injury to Child or that Mother had placed Child, Sibling Two, or Sibling One at unreasonable risk. At that time, the ongoing services case (MiSACWIS ID: 131045286) remained open with no services being provided to Mother.

The first three Updated Services Plans (USPs), (report dates: October 3, 2023-December 1, 2023, December 2, 2023-February 29, 2024, and March 1, 2024- May 29, 2024), contained no social work contacts from the ongoing services case manager. All the USP contacts made were linked through the original Category II investigation, and the two subsequent CPS investigations. These USPs were not completed until June 15, 2024, and June 16, 2024, with supervisory approval occurring on June 17, 2024.

The USP dated May 30, 2024, to August 27, 2024, notes the risk scored as intensive. During this reporting period, the ongoing case includes documentation of a home visit that occurred on August 15, 2024. CPS met with Mother and attempted to engage her in services with Families First. Mother refused services. 

A closing USP was completed dated August 28, 2024, to September 24, 2024. This USP documents a closing FTM was completed with Mother by phone on September 13, 2024. CPS attempted to engage Mother in services, but she again declined. She continued to deny current inhalant use. CPS documented advising Mother that if another complaint was received and substantiated, a petition could be filed due to her non-compliance with services.

The closing USP documents an email was received from CPS Centralized Intake on September 23, 2024, noting a new complaint (MiSACWIS Intake ID: 147640593) was received with concerns Mother had mental health issues, is unable to provide basic needs for her children and that her home was unsanitary with feces on the floors. Additionally, there were concerns Mother was diagnosed with schizophrenia and was prescribed medication but not taking it.

CPS made an unannounced home visit on September 23, 2024. CPS verified the well-being of Sibling One and Sibling Two. Mother denied the allegations about her mental health and told CPS she was potty training the twins and they remove their own diapers, but denied feces being spread on the floor. CPS documented they did not observe any feces in the home and documented the home to be “junky” but no visible safety hazards were observed. 

The ongoing case closed on September 24, 2024, noting Mother refused to participate in services. The risk re-assessment continued to score at an intensive risk level. 

During the ongoing case, monthly visits were not completed or documented with Mother and the children in February 2024, April 2024, and May 2024. CPS documented observing Sibling Two and Sibling One on March 28, 2024, and not again until June 28, 2024.  At least monthly contact is required during open services cases with the primary caregiver, victim, and non-victim children in the family. Additionally, the ongoing case was opened from December 2023 to September 2024, approximately ten months, with no services being provided to the family. 

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_{[1] PSM 713-01 Extension and Overdue Investigation Requirements - Case managers requesting an investigation extension, or for investigations going overdue (without an extension request), must complete all the following within 30-calendar days from the date of the referral, and within every 30-days thereafter:}

• _{Face-to face contact with each alleged child victim(s)}
• _{Safety assessment}
• _{Contact with parent/caregiver(s) of each victim}

  ---

Additional Information:

The OCA conducted interviews with MDHHS staff. The OCA was informed this case presented difficulties due to Mother’s refusal to participate in services, and her being difficult to deal with. MDHHS staff voiced further concerns regarding Mother’s choice of substance, specifically her use of inhalants. Inhalants do not appear on drug tests, and this posed difficulty capturing whether Mother was continuing to use inhalants during their involvement. 

The OCA was advised MDHHS consulted with the assistant attorney general (AAG) the night before the ongoing case was closed. MDHHS advised the OCA that because of the length of time that had passed since the case was opened, there was not enough to file a petition for removal. This decision also weighed on the belief by MDHHS staff that they did not have evidence Mother was still using inhalants. When asked if MDHHS considered filing a petition to order Mother to comply with services, some MDHHS staff advised they were not aware this was possible, while others were aware this could happen but explained that Wayne County does not do this. MDHHS staff said it is a difficult process to get petitions filed in Wayne County, including urgent matters. MDHHS staff advised the OCA investigator that Wayne County courts do not accept petitions without an AAG signature. Due to the challenges in processing necessary petitions, cases in Wayne County are not being escalated to the court for instances of caretaker non-cooperation. 

MDHHS staff informed the OCA there was a delay in the case transferring from the investigative case manager to an ongoing case manager. This was a reason the case was not properly serviced in the beginning and the assigned case manager at the time was overwhelmed with a large number of investigations. Additionally, MDHHS staff expressed an overall feeling of not having supportive supervisors which “make or break” staff. The OCA was told supervisors need to provide more support and guidance to case managers to retain staff and prevent further staffing issues. The OCA was advised that most case managers need about two years to really learn the job and feel comfortable in the role, with a supportive supervisor involved.

MDHHS staff also expressed feeling the training received through the Child Welfare Training Institute (CWTI) is not adequate and does not prepare case managers for the work. MDHHS staff advised the information presented in CWTI felt removed from what happens in the community during these investigations. MDHHS staff expressed they believe part of the current staffing problem at MDHHS is due to the lack of proper training. It was explained that it felt as though they were “being pushed into the water and hope you figure out how to swim.”

During the OCA’s investigation, the OCA obtained caseload count reports for Wayne County MDHHS and reviewed the caseload data for the case manager assigned to the CPS ongoing services case. The caseload count data was reviewed from October 2023 to September 2024. During this time period, the assigned case manager held between 27 and 33 cases. Caseloads of this size make it difficult, if not impossible, to meet all policy requirements in each case while ensuring the safety of each child. 

Law and Policy Review: 

As part of the OCA investigation, the OCA reviewed law and the protective services manual (PSM) surrounding the department’s requirement for cases to be escalated when parents are non-compliant with services, in addition to the reasons a petition can be filed with the court. 

MCL 722.628d Categories and departmental response: Sec. 8d.- outlines the department’s response and category classifications for investigations.  

(1) For the department's determination required by section 8, the categories, and the departmental response required for each category, are the following: 

(d) Category II - child protective services required. The department determines that there is evidence of child abuse or child neglect, and the structured decision-making tool indicates a high or intensive risk of future harm to the child. The department must open a protective services case and provide the services necessary under this act. 

(e) Category I - court petition required. The department determines that there is evidence of child abuse or child neglect and 1 or more of the following are true: 

(i) A court petition is required under another provision of this act. 

(ii) The child is not safe and a petition for removal is needed. 

(iii) The department previously classified the case as category II and the child's family does not voluntarily participate in services. 

(iv) There is a violation, involving the child, of a crime listed or described in section 8a(1)(b), (c), (d), or (f) or of child abuse in the first or second degree as prescribed by section 136b of the Michigan penal code, 1931 PA 328, MCL 750.136b. 

(2) In response to a category I classification, the department must do both of the following: 

(a) If a court petition is not required under another provision of this act, submit a petition for authorization by the court under section 2(b) of chapter XIIA of the probate code of 1939, 1939 PA 288, MCL 712A.2. 

(b) Open a protective services case and provide the services necessary under this act. 

PSM 713-01 CPS Investigation-General Instructions provides case managers with directions on when to reclassify Category III and Category II cases. For a Category II case, policy states a case must be escalated to a Category I when “the family refuses services or has not made any progress with services and there is continued and/or heightened risk of harm to the child.”   

PSM 714-1 Court Involvement states, “every effort must be made to keep families together whenever safely possible. When engagement efforts and service provision are insufficient to achieve and maintain child(ren) safety, a petition seeking court intervention may be necessary.” The case managers are then referred to PSM 715-3 Family Court Petitions, Hearings and Court Orders. PSM 714-1 continues on to explain “a request for removal is not necessary in all situations. Relief requested should be the least intrusive necessary to protect the child(ren) or resolve the emergency.”

OCA Analysis:

In this case, CPS substantiated Mother for placing her children at unreasonable risk of harm. An ongoing CPS services case was opened and Mother initially agreed to participate in services. CPS failed to complete a referral for Families First for Mother. In August 2024, CPS attempted to engage Mother in Families First, however, she refused. This resulted in the CPS ongoing services case to close with an intensive risk level. This was in violation of the law (MCL 722.628d(1)(e)(iii)) and PSM 713-01 as both require a Category II case to be reclassified as a Category I, with a court petition, if the family does not voluntarily participate in services. 

Additionally, PSM 714-1 outlines that MDHHS should make every effort to keep families together, and removal is not necessary in all situations. In this case, a petition to the court asking for in-home jurisdiction and orders for Mother to comply with services was needed initially to attempt to alleviate the risk of harm to the children. 

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The child advocate finds Wayne County MDHHS did not comply with MCL 722.628d(1)(e)(iii), PSM 713-01 and PSM 714-1 when the 2023 ongoing CPS case closed after Mother did not participate in services.	MDHHS agrees.
The child advocate finds MDHHS closing Category II cases when families are uncooperative with services leaves children at risk of further harm.	MDHHS agrees
The child advocate finds a petition should have been filed during the 2023 ongoing case as court authority was needed to order the parent to participate in services and secure the safety of the children involved.	MDHHS agrees
The child advocate finds there was a delay in the case transferring from the investigative case manager to an ongoing services case manager.	MDHHS disagrees. In Wayne County North Central MDHHS, certain cases are retained by the investigator for continued case management as part of standard practice. All CPS specialists have been trained and have access to all PSM policies as it relates to investigation and ongoing policy. There is no policy that requires a transfer of the case from CPS investigation to CPS ongoing.
The child advocate finds the assigned case manager had 23-33 cases assigned to them during the time the ongoing case remained on their caseload.	MDHHS agrees.
The child advocate finds some Wayne County MDHHS staff do not believe they are adequately trained and lack supervisory support.	MDHHS agrees. MDHHS recognizes the importance of ongoing training and support.

 

Recommendations:

Recommendation	MDHHS Response to Recommendation
The child advocate recommends MDHHS require a CPS program or section manager review and approve all Category II cases when there is no cooperation or benefit from services. The review should be completed before closure to determine compliance with MCL 722.628d(1)(e)(iii) and PSM 713-01.	MDHHS agrees in part. MDHHS recognizes there may be an opportunity to enhance practice in Category II cases and is actively working with CSA leadership and Evident Change to assess; however, it is unclear at this time if requiring CPS program or section manager review and approval on all Category II cases when there is no cooperation or benefit from services before closure is the best approach or whether it will have the intended impact. The department is currently exploring a shift from the Structured Decision Making (SDM) Risk Reassessment to an SDM Progress to Case Closure Tool which may help mitigate the identified concern. This tool has been utilized in other jurisdictions and can be customized to meet the unique needs of Michigan children, families, and staff: The tool emphasizes observable behavior change and the use of support networks, rather than mere service compliance. This allows staff to assess meaningful progress toward child safety and family stability. The tool integrates safety with family service plan progress, using a clear decision tree to guide case closure recommendations. This structure supports decisions and reduces ambiguity. Standardized criteria will help ensure all staff apply the same benchmarks, promoting equity and reducing subjectivity in case closure decisions. The tool will prompt detailed documentation of safety interventions and behavior change, improving decision making and supervisory review. The tool can be used at regular intervals or when new information arises, allowing staff to respond promptly to changing circumstances. The tool encourages the use of team meetings and other engagement strategies to assess progress collaboratively with families. CSA is interested in exploring this tool further before making any changes to CPS policy or practice.
The child advocate recommends if closure does not comply with policy, MDHHS require staff to comply with the cited law and policy above by submitting a petition to the court.	MDHHS agrees. This requirement is outlined in Child Protection Law and CPS policy, PSM 714-1.
The child advocate recommends Wayne County MDHHS hold regular trainings with their staff regarding MCL 722.628d(1)(e)(iii) and relevant policies to ensure future compliance. MDHHS should also hold regular training on how to handle ongoing cases and the provision of services to families.	MDHHS agrees.
The child advocate recommends MDHHS conduct an anonymous survey for case managers who participated in CWTI training between 2020 and 2024 to gather their genuine thoughts and feelings about CWTI training and its effectiveness in preparing them for their job responsibilities.	MDHHS disagrees. The pre-service institute (PSI) for child welfare case managers recently went through a lengthy redesign process and the new enhanced curriculum just launched in September 2025. Feedback has been, and continues to be, collected from case managers who attend initial training. All PSI trainees receive a level 1 evaluation after completing training. Additionally, level 2 evaluations (tests) are administered during training. All trainees also receive a level 3 evaluation, which measures training effectiveness and how trainees have applied their learning in practice, three months after completion of PSI, and again after nine months. This feedback, along with an in-depth needs assessments completed by Wayne State University, which included staff surveys and focus groups, informed the PSI curriculum redesign.
The child advocate recommends MDHHS discuss this Findings and Recommendations report with staff and ask what they think could help improve training and supervision.	MDHHS agrees. Wayne County North Central MDHHS will review the findings and recommendations at the local office level.

PDF Version of Report:  Case No. 2024-0379

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
September 12, 2025	December 17, 2025	January 12, 2026	2024-0342

Summary of recommendations:

The Child Advocate recommends strengthening compliance with MDHHS policies by ensuring private agencies and MDHHS follow FOM 722‑03 and 722‑03b and complete timely, thorough relative assessments when family members express interest in placement. The Advocate afurther recommends that Methodist Children’s Home enhance and document staff training on relative safety screens, DHS‑3130a assessments, and required timeframes, and provide proof of completed training. Additionally, the Advocate recommends that Methodist Children’s Home and MDHHS share and discuss the report’s findings with foster care and PAFC staff, and that MCI consider approving placement of the child with an eligible family member.

Case Background: 

This case came to the attention of the OCA after a complaint was received, and a preliminary investigation found relatives had come forward seeking placement of The Child but had not been assessed by the agency for placement. A full investigation was opened on August 2, 2024, to review why relative assessments had not occurred and to advocate for The Child to be placed with his family.

Case Objective:

The objective of this review is to identify areas for improvement in the child welfare system by looking at how the case involving The Child was handled by Methodist Children’s Home and Oakland County MDHHS. This report is not intended to place blame, but to highlight areas of concern regarding the case, inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children. This case came to the attention of the OCA after a complaint was received, and a preliminary investigation found relatives had come forward seeking placement of The Child but had not been assessed by the agency for placement. A full investigation was opened on August 2, 2024, to review why relative assessments had not occurred and to advocate for The Child to be placed with his family.

Family History and Case Background:

The Mother is the mother of five minor children, Sibling One (10), Sibling Two (8), Sibling Three (6), Sibling Four (5), and The Child (1). Sibling  One, Sibling Two, Sibling Three and Sibling Four’s legal father is Siblings Father, Legal Father is The Child’ legal father. On September 7, 2021, Wayne County court authorized a petition removing The Child’s siblings, Sibling One, Sibling Two, Sibling Three, and Sibling Four from their parental home. The children were removed due to concerns for physical abuse, physical neglect, failure to protect, abandonment, and improper supervision (MiSACWIS investigation ID: 107243926). The children were placed in the relative home of Aunt Two (maternal great aunt) on September 15, 2021. Their foster care case was handled by Methodist Children’s Home, with Wayne County MDHHS assigned to monitor (MiSACWIS ID: 7050650).

On December 1, 2022, The Child was born, while his siblings remained in foster care. A petition was filed and authorized by Oakland County court on December 3, 2022, removing The Child from his parental home (MiSACWIS investigation ID: 137553032). The Child was initially placed in an unrelated licensed foster home. On an unknown date between December 3, 2022, and January 27, 2023, two of The Child’s relatives, Maternal Aunt (maternal great aunt), and Cousin One and Cousin Two (maternal second cousins), requested placement of The Child. The Child’s foster care case was handled by Methodist Children’s Home, with Oakland County MDHHS assigned to monitor (MiSACWIS ID: 7050650).

The relative home assessments, MDHHS 5770s¹ for Maternal Aunt and the Cousin’s were initiated on January 27, 2023, and approved on February 6, 2023. At this time, The Child remained in an unrelated licensed foster home, and the agency began completing the required Children’s Foster Care Relative Placement Home Studies, also known as the DHS 3130a². Both 3130a’s began on February 8, 2023. Maternal Aunt requested placement of The Child again on February 23, 2023. The 3130a was approved for Cousin One and Cousin Two, and The Child was placed in their home on February 24, 2023. During The Child’s placement with Cousin One and Cousin Two, The Child was able to have contact and interact with other family members, including Maternal Aunt and his siblings.

On July 7, 2023, the parental rights of The Mother were terminated to Sibling One, Sibling Two, Sibling Three, and Sibling Four. Their father, Sibling Two Sr.’s, parental rights were maintained.

On May 7, 2024, The Child was moved from the cousins' home because of concerns about domestic violence between Cousin One and Cousin Two, which involved a Maltreatment in Care (MIC) CPS investigation. The Child was placed in an unrelated foster home.

On May 9, 2024, Maternal Aunt requested placement of The Child in writing via email. Additional requests for placement of The Child were made during a Team Decision Making Meeting (TDM)³ on June 3, 2024. These requests for placement were made by Maternal Aunt and another relative, Cousin Three (maternal second cousin). Cousin One also was interested in resuming placement of The Child, as she was separated from Cousin Two and planning to file for divorce. The agency did not provide the relatives with a response or inform them if assessments would occur.

Maternal Aunt continued attempts to gain custody of The Child and filed for guardianship of The Child on or around June 5, 2024. The guardianship was not recognized due to the open abuse and neglect case concerning The Child. On July 8, 2024, Maternal Aunt made another request to Methodist Children’s Home via email requesting placement of The Child.

On August 5, 2024, an emergency placement was needed for Sibling One, Sibling Two, Sibling Three, and Sibling Four due to concerns for supervision in the relative home placement with Aunt Two. Methodist Children’s Home completed a MDDHS 5770 for Maternal Aunt’s home on August 5, 2024.

The MDDHS 5770 was approved, and Sibling One, Sibling Three, and Sibling Four were placed in Maternal Aunt’s home. A separate MDDHS 5770 was completed for Cousin Three on August 5, 2024. The MDDHS 5770 was approved, and Sibling Two was placed in her home. Subsequent DHS 3130a’s were completed as required by the agency and approved on September 17, 2024. Maternal Aunt’s son, Cousin Four, also spoke with Methodist Children’s Home staff by phone on August 5, 2024, expressing interest in having The Child placed in his home. He also expressed interest in providing care for The Child’s siblings. This was a potential out of state placement for The Child as Cousin Four lives in Ohio with his wife. At this point, four relatives provided eight separate requests for The Child’s placement.

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<sub>[1] The MDHHS 5770, Relative Approval and Placement Safety Screen is required to examine the basic qualifications of a prospective caregiver and to identify immediate safety concerns in the caregiver’s home.

[2] After approval of the MDHHS 5770, a DHS 3130A- Relative Placement Home Study, must be completed for emergency placements within 30 calendar days of the child’s placement in the relative home. For planned placement changes, the DHS-3130a must be completed prior to placement.

[3] The Team Decision Making meeting is a facilitated meeting where key stakeholders, including family members, child welfare professionals, and other relevant parties, come together to make critical decisions regarding child welfare cases, particularly those involving potential out-of-home placements or changes in placement. These meetings aim to ensure that decisions are made collaboratively, with input from all involved parties, and prioritize the safety and well-being of the child.</sub>

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OCA Investigation and Continued Case Information: 

The OCA reviewed a Team Decision Making (TDM) meeting that occurred on June 3, 2024, concerning The Child’s placement when he was moved from the Cousins One and Two’s home. The OCA noted multiple relatives were documented as being present during the TDM. Additionally, it was documented that those relatives expressed interest in placement of The Child. The information contained in the TDM notes was confirmed with MDHHS staff to be an accurate description of what occurred during the TDM, and the OCA was advised the relatives were told Methodist Children’s Home would “look into” the relatives who expressed interest in placement.

The OCA conducted interviews with Methodist Children’s Home foster care staff on August 9, 2024, August 12, 2024, and August 13, 2024. Some of the staff spoken with on these dates were newly assigned to the family and were unaware of relatives requesting placement of The Child. One staff member interviewed during these dates was familiar with the family and was aware there were additional relatives who were asking for placement of The Child. The OCA was informed that these relatives were Maternal Aunt and Cousin Three. The OCA was further advised Methodist Children’s Home, “had not strongly considered moving The Child because he is doing well where he is.” Staff advised The Child’s siblings had been moved and placed with Maternal Aunt and Cousin Three. Methodist Children’s Home staff also confirmed multiple relatives attended the TDM that occurred on June 3, 2024, and requested placement of The Child, and these relatives were Maternal Aunt, Cousin Three, and Cousin One. The OCA expressed the importance of assessing relatives and the requirements per MCL 722.954a and Foster Care Manual (FOM), 722-03 and FOM 722-03b, with Methodist Children’s Home staff. During the interview on August 13, 2024, the staff was asked if the agency would be assessing the relatives who have come forward and was told “…we are going to have to per policy we don’t have a choice.” The OCA also stressed the importance of assessing relatives prior to termination of parental rights as this could assist with assessing who may be able to provide permanency pending the upcoming termination trial.

The OCA had additional discussions with MDHHS staff regarding The Child’s foster care case on August 15, 2024, September 16, 2024, and September 23, 2024. The MDHHS staff were either responsible for monitoring the foster care case or had direct oversight of the monitoring staff. MDHHS staff were aware of the relatives who had come forward expressing interest in placement of The Child and advised the private agency planned to assess the homes for placement of The Child. MDHHS staff expressed concern that the relatives supported the mother, who was facing termination of parental rights, as an apprehension they had for placing The Child in the relative homes. MDHHS staff acknowledged the relatives had placement of The Child’s siblings, who have the same mother.

The OCA was informed on September 6, 2024, Maternal Aunt’s son, Cousin Four, had still not received Interstate Compact on the Placement of Children (ICPC) paperwork to be assessed for placement of The Child. Cousin Four resides with his wife in Ohio, about three hours away from his mother (Maternal Aunt). Cousin Four spoke with the agency and requested placement of the children on August 5, 2024.

On September 9, 2024, parental rights for The Mother and Legal Father concerning The Child were terminated by the 6thJudicial Circuit Court in Oakland County.

The OCA held a case discussion with multiple staff members from Methodist Children’s Home and MDHHS on September 10, 2024. The OCA was informed the parental rights for The Child’s parents were terminated at the court proceedings on September 9, 2024. Methodist Children’s Home staff advised DHS 3130a’s were pending and being reviewed for approval concerning The Child’s siblings and their placements with Maternal Aunt and Cousin Three. Staff acknowledged Maternal Aunt’s son in Ohio was also interested in placement and said this would have to go through the ICPC process. The OCA asked if there was a reason why The Child was not placed with a relative or his siblings. The OCA was informed Cousin Three was no longer interested in taking placement of The Child and Maternal Aunt needed items to secure placement, such as a crib. The OCA asked if these were things the agency or MDHHS could help Maternal Aunt secure, and the OCA was told yes. During the September 10th meeting, the OCA expressed concerns about the lack of timeliness assessing The Child’s relatives and stressed the importance of placing children with relatives when appropriate. The OCA expressed concern with the long-term effects this could have for The Child and his siblings if they remain separated and do not get to grow up knowing each other due to The Child not being with family. It was expressed that even if Maternal Aunt was unable to take The Child because she has three of his other siblings, there are other relatives who have come forward who would care for The Child and provide him with the opportunity to know his family. The OCA reiterated policy supports children being placed with their relatives and with their siblings when possible, and there is an opportunity for the agency to adhere to both policies, FOM 722-03 and FOM 722-03b. The agency was encouraged to consider The Child’s future and the ability for him to know his culture, background and family when looking into the best interest of The Child.

The DHS 3130a for Cousin Three and placement of Sibling Two in her home was started on August 15, 2024, completed by staff on August 27, 2024, and approved by supervision on September 10, 2024. This DHS 3130a did not include an assessment of whether Cousin Three’s home was suitable for placement of The Child. As noted previously, Cousin Three expressed interest in providing placement for The Child in May 2024.

The DHS 3130a for Maternal Aunt was started on August 8, 2024, and completed by staff on September 3, 2024, concerning placement of Sibling One, Sibling Three and Sibling Four. The DHS 3130a was approved by supervision on September 17, 2024. This DHS 3130a did not include an assessment of whether Maternal Aunt’s home was suitable for placement of The Child. As previously noted, Maternal Aunt expressed interest in providing placement for The Child initially on May 9, 2024, in writing.

During this timeframe, Maternal Aunt, her son Cousin Four, and Cousin Three continued to express interest for wanting to take placement of The Child and wanting him to be with his family. Maternal Aunt also advised Methodist Children’s Home of her back up plan on who would care for The Child or any of the children if she became unable, given her age.

Methodist Children’s Home completed an addendum to the DHS 3130a regarding Maternal Aunt’s home on October 4, 2024. This addendum included assessing Maternal Aunt for placement of The Child. The addendum recommended Maternal Aunt for placement of The Child, noting Maternal Aunt was willing and able to meet the needs of the children in the home and placement of The Child in her home would reunite him with his siblings. This approval occurred 148 days after Maternal Aunt’s initial request was made and 25 days after parental rights were terminated and The Child became a Michigan Children’s Institute (MCI) ward.

On October 7, 2024, the OCA was informed The Child’s placement could not be changed due to his status as an MCI ward and the foster parents filing a complaint with the Foster Care Review Board (FCRB). Another meeting was held with staff from Methodist Children’s Home on October 8, 2024, where the OCA was again advised The Child could not be moved without approval from MCI. Concerns were expressed by staff that Maternal Aunt may have difficulty providing care for four children but acknowledged she had a strong support system to help her. The OCA asked why Maternal Aunt was not assessed when The Child was moved from his previous relative’s placement. The OCA was informed that she was not assessed at that time because they were hoping they would have been able to place The Child back with Cousin One. Methodist Children’s Home staff acknowledged The Child could have and should have been placed with a relative. The OCA was informed they would be recommending The Child be placed with Maternal Aunt but ultimately MCI would make the final decision on a change of placement.

The OCA conducted an interview with the MCI office on October 7, 2024. The MCI office was familiar with the case, and advised they were needing to decide if they were going to provide permission for the private agency to move The Child. The MCI office informed the OCA it was likely not going to allow The Child to be moved due to the long-term best interest for the child. The OCA was further advised the MCI office focuses on keeping siblings together and placement with relatives, but The Child had not had stability in his prior placements and had become attached to his current foster parents. At the time of this conversation, The Child had been placed with his current foster parents for five months. The MCI office advised the relative would still be able to be considered for adoption.

On October 18, 2024, the MCI office disagreed with moving The Child from his current unrelated foster home. To date, The Child remains placed away from his family. At the time of this report it has been over a year since The Child was moved from a relative’s home to an unrelated foster home.

The family of The Child continues to advocate for him to be placed with family and have expressed their interest in adopting him. Maternal Aunt continues to have placement of Sibling Three, Sibling One, and Sibling Four. The OCA learned Sibling Two was placed in an unrelated licensed foster home after the OCA investigation was concluded.

Law and Policy:

During this investigation, the OCA reviewed law and policy surrounding relative placement and the requirements for MDHHS and private agencies to assess relatives.

MCL 722.954a(2) states in part “Upon removal, as part of a child's initial case service plan as required by rules promulgated under 1973 PA 116, MCL 722.111 to 722.128, and by section 18f of chapter XIIA of the probate code of 1939, 1939 PA 288, MCL 712A.18f, the supervising agency must, within 30 days, identify, locate, notify, and consult with relatives to determine placement with a fit and appropriate relative who would meet the child's developmental, emotional, and physical needs. Preference shall be given to an adult related to the child within the fifth degree by blood, marriage, or adoption provided the relative meets all relevant state child protection standards.”

MCL 722.954a(5) states “before determining placement of a child in its care, a supervising agency must give special consideration and preference to a child's relative or relatives who are willing to care for the child, are fit to do so, and would meet the child's developmental, emotional, and physical needs. The supervising agency's placement decision must be made in the child's best interests.”

Additionally, MCL 722.954a(6) states “Reasonable efforts must be made to do the following:

(a) Place siblings removed from their home in the same foster care, kinship guardianship, or adoptive placement, unless the supervising agency documents that a joint placement would be contrary to the safety or well-being of any of the siblings.

(b) In the case of siblings removed from their home who are not jointly placed, provide for at least monthly visitation or other ongoing contact between the siblings, unless the supervising agency documents that at least monthly visitation or other ongoing contact would be contrary to the safety or well-being of any of the siblings.

FOM 722-03 and FOM 722-03b - The law is further supported in foster care policies, FOM 722-03 and FOM 722-03b. Both discuss relative placements, relative approvals and placement safety screens. FOM 722-03 identifies “maintaining continuity by placing the child with relatives and in their community whenever possible” as one of the four principles that must be considered for supporting the safety, permanency, and well-being of a child in foster care. Policy continues to state that case managers must make ongoing efforts to place siblings together unless the placement would be contrary to the safety or well-being of any of the siblings and these efforts should continue until case closure. Policy further outlines that a reassessment of a sibling split placement is required each quarter and must include efforts made to place all siblings together. Policy notes that termination of parental rights does not dissolve a child’s relationship to their siblings and efforts to place siblings in out-of-home care together must continue.

FOM 722-03b states that when children are placed in out-of-home care, preference must be given to placement with a relative. Policy outlines a Relative Approval and Placement Safety Screen or MDHHS 5770 is required to be used to examine the basic qualifications of a prospective caregiver and to identify immediate safety concerns in the caregiver’s home.

Case managers must complete a MDHHS 5770, Relative Approval & Placement Safety Screen for all adult relatives who express an interest in
placement, within five business days of the relative's written or verbal request for placement consideration. Verbal requests must be documented in a social work contact.

The MDHHS 5770 must be completed and approved prior to, but no more than 30 calendar days before a child's placement. All MDHHS 5770s must be completed in the electronic case management record. All adult relatives who express an interest in placement must be screened using the MDHHS 5770.

FOM 722-03b further outlines that after approval of the MDHHS 5770, a DHS 3130a - Relative Placement Home Study, must be completed for emergency placements within 30 calendar days of the child’s placement in the relative home. For planned placement changes, the DHS 3130a must be completed prior to placement.

In The Child’s case, law and policy were not adhered to by Methodist Children’s Home or MDHHS. Multiple relatives came forward interested in the placement of The Child. The agency did not assess these relatives timely which impacted The Child’s ability to be placed with his siblings and relatives.

Additional Research:

The OCA conducted additional research into the importance of placing children with relatives also known as kinship caregivers.

Kinship care is when youth live with relatives, including aunts, uncles, grandparents, siblings, extended family, or those previously known to the family with whom the youth have a relationship with. When a child’s home environment is unsafe, relative or kinship placements are the preferred option because they maintain family connections, cultural traditions, and minimize the trauma of separation.[1] Additional benefits for placing children with relatives or kin are increased placement stability, improved behavioral outcomes, and promotion of sibling relationships.²

Child welfare agencies across the country recognize the importance of placing children with family members when children cannot remain in their home safely. Both the Casey Family Foundation, and the Annie E. Casey Foundation recognize separating children from their family is traumatic, they deserve to be placed with kin, relatives by blood or marriage, or people they consider their “chosen family.” Placing children in kinship care helps to minimize trauma and preserves their cultural identity and connections to their communities.³

The Annie E. Casey Foundation describes benefits of Kinship Care compared to children in the general foster care population to include “kids in kinship care tend to be more likely to stay with their siblings and maintain lifelong connections to family, have more stability, have better physical health and experience fewer behavior problems, have better academic outcomes, and have continued positive outcomes as adults, including better educational achievement and employment prospects, as well as reduced likelihood of receiving public assistance or experiencing homelessness or incarceration.”⁴

On September 7, 2022, Governor Whitmer proclaimed September Kinship Care Month. In her proclamation, it states in Michigan “about 53,000 children are being raised by kinship caregivers, defined as relatives or others who are close to the youth and their families.” The proclamation describes kinship care as “the full-time care, nurturing and protection of children by family members, close family friends, or other important adults in the child’s life.” The proclamation quotes MDHHS Children’s Services Agency executive director, Demetirus Starling, as saying “MDHHS believes children who need placements should be placed with their relative whenever possible. Maintaining connections with relatives, friends, and communities they know, and love is vital to their physical and emotional well-being.”⁵

In the recent published opinion, In re D.M.A.N., Minor, the Michigan Court of Appeals conditionally reversed the trial court’s order terminating the respondents’ parental rights and remanded the case for further proceedings. The appellate court emphasized that the Department of Health and Human Services (DHHS) had completely disregarded its statutory obligation under MCL 722.954a(2) to investigate potential relative placements. The court noted:

“MCL 722.954a(2) provides that when a child is removed from his or her parents, DHHS must, within 30 days, identify, locate, notify, and consult with relatives to determine placement with a fit and appropriate relative who would meet the child’s developmental, emotional, and physical needs.”

The record demonstrated that this obligation was not met, as multiple relatives expressed interest in caring for the child, yet DHHS failed to explore their fitness. The court concluded that this omission violated DHHS’s statutory duties and jeopardized the child’s right to maintain relationships with safe relatives.

Because the outcome of the case could have been different had DHHS complied with the law, the appellate court conditionally reversed the trial court’s best-interests determination and remanded the matter “for a determination as to whether a suitable relative placement is available.” The opinion further stressed that DHHS’s inaction “seriously affects the fairness, integrity, and public reputation of judicial proceedings. "This case illustrates the critical importance of DHHS’s duty to investigate relative placements before pursuing termination of parental rights, reinforcing the principle that preserving familial bonds must be prioritized when safe and appropriate relatives are available.

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_{[1] “About Kinship Care.” Child Welfare Information Gateway. https://www.childwelfare.gov/topics/outofhome/kinship/about/}

_{[2] Child Welfare Information Gateway. (2022). Kinship care and the child welfare system. U.S. Department of Health and Human Services, Administration for Children and Families, Children's Bureau https://www.childwelfare.gov/pubs/f-kinship/}

_{[3] First Placement With Family (2024); Casey Family Programs. https://www.casey.org/first-placement-family-placement/}

_{[4] What Is Kinship Care? (2014, 2025); The Annie E. Casey Foundation. https://www.aecf.org/blog/what-is-kinship-care.}

_{[5] Michigan recognizes the important role kinship caregivers play for children who need loving homes (2022). https://www.michigan.gov/mdhhs/inside-mdhhs/newsroom/2022/09/07/kinship-2022}

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Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The child advocate finds The Child was removed from his parental home on December 3, 2022, and placed in an unrelated licensed foster home, separate from his siblings. a. At the time of The Child’s placement, relatives Maternal Aunt and Cousin Two and Cousin One Cousin, came forward in January 2023 requesting placement of The Child. b. Methodist Children’s Home completed the required MDHHS 5770s and approved both homes for placement on February 6, 2023, effective January 27, 2023. c. The Child was moved to the relative home of the Cousins One and Two on February 24, 2023.	MDHHS agrees. The MDHHS-5770 was approved in MiSACWIS on 02/06/2023 and the MDHHS-3130-A was approved in MiSACWIS on 02/23/2023 by Methodist Children’s Home.
The child advocate finds The Child was moved from the Cousins One and Two home on May 7, 2024, and placed in an unrelated foster home.	MDHHS agrees. On May 7, 2024, the agency moved The Child from Cousin One’s home due to a domestic violence incident involving Cousin One and Cousin Two. Cousin Two was arrested. Cousin One appealed the move through foster care review board (FCRB). FCRB agreed with MDHHS and Methodist Children’s Home that the move was in The Child’s best interest. On May 7, 2024 The Child was placed in a licensed foster home through Methodist Children’s Home.
The child advocate finds Maternal Aunt, who was previously approved for placement of The Child in February 2023, requested placement of The Child on May 9, 2024, June 3, 2024, and July 8, 2024. a. Additional requests were made to Methodist Children’s Home on June 3, 2024, by Cousin Three. Cousin One was also interested in resuming placement of The Child, as she was separated from Cousin Two and filed for divorce.	MDHHS agrees.
The child advocate finds Methodist Children’s Home did not complete the MDHHS 5770 relative safety screens for Maternal Aunt or Cousin Three, within the five days of written and verbal requests for placement of The Child as required by FOM 722-03b.	MDHHS agrees. An MDHHS-5770 was completed on October 4, 2024, for placement with Maternal Aunt. An MDHHS-5770 was completed on August 5, 2024, for Cousin Three regarding placement of Sibling Two (sibling of The Child).
The child advocate finds an emergency placement was needed for The Child’s siblings, Sibling One, Sibling Two, Sibling Three, and Sibling Four on August 5, 2024. a. Methodist Children’s Home completed a MDHHS 5770 for Maternal Aunt and approved her for placement of Sibling One, Sibling Three, and Sibling Four. The children were subsequently placed in her home. b. Methodist Children’s Home completed a MDHHS 5770 for Cousin Three and approved her for placement of Sibling Two He was subsequently placed in her home. c. Subsequent DHS 3130a’s were completed as required and approved on September 17, 2024. d. During this process Methodist Children’s Home did not include an assessment for placement of The Child with Maternal Aunt or Cousin Three. e. The Child’s placement in Maternal Aunt or Cousin Three’s home would keep him with his family and place him with siblings.	MDHHS agrees.
The child advocate finds the OCA began having discussions with staff at Methodist Children’s Home and MDHHS regarding the importance of assessing relatives interested in placement on August 9, 2024. a. The OCA requested Methodist Children’s Home complete proper assessments on relatives interested in placement of The Child on August 12, 2024, August 13, 2024, August 15, 2024, and September 10, 2024. b. On September 9, 2024, parental rights for The Child’s parents were terminated and he became an MCI ward. c. Due to The Child being an MCI ward, MCI had to approve a move from The Child’s current placement.	MDHHS agrees. Oakland County MDHHS staff and leadership met with OCA Deputy Director and OCA investigator on October 7, 2024, to discuss placement assessment concerns. OCA spoke with Oakland Section Manager on September 23, 2024, and subsequently met with Oakland POS monitor on September 25, 2024.
The child advocate finds Methodist Children’s Home completed an addendum on October 4, 2024, to Maternal Aunt’s DHS 3130a for The Child’s siblings, to include The Child in their assessment. Maternal Aunt was approved for placement of The Child.	MDHHS agrees. Oakland County MDHHS contacted Methodist Children’s Home to inquire about the safety assessment of Maternal Aunt. Methodist Children’s Home completed an addendum to address The Child’s placement request on October 4, 2024. On October 18, 2024, a conference was held with MCI regarding placement of The Child. During the conference, Methodist Children’s Home recommended a placement change to Maternal Aunt. MCI decided to not disrupt placement until there was a better understanding of permanency related to competing parties. Methodist Children’s Home informed the relatives interested in placement of The Child that he would remain in his current placement until all Adoptive Family Assessments (MDHHS-5643) were completed. There was a relative out of state, Cousin Four, who was interested in placement. A referral was submitted to Michigan’s Interstate Compact on the Placement of Children (ICPC) and Methodist were awaiting the final report from Ohio. The Adoptive Family Assessment for Maternal Aunt was approved on April 16, 2025. The Adoptive Family Assessment for The Child’s current placement was approved on March 17, 2025. There was a preliminary assessment pending for another relative, Aunt Two, who was identified from reviewing prior CPS history.
The child advocate finds Methodist Children’s Home took 148 days to complete an assessment regarding placement after Maternal Aunt’s initial request was made. a. For 123 of these days, The Child was a temporary ward of the court and MCI would not have had to approve a placement change. b. The assessment occurred after parental rights were terminated and The Child became an MCI ward.	MDHHS agrees. The Child remains with his current foster parents pending the completion of Adoptive Family Assessments on all competing parties including one interested relative who resides out of state. There are four competing parties interested in adopting The Child.
The child advocate finds MCI informed the OCA on October 7, 2024, consideration to place children with family and siblings is a priority of the MCI office. a. On October 18, 2024, MCI made the decision not to move The Child from his current unrelated foster home placement. This has kept The Child from being placed with his family and his siblings. b. The Child had only been placed in his current unrelated foster placement for five months at the time of the MCI's decision.	MDHHS agrees. The Child remained with his foster parents pending the completion of all Adoptive Family Assessments.
The child advocate finds that The Child has been placed in the licensed foster home for 491 days as of September 10, 2025. The agency reports The Child is bonded with his foster family and working to build a secure attachment. These are factors MCI will consider when reviewing the competing party adoption.	MDHHS agrees. The Child remains with his current foster parents pending the completion of Adoptive Family Assessments on all competing parties.
The child advocate finds MCI should provide information or evidence used to show The Child had bonded with his foster parents after five months of placement and what training they’ve received to make that determination.	MDHHS disagrees. It was not necessarily the bond or lack of a bond that The Child may have had with his foster parents that was a determining factor; it was his young age and the number of moves at his young age that could affect his ability to form a healthy attachment.
The child advocate finds MDHHS did not comply with MCL 722.954a(2) when choosing not to place him with his relative because none of the listed good cause exceptions from MCL 722.954a(2) applied to The Child’s circumstances.	MDHHS agrees.
The child advocate finds MDHHS did not comply with MCL 722.954a(6)(a) when choosing not to place The Child with his siblings because there is no documentation to indicate that a joint placement would be contrary to the safety or well-being of any of the siblings	MDHHS agrees.

 

Recommendations:

Recommendation	MDHHS Response to Recommendation
The child advocate recommends private agencies and MDHHS ensure FOM 722-03 and 722-03b are followed and proper relative assessments are completed when relatives express interest in placement of a child(ren) in their home.	MDHHS agrees.
The child advocate recommends private agencies be held accountable for failing to adhere to FOM 722-03b in relation to timely assessments of relatives and placement with siblings.	MDHHS agrees.
The child advocate recommends Methodist Children’s Home complete additional training on relative safety screens, DHS 3130a’s and the required timeframes for completing these assessments.	MDHHS agrees.
The child advocate recommends Methodist Children’s Home provide proof of the training completed to the child advocate.	MDHHS agrees.
The child advocate recommends Methodist Children’s Home and MDHHS share and discuss the findings and recommendations outlined in this report with MDHHS foster care and Placement Agency Foster Care staff.	MDHHS agrees.
The child advocate recommends MCI approve a replacement of The Child into a family member’s home who is approved for placement.	MDHHS disagrees. Following the completion of adoption assessments an adoption and placement decision will be made. There are many factors to be considered in determining a permanent placement for The Child.

PDF Version of Report: Case No. 2024-0342

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
July 30, 2025		December 12, 2025	2023-0593, 2023-0866, 2024-0618

Summary of recommendations:

The Child Advocate recommends strengthening CPS practice and oversight by enhancing threatened‑harm assessments, requiring case managers to review prior termination records, evaluate parental progress, and determine whether mandatory petitions apply. Additional oversight is advised through second‑line or director approval for birth‑match investigations involving parents with prior terminations. The Advocate further recommends amending policy to require direct consultation with an infant’s treating medical provider in substance‑exposed infant cases, clarifying who qualifies as medical staff, and ensuring all CPS case managers receive training on the Plan of Safe Care Protocol, birth‑match investigations, threatened‑harm assessments, and substance‑exposed infant policy. Finally, the Advocate recommends requiring case managers to immediately provide a safe sleep environment, such as a pack‑n‑play, when one is not present in the home.

Case Objective: 

The objective of this review is to identify areas for improvement in the child welfare system by looking at how CPS investigations involving Child One, Child Two, and Child Three were handled by Kent, Wayne, and Calhoun County MDHHS, and the involvement of MDHHS staff, medical professionals, and law enforcement. This review reinforces the idea that the safety and well-being of a child is a shared responsibility of the family, community, law enforcement, and medical professionals aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of the investigations; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children. 

Case Summary: 

Child One - Date of Birth: June 23, 2023, Date of Death: August 25, 2023

Child Two - Date of Birth: September 27, 2023, Date of Death: December 27, 2023

Child Three - Date of Birth: February 27, 2011

Child One was two months old when he died on August 25, 2023. Pursuant to MCL 722.627k, MDHHS notified the OCA of the child fatality. On October 4, 2023, the OCA opened an investigation into the administrative actions of CPS regarding Child One’s death. 

Child Two was three months old when he died on December 27, 2023. Pursuant to MCL 722.627k, MDHHS notified the OCA of the child fatality. On February 1, 2024, the OCA opened an investigation into the administrative actions of CPS regarding Child Two’s death.

The case involving Child Three and her siblings came to the attention of the OCA with concerns about the children’s safety while remaining in their home. On October 18, 2024, the OCA opened a full investigation to determine if a petition should be filed to safeguard the children.

The following report summarizes the information and evidence found during the OCA investigations. These cases are being presented together in a joint Findings and Recommendations Report given the similarities in the family history and the issues identified.

Child One

Family History and Background:

Mother One is the mother of Child One, Sibling One (11), and Sibling Two (10). Siblings’ Father is the father of Sibling One and Sibling Two. Father One is Child One’s father and lived with Mother One at the time of Child One’s death. Father One has two additional minor children, Half-Sibling One (14) and Half-Sibling Two (10), who reside with their mother Siblings’ Mother. 

The scope of this investigation surrounded three CPS investigations, one which occurred prior to Child One’s birth, an investigation completed by CPS at the time of Child One’s birth, and Child One’s death investigation. The family has prior CPS history dating back to 2005, including a Category I removal in 2008 due to substance abuse and the family not participating with CPS. Ultimately, because of Mother One’s continued substance use, concerns for domestic violence, and her lack of participation in the service plan, her parental rights were terminated to two of her other children, in May 2009.

Mother One gave birth to Sibling One in March 2012. A birth match¹ investigation was completed. This investigation resulted in no finding of child abuse or neglect and was dispositioned as a Category IV. Sibling One was tested for substances at birth and was found to have no substances in his system. Additionally, Mother One was no longer in the violent relationship she was involved with in 2008 when her children were previously removed, and her rights were terminated. A Category IV birth match investigation was also completed following Sibling Two’s birth and there was no evidence suggesting Mother One was using substances. 

Between May 2013 and March 2022, Mother One was the subject of three CPS investigations which resulted in no findings of child abuse or neglect. These investigations were dispositioned as Category IV investigations. These investigations concerned potential improper supervision and domestic violence. Prior to Father One’s involvement with Mother One, he was only the subject of one CPS investigation in 2013 involving physical neglect and improper supervision that was closed as a Category IV. 

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_{[1] A birth match is defined by CPS policy as “an automated system that notifies Centralized Intake when a new child is born to a parent who previously had their parental rights terminated in a child protection proceeding, caused the death of a child due to abuse and/or neglect, or has committed a serious act of child abuse and/or neglect.”}

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Review of November 2022 Investigation (MiSACWIS ID: 136953016):

The focus of the OCA’s investigation concerning the Family One starts with a November 2022 CPS investigation. On November 14, 2022, CPS received a complaint which expressed concern Mother One was drinking heavily to the point of intoxication. According to the complaint, on November 14, 2022, Father One woke up and found Mother One intoxicated. Mother One became upset and attacked Father One physically in front of the children. The children got an adult neighbor to assist but witnessed the domestic violence incident occur. The complaint stated Father One was observed with a “busted lip” and scratches to his back, neck and rib area. Additionally, the complaint stated Father One reported pain in his ribs due to Mother One tackling him and holding him down while shoving her knees into his ribs. The referral source informed Centralized Intake Mother One left the home prior to law enforcement arriving and an arrest warrant was being pursued. The complaint was accepted and assigned to Kent County CPS for investigation.

When CPS began their investigation, they contacted the school and were informed Mother One had unenrolled Sibling Two and Sibling One earlier that morning because she was moving to her mother’s home in White Cloud (Newaygo County). Kent County CPS asked Newaygo County CPS to conduct a courtesy home visit² with Mother One, her mother, and the children to verify the children’s wellbeing and to interview Mother One. 

Newaygo County CPS conducted an unannounced home visit to Mother One’s mother’s home on November 16, 2022. CPS was able to see Sibling One and Sibling Two from outside the home, but Mother One would not allow CPS to enter the home. CPS did not interview the children during this visit. Newaygo County CPS interviewed Mother One on the porch of the home. Mother One advised CPS Father One was “psychotic”, and he started saying “crazy things” when he became upset with her. She further advised Father One pushed her, so she pushed him back. Mother One denied the children witnessed any physical altercation, informing CPS the children had been waiting in the car to be taken to school. Mother One advised CPS of previous altercations between her and Father One, which according to Mother One, occurred over the past summer. Mother One denied being intoxicated the morning of the altercation and told CPS she had found out she was pregnant over the same weekend. Mother One admitted to drinking alcohol Saturday prior to finding out she was pregnant. She admitted to having a history of substance abuse but denied any current issues with substances. CPS asked Mother One to submit to a drug screen, but Mother One refused. CPS created an initial verbal safety plan with Mother One that said she planned to continue residing with her mother. CPS documentation of the interview states there was no further safety planning necessary at that time.

On November 23, 2022, White Cloud Elementary school staff informed CPS the children were not enrolled there as previously planned and the mother arranged for the children to return to their previous elementary school. On November 29, 2022, CPS interviewed the children at Cedar Springs Elementary. Sibling One advised CPS they returned home, residing with his mother’s boyfriend, Father One. Sibling One denied having any concerns or that anything happened prior to them going to their grandmother’s home. During CPS’ interview with Sibling Two, Sibling Two advised he does not like it when his mom drinks and smokes, that she argues with his stepdad (Father One), and he tries to stay away from her when she is drinking. He advised CPS he had witnessed them arguing but denied anything physical happening.

During a home visit on December 6, 2022, Father One was interviewed and informed CPS the complaint allegations were accurate. He advised Mother One had been drinking all night and all weekend, was acting hostile with him, and after he tried to push away from her, she assaulted him. Father One told CPS both children witnessed the altercation, and they have witnessed previous domestic violence incidents between the two of them. CPS created a written safety plan with Father One during this home visit. Father One agreed to work with services. Proactive steps were identified in the safety plan stating Father One would continue locking up marijuana and firearms. He further agreed to separate from Mother One and walk to his sister’s home if he and Mother One began arguing. Father One agreed to reactive steps of calling 911 if a fight became physical and not smoking in front of the children. He also agreed to ensure a sober caretaker is present while smoking or under the influence of marijuana.

According to the CPS report, CPS completed a phone consultation with a YWCA liaison regarding the possible domestic violence between Father One and Mother One. The liaison advised CPS based on the information provided, there did not appear to be a pattern of coercive control, but Mother One’s use of violence appeared related to her level of intoxication. It was explained to CPS the liaison’s assessment indicated a significant substance abuse issue for Mother One. The liaison recommended a substance abuse evaluation/service be completed. The liaison also recommended CPS consider in-home services and create a detailed safety plan around Mother One’s alcohol use. CPS documented attempting to offer services to Mother One but she denied needing to participate in any substance abuse related services. 

On December 13, 2022, CPS interviewed Father One’s other children, Half-Sibling One and Half-Sibling Two. Both children advised witnessing arguing between Father One and Mother One, and both adults smoke and drink. 

CPS reviewed the police report from the Kent County Sheriff's Office regarding the incident on November 14, 2022. The police report indicated Father One explained the incident the same way he explained it to CPS. The officers documented the injuries to Father One supported his claim of being assaulted by Mother One. Domestic violence charges were authorized against Mother One and an arrest warrant was issued. 

CPS documented reviewing policy around domestic violence and substance abuse, determining that there was not a preponderance of evidence supporting the allegation of improper supervision. The investigation was closed as a Category IV on January 6, 2023.

During this investigation, CPS did not consider threatened harm as a possible maltreatment. Evidence existed for both historical and current threatened harm. Mother One had her rights terminated in the past due to substance use and domestic violence. This investigation had evidence of current domestic violence and concerns for Mother One abusing alcohol. CPS was informed by the YWCA liaison that Mother One would benefit from substance abuse evaluation and services.

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_{[2] In cases in which parents, caregivers, or children are in other counties, requests for assistance in other counties are made to complete interviews and home visits with the family, known as courtesy home visits.}

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Review of June 2023 Investigation (MiSACWIS ID: 145953327):

On June 19, 2023, CPS received a complaint regarding allegations of physical abuse of Child One. The complaint expressed concern Child One was born and his meconium tested positive for cocaine and THC metabolites. An additional concern was noted in the complaint for Mother One’s parental rights being previously terminated to two of her children. The complaint was accepted and assigned to Kent County CPS for investigation. 

An unannounced home visit was conducted on June 19, 2023, to the family home by the on-call CPS case manager. Mother One, Father One, and all three children were present. Mother One admitted to CPS she used marijuana during her pregnancy and continued her use after discharge from the hospital despite breastfeeding. She denied using cocaine. Father One also advised CPS he smokes marijuana and denied the use of any other substances. Mother One refused to drug screen and CPS did not document offering Father One a drug screen. During the home visit, CPS did not observe a safe sleep environment for Child One, noting that an infant cradle and swing were identified as Child One’s sleeping area. CPS was advised by Mother One that a bassinet had been ordered and would arrive later that week. There was also an unassembled crib observed in the home. CPS documented discussing safe sleep with the family and implemented a detailed safety plan around substance use. It is not documented whether the safety plan was verbal or written.

Additional home visits were attempted by the assigned case manager but were not successful and CPS had difficulty contacting Mother One and Father One. A collateral contact was made to White Pine Family Medicine on July 17, 2023. CPS was advised Child One’s first appointment was canceled and the family no showed for the rescheduled appointment. 

On July 21, 2023, CPS spoke with Siblings’ Father, father of Sibling One and Sibling Two. Siblings’ Father is Child One’s legal father because Mother One and Siblings’ Father were still married when Child One was born. Siblings’ Father advised CPS he was currently driving Mother One to a court hearing which was regarding Mother One violating a no-contact order with Father One. Siblings’ Father denied being aware Child One was born positive for cocaine and marijuana, adding that he was also unaware Mother One was using either substance. CPS completed the vulnerable child assessment³ with Siblings’ Father, and he had no concerns for Child One. CPS then spoke with Mother One who acknowledged not adhering to the no contact order. Mother One told CPS she had transportation issues, which is why the well-child appointments for Child One were missed. CPS informed Mother One of their intent to refer her for Early-On and Maternal Infant Health Program (MIHP) services. Social work contacts in the investigation document referrals to both programs were made but there is no documentation that implementation of the services occurred prior to the investigation closure.

As a result of Child One not experiencing withdrawals and not needing medical intervention after being born positive for substances, CPS found no preponderance of evidence to support physical abuse of Child One. The CPS investigation was closed on July 21, 2023, as a Category IV. The risk level was scored as high-risk level due to Mother One’s prior CPS history, history of domestic violence, and substance use. 

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_{[3] A vulnerable child assessment is required when a child has been identified as vulnerable. The case managers are required to contact one or more individuals, excluding the perpetrator, with knowledge of the child’s needs and document concerns related to potential child abuse and/or neglect, the caregiver’s ability to meet the needs of the child, and if the child has any unmet medical, mental health, or safety needs.}

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Additional Evidence Regarding June 2023 Investigation (MiSACWIS ID: 145953327):

Interviews were conducted with MDHHS staff by the OCA investigator. MDHHS staff informed the OCA this case was difficult to disposition. MDHHS staff advised there were no other maltreatments explored during this investigation, and they were only looking at the maltreatment of physical abuse. MDHHS staff were aware of Mother One’s rights being previously terminated due to substance abuse. MDHHS staff advised the OCA Mother One and Father One were not cooperative with additional home visits after CPS on-call responded, stating this was taken into consideration when the decision was made to close the investigation. MDHHS staff felt that due to the parents not cooperating, they would not be able to service them properly in an open case.

Review of CPS Investigation of Child One’s death, August 2023 (MiSACWIS ID: 149773205):

On August 25, 2023, CPS Centralized Intake received a complaint regarding physical neglect of Child One. The complaint expressed concern that the night prior (August 24, 2023), Mother One and Father One went to bed with Child One. Child One was positioned between Mother One and Father One. When they woke up the morning of August 25, 2023, Child One was unresponsive. Child One was pronounced deceased. The complaint was accepted and assigned to Kent County CPS for investigation. 

CPS began their investigation by contacting the assigned detective at the Kent County Sheriff’s Department. The detective advised CPS it appeared Child One had been deceased for some time as rigor was in his arms and he was pale in color. The detective further informed CPS that Mother One admitted to using marijuana and alcohol the previous night and an empty bottle of alcohol was observed as well as evidence of possible cocaine use.

On August 25, 2023, CPS went with the assigned detective to Mother One’s mother’s home where Mother One was with her children. During the home visit, Mother One admitted to violating the active no-contact order and co-sleeping together with Father One and Child One. Mother One told CPS she was drinking vodka and smoking marijuana the night of Child One’s death. Mother One admitted to CPS she used cocaine prior to her knowing she was pregnant which resulted in Child One being born positive. Mother One agreed to a safety plan for Sibling One and Sibling Two to remain in the care of their father, Siblings’ Father, with supervised visits. Mother One completed a drug screen for CPS. 

CPS and the detective then went to Father One’s home, where Child One’s death occurred. Father One spoke with them outside and did not allow entry to the home. Father One advised CPS he and Mother One had both been drinking and that he had smoked marijuana as well. He advised CPS Mother One drinks almost every night but did not drink while she was pregnant. He acknowledged Mother One was not supposed to be in the home due to the no-contact order. CPS implemented a verbal safety plan with Father One that his children, Half-Sibling Two and Half-Sibling One, would remain in the care of their mother and he would have supervised visitations. He also completed a drug screen for CPS. CPS went back to the home on August 29, 2023, to observe the home conditions. CPS noted the home was cluttered and there was no crib, bassinet, or pack n play observed in the home.

The CPS investigation documents drug screen results for Father One and Mother One both came back positive. Mother One was positive for THC and hydrocodone while Father One was positive for THC and cocaine. CPS summarized the police report which documented charges for involuntary manslaughter related to Child One’s death were submitted to the prosecutor’s office for Mother One. 

Child One’s cause of death was ruled Probable Asphyxia by Suffocation and his death was ruled accidental. CPS found a preponderance of evidence supporting threatened harm of physical neglect of Child One by Mother One and Father One. CPS filed a petition against Mother One, Father One, and Siblings’ Father on December 13, 2023. The children were removed from Father One and Mother One. Sibling One and Sibling Two remained in their father’s care while Half-Sibling Two and Half-Sibling One remained in their mother’s care. The CPS investigation was closed on 01/10/2024.

On January 27, 2025, Mother One pled guilty to Child Abuse Fourth Degree and Controlled Substance Use. On April 23, 2025, Mother One was sentenced to 12 months of probation. 

Child Two

Family History and Background:

Mother Two is the mother of Sibling One (1) and Child Two (3 months TOD). Bio Father is the father of both children but due to a legal marriage at the time of the children’s births, Legal Father was the legal father of the children during case involvement prior to Child Two’s death. 

Mother Two and Legal Father also share three additional children, Legal Father II, Half-sibling One and Two. In 2014, the children were removed from Mother Two and Legal Father’s care due to medical neglect, physical neglect, maltreatment, substance abuse and threatened harm. Following the children entering foster care, Mother Two was substantiated for sexual abuse of Legal Father and Half-sibling One. A mandatory supplemental petition was filed adding these allegations to the court case, however, this was later dismissed. The parents continued to struggle with substance abuse for the duration of the foster care case and failed to address the issues that brought the children into care. In 2016, parental rights were terminated. In April 2019, Mother Two and Legal Father had another child, Half-sibling Three, who was born positive for THC and cocaine. A petition was filed in May 2019 requesting their parental rights be terminated to Half-sibling Three due to the parent’s previous termination of parental rights, the current risk of harm to the child, and the parent’s not rectifying the issues that led to the prior terminations. Parental rights were terminated in September 2019 with no additional services being provided to the parents.

The scope of this investigation begins with the birth of Mother Two’s next child, Sibling One, the birth of Child Two, and Child Two’s death. Both investigations following Sibling One and Child Two’s births were considered birth match investigations but also investigations involving drug positive infants. 

Review of 2022 CPS Investigation (MiSACWIS ID: 125632891):

On March 19, 2022, MDHHS Centralized Intake received a complaint regarding physical abuse, physical neglect, and threatened harm of Sibling One by Mother Two. The complaint stated Mother Two gave birth to Sibling One and there was concern for her not receiving any prenatal care. Additionally, the complaint stated Mother Two was positive for marijuana upon admission, she admitted to smoking marijuana during her pregnancy, and the urine screen completed for Sibling One was positive for THC. The complaint was accepted and assigned to Wayne County MDHHS for investigation.

CPS met with Mother Two and Bio Father at the hospital on March 19, 2022. Mother Two admitted to CPS that she did not receive prenatal care during her pregnancy because she did not have health insurance. She also advised CPS she smoked marijuana during her pregnancy to help with her appetite and nausea. Mother Two advised CPS she previously had her rights terminated to her other children for medical neglect and now she wanted a chance to be a parent. CPS spoke with Bio Father who advised he did not know where Mother Two’s other children reside and told CPS he does not ask questions about her other children. He was aware she smoked marijuana during her pregnancy. Prior to leaving the hospital, CPS spoke with both parents about safe sleep practices and created a safety plan. The parents agreed to a relative, Relative, providing supervision for Sibling One upon their release from the hospital. 

CPS conducted home visits with the family on March 20, 2022, and March 22, 2022, documenting no concerns with the household conditions. Safe sleep arrangements were documented by CPS to be appropriate with a bassinet identified as Sibling One’s sleeping area. CPS suggested Mother Two have Bio Father sign an affidavit of parentage as legally she remained married to Legal Father, making Legal Father Sibling One’s legal father. Mother Two stated her relationship with Bio Father is stable, noting she was in a different place than she was when her parental rights were previously terminated. She agreed to a drug screen for CPS on March 22, 2022. Mother Two’s drug screen came back negative for all substances.

CPS obtained the results of Sibling One’s meconium screen which came back positive for THC and opiates. CPS asked Mother Two about the use of opiates during pregnancy. Mother Two denied the use of any substance other than marijuana. 

CPS spoke with staff from Woodhaven Pediatrics regarding Sibling One as this office was identified as Sibling One’s physician’s office. CPS was advised Sibling One was seen on April 1, 2022, and was doing well. Woodhaven Pediatrics staff explained Sibling One’s formula had to be changed with rice added because Sibling One was not gaining weight. Sibling One was seen again on April 13, 2022, for a weight check and was progressing normally at that time. Woodhaven Pediatrics staff denied knowing Sibling One tested positive for any substances as they did not receive any communication from the hospital. CPS then contacted staff at Henry Ford Hospital and spoke with a nurse. CPS inquired on if Sibling One suffered withdrawals. The nurse advised CPS it was possible Sibling One experienced withdrawals after being discharged home because the meconium results had not been received prior to her discharge. CPS was further advised withdrawal symptoms could include tremors, sneezing, feeding difficulties, not sleeping, and seizures. CPS was also told infants born positive for substances usually struggle with feeding and weight gain. The nurse told CPS, Sibling One’s urine screen was negative for opiates which indicated Mother Two did not have any opiates in her system for the day or two prior to Sibling One’s birth.

The investigation was closed on April 27, 2022, as a Category IV with no preponderance of evidence to support physical neglect, physical abuse, or threatened harm. There is no documented threatened harm assessment completed for this investigation, and the Infant Plan of Safe Care was only listed as “an early on referral was made.” An Infant Plan of Safe Care is required⁴ with cases involving an infant who tests positive for substances at birth, requiring additional assessment and implementation of services for the parents and child. 

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_{[4] Protective Services Manual PSM 716-7 states “In an investigation involving an infant born exposed to substances or having withdrawal symptoms, or Fetal Alcohol Spectrum Disorder (FASD), the case manager must develop an infant plan of safe care that addresses:}

• _{The health and safety needs of the infant.}
• _{The health and substance use treatment needs of the birthing parent or caregiver.}
• _{The needs of all household members, including caregivers who reside outside of the home.}
• _{For example, a parent involved in the care of the infant who does not reside in the home or other consistent caregivers, like babysitters.”}
  

_{Additionally, the Child Abuse Prevention and Treatment Act requires a plan of safe care.}  

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Review of September 2023 CPS Investigation (MiSACWIS ID: 151443186):

On September 28, 2023, MDHHS Centralized Intake received a complaint regarding Child Two’s birth with concerns of physical neglect by Mother Two. The complaint stated Mother Two’s urine drug screen was positive for marijuana and fentanyl. The complaint explained the fentanyl was provided to Mother Two during delivery. It was stated Child Two was not showing any signs of withdrawal, was bonding appropriately with Mother Two, and his meconium screen was pending. This complaint was accepted and assigned for investigation to Wayne County MDHHS.

CPS began their investigation by speaking with the Beaumont Hospital social worker on September 28, 2023. CPS was informed Child Two was not showing any signs of withdrawal and was in the process of being discharged home with Mother Two. The social worker advised Mother Two admitted to not obtaining prenatal care during her pregnancy and using marijuana. CPS completed the vulnerable child assessment with this social worker. 

On September 29, 2023, CPS completed a scheduled home visit with Mother Two, Sibling One and Child Two. Mother Two confirmed she used marijuana during her pregnancy and did not obtain prenatal care because she did not have insurance. She confirmed her parental rights were previously terminated to other children. CPS created a safety plan with Mother Two that she would not use marijuana in the presence of the children and ensure there was a sober caretaker. Records do not indicate if this was a written or verbal safety plan and there is no uploaded safety plan in MiSACWIS. Child Two’s bassinet was observed in the home, and CPS documented safe sleep practices were discussed with Mother Two.

On October 3, 2023, Child Two’s meconium screen was received along with medical records from Beaumont Hospital. Child Two’s meconium was positive for marijuana. CPS conducted an additional visit to the home on October 6, 2023, to meet with Bio Father. Bio Father informed CPS he was aware Mother Two was using marijuana during her pregnancy for nausea but denied knowing how often she was using it. He denied having any concerns for Mother Two or the children. During this visit, Mother Two mentioned she needed to find a new pediatrician because the current one was not accepting new patients. She planned to switch both children to the same pediatrician once she found one. 

CPS sent a medical records request to Caring Pediatrics after being advised this was the new office that would see both Sibling One and Child Two. There was no documentation in the CPS investigation regarding any medical records received from this office. There are no documented efforts by CPS to obtain records from the previous pediatrician’s office, Woodhaven Pediatrics, and no vulnerable child assessment was completed concerning Sibling One.

The investigation was closed on November 8, 2023, as a Category IV with no preponderance of evidence supporting physical neglect of Child Two by Mother Two. The newborn toxicology section of the CPS history and trends was checked “not applicable” in the system; therefore, no plan of infant safe care was documented within the case as required by the Michigan Plan of Safe Care Protocol. Additionally, the OCA verified no threatened harm assessment was completed.

Review of CPS Investigation of Child Two’s death, December 2023 (MiSACWIS ID: 156213404):

On December 27, 2023, MDHHS Centralized Intake received a complaint regarding Child Two’s death, with concerns of physical neglect, from two referral sources. The first referral source stated Child Two was found unresponsive at the home and was not able to be resuscitated. According to Mother Two, Child Two was last known to be alive around midnight, and she thought she may have rolled over on top of him. The second referral source advised Child Two was found unresponsive after co-sleeping in bed with Mother Two. Concerns were further expressed for pillows and blankets being in the shared bed. The referral source advised Mother Two admitted to drinking and her PBT test was 0.073. The complaint was accepted and assigned to Wayne County MDHHS for investigation. 

On December 27, 2023, CPS began their investigation and was informed by the investigating detective from the Taylor Police Department that Mother Two was still intoxicated that morning at the hospital. CPS was able to confirm with the detective that Mother Two’s blood alcohol content was a 0.073. The detective advised charges would be pursued due to her being intoxicated at the time of the death and having a history with CPS.

On December 27, 2023, CPS made an unannounced home visit and spoke with Relative, who is Bio Father’s mother. Records state Mother Two and the children resided with Relative during these events. During the interview, Relative advised CPS Mother Two was not home, and Bio Father resided with his uncle. Relative was unaware if Mother Two was under the influence of substances or intoxicated the night of Child Two’s death, admitting that she herself was in her room under the influence. CPS noted Relative was slurring her words during the interview. Relative completed a drug screen for CPS. During the home visit, CPS documented observing a 750ml bottle of Seagram’s 7 whiskey. There was a crib observed in the home containing items inside making it an unsafe sleep environment. 

On December 28, 2023, CPS completed a scheduled home visit with Mother Two, Bio Father and Sibling One. Bio Father advised not seeing Child Two or Sibling One since Christmas until Child Two’s death occurred. He told CPS he had been living in and out of the home since January 2023 and was co-parenting well with Mother Two. Bio Father advised being with his girlfriend at the time Mother Two called him stating Child Two was flipped over. He told CPS that when he got to his mother’s home, Child Two was already taken to the hospital, and he was informed Child Two had passed. Bio Father denied knowing if Mother Two was under the influence of any substances and denied knowing how often his mother drank alcohol.  

Mother Two advised CPS she consumed approximately four to five shots of Seagram’s 7 Whiskey and stopped drinking around 9pm. She did not recall using her marijuana pen that night. She explained she went to bed around 12am and Child Two was in his crib. A few hours later, he woke up fussy, so she brought him into bed with her and fell asleep. Mother Two advised CPS she woke up around 5am to find Child Two face down in the bed and limp. Mother Two completed a drug screen which later came back positive for THC.

On December 28, 2023, Sibling One was placed in a Temporary Voluntary Arrangement (TVA) with her father, Bio Father. CPS contacted Legal Father on January 26, 2024 due to him being legally married to Mother Two at the time the children were born, making him the legal father of both Sibling One and Child Two. Legal Father confirmed still being legally married to Mother Two and advised CPS the children were not biologically his children. He advised CPS he has never assumed responsibility for the children as they are not his. CPS informed him that because he was legally the father, he would be included on the petition filed with the court concerning Sibling One. CPS filed a mandatory termination petition on February 13, 2024. During the court case, Bio Father submitted to DNA testing to become the legal father of Sibling One.

The investigation was closed on February 16, 2024, as a Category I with a preponderance of evidence to support physical neglect of Child Two and Sibling One by Mother Two, as well as placing a child at unreasonable risk of both children by Legal Father.

The OCA obtained the autopsy completed for Child Two. Child Two’s cause of death could not be determined, and his death was ruled indeterminate.

Child Three

Family History and Background:

Mother Three is the mother of Child Three (14), Sibling One (16), Sibling Two (9) and Sibling Three (1). In 2018, Child Three, Sibling One, and Sibling Two were removed from Mother Three’s care due to concerns for improper supervision related to her substance abuse. After failing to participate in services through the foster care case and continuing to abuse substances, Mother Three released her parental rights to Child Three and Sibling One. Child Three and Sibling One were adopted by their maternal grandmother, Maternal Grandmother in 2021. Sibling Two was placed in the care and custody of her father, Tyjuan and the foster care case closed in 2022. On May 19, 2024, Mother Three gave birth to Sibling Three. 

This case originally came to the attention of the OCA with concerns for Maternal Grandmother’s ability to care for Child Three and Sibling One due to them having extensive behavioral needs and both being involved in the Juvenile Justice system. There were additional concerns Mother Three was residing in Maternal Grandmother’s home with the children, and had given birth to a new baby, Sibling Three, who was positive for substances. There were concerns for the safety of Sibling Three in Mother Three’s care.  

Review of May 2024 CPS Investigation (MiSACWIS ID: 171823448):

Sibling Three was born positive for high levels of cocaine, but she did not experience withdrawal symptoms. Mother Three admitted to using cocaine during her pregnancy prior to finding out she was pregnant and after finding out. A CPS investigation began on May 21, 2024, as a result of Sibling Three being born positive for substances, and Mother Three losing custody of other children in the past. The complaint was assigned to Calhoun County for investigation. 

During CPS’ investigation, Mother Three completed two drug screens, both of which came back positive for marijuana and cocaine. The second drug screen was completed on July 1, 2024. The levels of cocaine were so high, forensic fluids contacted CPS to inform them of the high levels and concern for Mother Three, as the level she tested positive for of cocaine can be lethal. CPS documented a safety plan was implemented as part of the Infant Safe Care Plan, noting that Mother Three agreed to not use illegal substances or keep them in the home, she will utilize safe sleep practices, the child will be placed in a crib/pack and play or bassinet, the children will be supervised by a sober caretaker, and Sibling Three will attend all doctor appointments.  

Due to Sibling Three not experiencing any withdrawal from cocaine, CPS found no preponderance of evidence to support physical injury of Sibling Three by Mother Three. CPS also documented Maternal Grandmother was able to be a sober caretaker for Sibling Three. The investigation was closed on June 14, 2024, as a Category IV. CPS referred Mother Three to work with Early on and a maternal infant health program called Twenty Hands. Mother Three initially told CPS she was not willing to complete substance abuse services but later agreed to seek services herself through a provider called Summit Point.  

During CPS’ investigation, CPS did not complete an adequate Infant Plan of Safe Care for Sibling Three per policy. Referrals were completed for Early On and a maternal infant health program, however, CPS did not ensure implementation of these services as required by law and policy. CPS also did not discuss Mother Three’s participation in substance abuse treatment with her service provider, as required by law and policy.  

Additionally, CPS did not consider the maltreatment of threatened harm of placing a child at unreasonable risk and only investigated the complaint as identified by Centralized Intake, which was physical injury. Protective Services Manual (PSM) 712-1 states if CPS investigators “learn of a new allegation, suspects new maltreatments or identifies additional household victims, they must thoroughly investigate those allegations as part of the active investigation and document the findings in the disposition”. Though there was evidence of threatened harm of placing a child at unreasonable risk, no additional maltreatment was added to the CPS case.  

Because Mother Three previously voluntarily terminated her parental rights to her other children, a legally mandated petition was not required. However, the OCA believes a petition was necessary to safeguard Sibling Three given Mother Three’s extensive, continued drug use and her CPS history. Although Mother Three was utilizing Maternal Grandmother as support, Maternal Grandmother had her own set of issues and concerns that needed her attention relating to her legal minor children, Child Three and Sibling One.

Review of the September 2024 CPS Investigation (MiSACWIS ID: 187053487): 

A new complaint was received on September 26, 2024, with concerns Mother Three was physically neglecting and placing Sibling Three at unreasonable risk. There were concerns Mother Three was leaving Sibling Three while she continued to use drugs. The complaint was assigned to Calhoun County for investigation. Mother Three admitted she last used cocaine two weeks earlier, she used on the weekends, was using drugs less often and said she used outside of the home away from the children. Mother Three advised when she would leave the home to use drugs, she would leave Sibling Three in the care of Maternal Grandmother.  During this time, Maternal Grandmother was continuing to have her own CPS investigations, and concerns related to Sibling One and Child Three.  

CPS made a referral for Mother Three to work with Families First and a separate referral for Maternal Grandmother to work with Families First. When the OCA began their investigation, Families First was not working with Mother Three and was only working with Maternal Grandmother. Mother Three continued to leave Sibling Three in Maternal Grandmother’s care for days at a time while she went and used substances. The OCA conducted a meeting with Calhoun County on October 21, 2024, expressing concern for Sibling Three being left in the home. The OCA expressed a petition was likely needed due to Mother Three’s continued drug use and her prior CPS history.  

On October 24, 2024, CPS filed a petition removing Sibling Three from Mother Three’s care. Maternal Grandmother was not approved for placement due to her own CPS investigations and the needs of Sibling One and Child Three. Sibling Three was placed in an unrelated, unlicensed foster home. A supplemental petition was filed on February 11, 2025, requesting to terminate the parental rights of Mother Three to Sibling Three as Mother Three had not had contact with the department or seen Sibling Three since the day Sibling Three was removed. A termination trial was held on March 12, 2025, and Mother Three’s parental rights to Sibling Three were terminated. 

OCA Analysis:

In all three OCA investigations, the OCA observed case managers did not assess or investigate threatened harm. In each of the family circumstances, threatened harm existed as the parents had prior terminations for substance use and there were current concerns for ongoing substance use. In Family One’s case, Mother One also had a history of domestic violence which was another factor that led to her prior terminations. The circumstances during CPS’ involvement were related to domestic violence. 

Additionally, the OCA noticed investigations involving birth match complaints were not adequately completed, and infant safe care plans were not put into place as required. 

Policy Review:

As part of the OCA investigations, the OCA investigator reviewed historical and current MDHHS policy manuals regarding the issues identified in the cases involving Child One, Child Two and Child Three. The following section is a review of what MDHHS policy says regarding birth match investigations, threatened harm, the DHS-3 Sibling Evaluation Form, and investigations involving substances/substance exposed infants.

Birth Match: When reviewing PSM 713-08, Special Investigation Situations, birth match is defined as an automated system that notifies Centralized Intake when a new child is born to a parent who previously had their parental rights terminated in a child protection proceeding, caused the death of a child due to abuse and/or neglect, or has committed a serious act of child abuse and/or neglect. Additionally, policy explains how to manually add a birth match. There is no guidance or outlined policy for case managers on how to investigate a birth match nor is there reference to PSM 711-2 which identifies a birth match as historical threatened harm. This policy refers case managers to PSM 713-11, Assessments, for additional guidance on assessing threatened harm. 

A historical version of PSM 713-08, dated 06/10/2010, previously instructed case managers on what was required when a parent has a prior termination of parental rights, and a new child is born. This version of policy identified the investigation focus should be on the reasons for the prior removal and/or termination of parental rights, how the family has addressed those specific issues, the differences and similarities between prior and current child abuse/neglect allegations, and use specific facts to demonstrate the family has, or has not, resolved the risk and safety issues that resulted in the previous court actions. This guidance no longer occurs in CPS policy.

Threatened Harm: PSM 711-2, Definitions, Responsibilities and Maltreatment Types, defines threatened harm as “an action, accidental or non-accidental, inaction or credible verbal threat by a person responsible and absent intervention, there is high probability that harm will occur.” The policy further states a child found in a situation where harm is highly probable to occur based on a current or historical circumstance; historical circumstance examples include a confirmed case that included an egregious act of child abuse and/or neglect, a confirmed case that included threatened harm, prior termination of parental rights and conviction of crimes against children. Current circumstance examples include allegations of threatened harm in the current referral, child left home alone, domestic violence, a residence where drugs are manufactured and/or sold. Case managers are directed to PSM 713-11 for guidance on assessing threatened harm.

PSM 713-11 Assessments, dated 08/01/2023, details five areas that the caseworker must assess when threatened harm has been discovered, alleged, or confirmed. These five areas include the “…severity of the past behavior, length of time since the past incident, evaluation of services, benefit from services (including if conditions have been rectified), and vulnerability of child(ren).” The policy also directs caseworkers to PSM 715-3 Family Court: Petitions, Hearings, and Court Orders for more information on potential mandatory legal action. 

DHS-3 Sibling Evaluation Form: Prior to 12/01/2019, PSM 715-2 required a DHS-3 Sibling Evaluation Form be completed on all cases where a child remains in the home when sibling(s) are/were permanent wards because of a child abuse and/or neglect court action. Policy also required the DHS-3 to be reviewed and signed by a second-line approver prior to the approval of the investigation, which ensured upper management oversight on birth match investigations. 

Current policy no longer requires the DHS-3 to be completed when a child is left in the home when sibling(s) were permanent wards, removing the second-line oversight on these decisions.

Investigations involving substances/substance exposed infants: PSM 716-7, Cases Involving Substances, effective 08/01/2023, discusses parental substance use and/or positive toxicology in an infant does not in and of itself indicate child abuse and/or neglect has occurred or that the infant has experienced serious harm. Policy states case managers must reach conclusions based on the presence or absence of evidence of child abuse and/or neglect as defined in PSM 711-4. PSM 716-7 then provides case managers with things to consider when determining if child abuse and/or neglect occurred to assist with their assessment. This policy also provides the following list of additional requirements case managers must complete for investigations involving infants exposed to substances:

• Contact with medical staff to obtain the following information, if available:
  
  • Results of medical tests indicating infant exposure to substances and/or alcohol.
  • The health and status of the infant.
  • Documented symptoms of withdrawal experienced by the infant.
  • Medical treatment the infant or birthing parent may need.
  • Observations of the parent's care of the infant and the parent's response to the infant's needs.
  • To be considered serious physical abuse, a medical practitioner must confirm the infant's exposure, and any related symptoms meet the definition of serious physical harm.
  • Interview with the infant's parents and any relevant caregivers to assess the need for a referral for substance use disorder prevention, treatment, or recovery services.
  • Assessment of the parent's capacity to adequately care for the infant and other children in the home.
  • Coordination between the case manager, medical professional(s) and family to co-develop an Infant Plan of Safe Care (POSC) if necessary.
  • Contact with substance use treatment providers, if applicable, to determine the parent's level of participation.

PSM 716-7 also identifies guidance for case managers to assist with assessing parenting capacity related to a parent’s substance use, whether child abuse and/or neglect occurred and how to best address safety. This guidance states case managers should consider the following:

• Does the use extend to the point of intoxication, unconsciousness, or inability to make appropriate decisions for the safety of their child(ren)?
• Does the use of substances cause reduced capacity to respond to the child's cues and needs?
• Is there evidence to demonstrate difficulty regulating emotions or controlling anger?
• Are the following emotions regularly demonstrated?
  • Aggressiveness.
  • Impulsivity.
• Is there an appearance of being sedated or inattentive?
• Is there demonstrated ability to consistently nurture and supervise the child(ren) according to their developmental needs?
• Do co-occurring issues exist which would impact parenting or exacerbate risk such as:
  • Social isolation.
  • Poverty.
  • Unstable housing.
  • Domestic violence.
• Are there supports such as family and friends who can care for the child(ren) when the parents are not able to? Are the parents willing to use their supports when necessary?
• Has the use of substances caused substantial impairment of judgement or irrationality to the extent the child was abused or neglected?
• Any other factor which demonstrates inability to protect the child(ren) and maintain child safety.

PSM 716-7 further requires case managers to document an Infant Plan of Safe Care during investigations involving an infant born exposed to substances or having withdrawal symptoms, or Fetal Alcohol Spectrum Disorder (FASD). It is required for the plan to address the health and safety of the infant, the treatment needs of the substance using parent or caregiver, and the needs of other household members or caregivers. Regardless of the case disposition, an Early On referral is required to be referred in addition to another service provider. It is required the referrals and implementation of these services be documented in the Newborn Toxicology section located in CPS History and Trends of the case management system.

Additional Research:

During the OCA’s investigation, additional research was conducted concerning prenatal drug exposure and the effects on children. There are numerous research studies that show prenatal drug exposure can have long term effects on children that can continue well into their childhood. 

One research study, Prenatal Tobacco, Marijuana, Stimulant, and Opiate Exposure: Outcomes and Practice Implications in Clinical Perspectives- Prenatal Drug Exposure , discusses Neurobehavioral Teratology , which is the “…framework used to study prenatal drug exposure to a foreign agent on a child’s central nervous system (CNS) and behavior. An important principle of teratology is that the harm caused by a toxic agent is a function of several factors, including the individual’s genetic makeup, the fetal and postnatal environment, the dose of the agent, and the developmental state of the fetus at the time of exposure” (Sonia Minnes, July 2011). The article continues to discuss that the “…damage to the child’s CNS during the prenatal period continues to have effects through fetal, neonatal, infant, and childhood development; and CNS injury may result in behavioral impairments rather than physical birth defects.” The research article continues to discuss how “…the child’s CNS disruption can hinder their ability to reach full developmental and academic potential directly and in combination with parental and environmental factors.” 

According to the research article, “drug metabolites interact with an individual’s genetic make up to influence cognitive development and behavior”, and “active metabolites can penetrate the fetal blood-brain barrier and interfere with early neuronal cell development or cause neuronal death (Lee et al., 2008).” Research conducted has also shown maternal drug abuse also has indirect effects on the fetus, “…for example, crack cocaine, heroin, tobacco, and marijuana cause vasoconstriction that restricts the fetal oxygen supply.” “Neonatal abstinence syndrome (NAS), occurs after opiate use during pregnancy, puts the infant under physiological stress that increases the risk of health and possibly developmental problems. Neuroimaging studies have revealed evidence of physiological brain changes in prenatally drug-exposed children, some of which correlated with the results of behavioral assessments.” 

The research article includes information on the potential effects on birth and pregnancy outcomes by substance. For marijuana, mild withdrawal symptoms and poor autonomic control (ability to adjust one’s level of alertness as required for a task) were some observations made. “Prenatal marijuana exposure had persistent negative effects through age 16 on higher-order thinking, including problem solving, memory, planning, impulsivity and attention (Fried, 2002, Fried, Watkinson, and Gray 2003, Goldschmidt et all., 2008, Richardson, Goldschmidt, and Larkby, 2007). Another concern noted in the research is “prenatal marijuana exposure may have long-term emotional and behavioral consequences. At age 10, children who have been exposed to the drug during their first and third trimester of gestation reported more depressive symptoms than those unexposed controls (Gray, 2005).” Prenatal marijuana exposure also at least doubled the risk of both tobacco and marijuana use in 16–21-year-olds. 

For cocaine, neonatal/in Sibling Three observations included early neurobehavioral deficits related to orientation, state regulation, autonomic stability, attention, sensory and motor asymmetry, jitteriness, poor clarity of infant cues during feeding interaction, delayed information processing and general cognitive delay. Childhood observations included lower nonverbal perceptual reasoning, lower weight for height, lower weight curve trajectories, attention problems, and disruptive behaviors by self-report and caregiver report. According to the research article observations were made that prenatal exposure to methamphetamine results in poor movement quality (with third trimester exposure), lower arousal, increased lethargy, increased physiological stress, and no mental or motor delay in infants and toddlers. Opiates, have effects on the neonatal abstinence syndrome, result in less rhythmic swallowing, possible delays in general cognitive functioning, result in anxiety, aggression, feelings of rejection and disruptive or inattentive behavior.  

The research article also explored interventions for drug exposed children, noting most of the studies conducted have been on services provided to the substance-abusing mothers by community nurses designed to educate and support mothers in improving their parenting skills, their home environments, and the child’s development. The research article noted one study in particular which had “…nurses visiting substance-abusing mothers and their infants every other week for the first 18 months of a child’s life (Black et al., 1994)” discussing “…child development, child care and safety, modeling parent child activities that promote child development; addressed mother’s concerns, such as relationship problems, affordable housing, and financial issues; and provided information about community resources and advocacy.” The study found “…mothers who received the intervention were marginally more likely than a control group to be drug-free, keep primary health appointments, be more emotionally responsive, provide a stimulating home environment, and score lower on a measure of child-abuse potential at the end of the 18-month study period.”

The OCA also received the National Abandoned Infants Assistance Resource Center’s fact sheet on Perinatal Marijuana Exposure  (PME). This document raises concerns about the impact of maternal marijuana use on the developing fetus, through early childhood, noting that “marijuana is the most common illicit drug used by pregnant women.” Tetrahydrocannabinol (THC) is the major psychoactive component of marijuana that crosses the placental barrier. “One-third of THC in the mother’s blood is estimated to cross the placental barrier.” THC can also be transferred through the mother’s breast milk. THC content of marijuana has substantially increased over the past 20 years, resulting in the fetuses of marijuana-using mothers being exposed to significant amounts of THC. The fact sheet discusses “…recent research findings point to some adverse biological and developmental consequences of PME, including:

• an association between aspects of nervous system functioning and prenatal exposure to marijuana resulting in compromised patterns found in Sibling Three (e.g., poor sleep patterns, easily startled into agitation) and in childhood (e.g., hyperactivity, inattention, impulsivity);
• persistent negative effects (birth through age 16) on executive functioning, in particular, on attention, problem solving, memory and planning;
• increased levels of depressive symptoms at age 10,
• greater likelihood to initiate and use marijuana at higher levels by age 14 and a doubled risk of marijuana and tobacco use at ages 16-21
• possible harm to embryonic development, as early as two weeks after conception
• possible higher risk of exhibiting a compromised immune system; and
• possible low birth weight or preterm birth.

In December 2024, the American Academy of Pediatrics issued an article, Sleep-Related Sudden Unexpected Infant Death Amount Infants Prenatally Substance Exposed  which explored maternal substance use during pregnancy and the risk of sudden unexpected infant death (SUID), including through unsafe sleep practices. The study used data concerning SUID with sleep-related deaths of infants between 2015 and 2020 and included both infants who were born with prenatal exposure to substances or infants non-exposed. The study found that “of 2010 infants who experienced sleep-related deaths, 283 (14%) were prenatally exposed. More than half of deaths involved an adult bed (52%, n=1045) or surface sharing with an adult (53%, n=1074). Supervisors of prenatally exposed infants were disproportionately impaired at infant death versus nonexposed (34%, n= 97 vs 16%, n=279). Statistically significant associations between prenatal exposure history and vulnerability factors (insurance, child welfare involvement, intimate partner violence, health care barriers) were identified (p <.05).” The study concluded “sleep-related SUID across infants prenatally exposed versus nonexposed differ in sleep environment characteristics and contributory social vulnerability. Disproportionate sleep environment hazards (surface sharing, supervisor impairment) are identified amount prenatally exposed infants that should compel targeted prevention efforts, including safe sleep messaging, discouraging surface sharing, and engaging support persons during impairment periods.” 

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_{[5] Minnes, S., Lang, A., Singer, L., Mandel School of Applied Social Sciences, Case Western Reserve University, & School of Medicine. (2011). Prenatal tobacco, marijuana, stimulant, and opiate exposure: Outcomes and practice implications. In Addiction Science & Clinical Practice [Journal-article]. https://nationaldec.org/wp-content/uploads/214-Article.pdf} 

_{[6] Teratology is “the study of congenital abnormalities, their causes and the treatment options available for those affected. These abnormalities are principally the result of infections, physical agents, metabolic conditions or chemicals and can cause death as well as physical, behavioral, and intellectual deficits.” Belanger BG, Lui F. Embryology, Teratology TORCH. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545148/}

_{[7] Jutras-Aswad, D., DiNieri, J. A., Harkany, T., Hurd, Y. L., National Abandoned Infants Assistance Resource Center, & University of California, Berkeley. (2009). Perinatal marijuana exposure. In European Archives of Psychiatry and Clinical Neuroscience (Vols. 259–7, pp. 395–412) [Journal-article]. University of California, Berkeley. https://nationaldec.org/wp-content/uploads/165-Article.pdf} 

_{[8] Stephanie Anne Deutsch, Claire E. Loiselle, Jobayer Hossain, Allan De Jong; Sleep-Related Sudden Unexpected Infant Death Among Infants Prenatally Substance Exposed. Pediatrics December 2024; 154 (6): e2024067372. 10.1542/peds.2024-067372}

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OCA Data:

The OCA began tracking emerging trends when a new case management system, Michigan Child Advocate Investigation System (MiCAIS) was implemented at the OCA in July 2020. The OCA began tracking the emerging trends of unsafe sleep practices and infants born drug positive in July of 2020.

Since the OCA began tracking these emerging trends, the OCA has reviewed 1,714 child deaths. 256 of the child deaths reviewed included children who were born drug positive. 179 of these child deaths included children were born positive for marijuana only. 

543 of the child deaths reviewed included the death of an infant who died in an unsafe sleep environment. 119, or 21.9% of the 543, children were born positive for substances at birth. 88, or 16% of 543 children were born positive for marijuana only. 

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The child advocate finds the 2022 investigation concerning Family One did not follow the requirements for assessing threatened harm per, PSM 713-11. Mother One had her rights previously terminated to children due to substance use and domestic violence, and there were concerns of both present during the 2022 investigation.	MDHHS Agrees.
The child advocate finds the 2023 investigation concerning Family One did not consider and apply threatened harm as it related to Mother One’s substance use and her prior terminations. MDHHS did not identify an infant plan of safe care for Child One. Staff did not accurately assess parenting capacity as it related to Mother One’s substance use.	Finding 2 (1): MDHHS agrees. The Infant Plan of Safe Care did not fully meet the expectations outlined in policy. While there were referrals to services to Maternal Infant Heath Program and Early On, the county did not follow through to document implementation of those services. MDHHS Finding 2 (2): MDHHS agrees.
The child advocate finds MDHHS did not follow PSM 713-01, CPS Investigation- General Instructions and Checklist during the 2023 investigation by not observing and documenting a proper sleeping environment for Child One. Additionally, CPS did not assist the family in obtaining a proper sleeping environment.	MDHHS agrees to the extent that the specialist did not verify that the family received nor assembled the bassinet.
The Child Advocate finds the 2023 investigation concerning Family One inadequately completed the vulnerable child assessment by asking the vulnerable child questions of Child One’s legal father, who was unaware of his medical needs or history.	MDHHS disagrees. Vulnerable child policy requires a specialist to contact one or more individuals, excluding the perpetrator, with knowledge of the child’s needs. The specialist completed the vulnerable child policy questions with the legal father of the child and not an alleged perpetrator. His demonstrated a comprehensive understanding of the child’s needs. Although the documentation did state, “There are no unmet medical and/or safety needs is aware of,” this does not indicate a lack of knowledge or awareness. Rather, it indicates a certainty about the medical and safety needs that he does possess.
The Child Advocate finds the 2022 investigation concerning Family Two, did not properly assess threatened harm following Sibling One’s birth. No threatened harm assessment was completed to determine the severity of the past behavior, length of time since the past incident, evaluation of services, benefit from services (including if conditions have been rectified), and vulnerability of child(ren).	MDHHS agrees.
The Child Advocate finds the 2022 investigation concerning Family Two did not follow MDHHS policy PSM 716-7. The infant plan of safe care was documented to be completed by an Early-On referral being made. No additional services were referred or implemented. Staff did not follow the guidance for assessing parenting capacity as it related to Mother Two’s substance use.	MDHHS Agrees.
The Child Advocate finds the 2023 investigation concerning Family Two did not properly assess threatened harm following Child Two’s birth. No threatened harm assessment was completed to determine the severity of the past behavior, length of time since the past incident, evaluation of services, benefit from services (including if conditions have been rectified), and vulnerability of child(ren).	MDHHS Agrees.
The Child Advocate finds the 2023 investigation concerning Family Two did not follow MDHHS policy PSM 716-7. An infant plan of safe care was not completed following Child Two’s birth, though required by Michigan’s Plan of Safe Care Protocol and policy. Staff did not follow the guidance for assessing parenting capacity as it related to Mother Two’s substance use.	MDHHS Agrees.
The child advocate finds the May 2024 investigation concerning Sibling Three did not consider and apply threatened harm as it related to Mother Three’s continued drug use and her prior release of parental rights for drug use.	MDHHS disagrees. Threatened harm as defined by policy is “An action, inaction or credible verbal threat by a person responsible and absent intervention, there is a high probability that harm will occur.” The investigator thoroughly assessed all aspects of historical threatened harm. The investigator assessed past behavior, the vulnerability of the child, her support system at the time of the investigation, her willingness to comply with services at the time of the investigation, and her criminal history. In this case, another appropriate adult was also living in the home and assisting in the care of the child. She also remained engaged and cooperative throughout the prevention case.
The child advocate finds the May 2024 investigation concerning Sibling Three did not follow MDHHS policy PSM 716-7. The infant plan of safe care was documented to be an Early On referral, Mother Three agreeing to not use substances in the home, utilizing safe sleep practices, the children being supervised by a sober caretaker, and ensuring Sibling Three is taken to all doctor’s appointments. Staff did not follow the guidance for assessing parenting capacity as it related to Mother Three’s substance use.	MDHHS disagrees. Mother Three admitted to her past and current use of substances and agreed to a safety plan that included a provision in which she would always have a safe and sober caregiver for Mother Three was also aware of and agreed to this safety plan, and there were no substance abuse concerns with Mother Three. All records show that the family complied with this safety plan throughout the case. Furthermore, records indicated Mother Three would use substances only when she left the home. There was no evidence of Mother Three using substances in the home, nor of her providing care to while under the influence. Mother Three agreed to participate in services to address her substance use, including random drug screens, as well as Families First, to which she was referred in October of 2024. This was in accordance with PSM 716-7 which states, “Substance use by a parent/caregiver may be a risk factor for child maltreatment. For cases involving known substance use, case managers must evaluate its impact on child safety. Substance abuse is a mental health disorder. Case managers should assist the parent/caregiver in accessing relevant supports and services.” Additionally, a referral involving only substance use is insufficient for investigation or confirmation of child abuse or child neglect. Mother Three presence in the home is a positive support and provided necessary care to the baby, ultimately mitigating the Department’s immediate concerns of substance abuse and its effect on her ability to care. When Mother Three did not follow through with provided services, a petition was filed in accordance with policy, and removal of was granted by the Court. The infant plan of safe care stated only an Early On referral, yet the investigative report documented multiple other service referrals. In a contact dated 07/11/2024, Mother Three was provided with information on a substance abuse assessment; an intake date was confirmed on 08/01/2024. On 07/19/2024, a referral was made for a home visiting program. At the conclusion of the investigation, a referral was made to the local county’s prevention team. A prevention specialist was assigned to the family.
The child advocate finds MCL 722.638 states the department shall submit a petition for authorization by the court if (b) The department determines that there is risk of harm, child abuse, or child neglect to the child and either of the following is true: (i) The parent's rights to another child were terminated as a result of proceedings under section 2(b) of chapter XIIA of 1939 PA 288, MCL 712A.2, or a similar law of another state and the parent has failed to rectify the conditions that led to the prior termination of parental rights. Family One & Family Two had previous terminations, and the issues that prompted those actions were not resolved.	MDHHS Agrees.
The child advocate finds MDHHS did not adhere to MCL 722.638 because threatened harm assessments were incomplete or not completed.	MDHHS Agrees.
The child advocate finds PSM 713-08, policy regarding how to conduct Birth Match investigations is inadequate and does not provide guidance to case managers on how to properly conduct these investigations.	MDHHS agrees in part. While birth match investigations must be conducted in accordance with PSM 713-01, like any other investigation, MDHHS will evaluate whether additional policy guidance is needed to specifically address birth match investigations.
The child advocate finds historical policy, 713-08 dated 06/10/2010, had guidance for case managers regarding what was required when a parent has a prior termination of parental rights, and a new child is born. This guidance provided more clear and direct questions to assess than the current questions within the threatened harm policy.	MDHHS agrees in part. Although many elements of the 2010 policy remain present in the current threatened harm policy (PSM 713-11), MDHHS will evaluate whether additional policy enhancements are needed to provide clearer guidance for staff assessing these situations.
The child advocate finds that additional efforts are needed to ensure the safety and well-being of children born to parents who have previous terminations of their parental rights.	MDHHS agrees in part. While the Department recognizes the opportunities for improvement in this specific case, the recommendation will be reviewed further to determine if this is a systemic issue and how best to mitigate the area of concern.
The child advocate finds PSM 713-08 changed and no longer requires the DHS-3 Sibling Placement Evaluation form be completed when a new child is born to a parent who has prior terminations of parental rights. This ceased the requirement for second line oversight and approval on birth match investigations.	MDHHS agrees.
The child advocate finds the OCA has reviewed 1,714 child deaths since MiCAIS was implemented in July 2020. 543, or 31.6% of these deaths involved an infant who died in an unsafe sleep environment. 256 of the total deaths reviewed involved children who were born positive for substances, with 179 of those being born with marijuana exposure only. 21.9% of the infants who died in an unsafe sleep environment, were born positive for substances. 16% of infants who died in an unsafe sleep environment were born with only marijuana exposure.	No response needed

 

Recommendations:

Recommendation	MDHHS Response to Recommendation
The child advocate recommends MDHHS amend PSM 713-11 pertaining to threatened harm assessments to include the question: does the threatened harm include a prior termination of parental rights. If this is answered yes, the following additional steps should be required and answered by the case manager. The prior case and court orders leading to the prior termination of parental rights should be reviewed and summarized by the case manager. How has the parent addressed those specific issues? What are the differences and similarities between prior and current child abuse and/or neglect allegations? Detail specific facts that demonstrated whether the family has, or has not, resolved the risk and safety issues that resulted in the previous court actions. Is a mandatory petition required per MCL722.638?	MDHHS agrees in part. Although this recommendation closely aligns with existing policy on threatened harm assessments, MDHHS will review it to determine whether further enhancements are needed to strengthen guidance for these investigations.
The child advocate recommends MDHHS require second line or director approval on birth match investigations to provide additional oversight in decision-making on cases involving new infants born to parents who have previously lost their parental rights.	MDHHS agrees in part. While the Department recognizes the opportunities for improvement in this specific case, the recommendation will be reviewed further to determine if this is a systemic issue and how best to mitigate the area of concern.
The child advocate recommends MDHHS amend PSM 716-7 to add new language requiring CPS specialists to contact and speak with the substance exposed infant’s treating medical provider. When doing so, CPS specialists should determine the status of the infant’s physical health, if they are receiving any medical treatment for withdrawal symptoms, what that medical treatment involves, and if the infant’s exposure and any related symptoms meet the definition of serious physical harm. Policy can further define medical staff or practitioners, to mean the child’s treating medical provider who has received formal training to practice medicine. This should include individuals such as a physician, nurse, or a licensed medical provider who are qualified to report about the infant’s physical health, medical treatment being provided to the child for withdrawal symptoms, and what the medical treatment involves.	MDHHS disagrees. PSM 716-7 already requires that investigations involving infants exposed to substances or alcohol also include the following: Contact with medical staff to obtain the following information, if available: ο Results of medical tests indicating infant exposure to substances and/or alcohol. The health and status of the infant. Documented symptoms of withdrawal experienced by the infant. Medical treatment the infant or birthing parent may need. Observations of the parent's care of the infant and the parent's response to the infant's needs. To be considered serious physical abuse, a medical practitioner must confirm the infant's exposure, and any related symptoms, meet the definition of serious physical harm. Interview with the infant's parents and any relevant caregivers to assess the need for a referral for substance use disorder prevention, treatment, or recovery services. Furthermore, medical practitioner is defined in PSM 711-4 as follows: A physician or physician’s assistant licensed or authorized to practice under part 170 or 175 of the public health code, MCL 333.17001 to 333.17088 and MCL 333.17501 to 333.17556. A nurse practitioner licensed or authorized to practice under section 172 of the public health code, MCL 333.17210. MDHHS previously agreed to enhance PSM 716-7 to mirror or link the language reflected in PSM 711-4.
The child advocate recommends all CPS case managers be trained on the Michigan Governor’s Task Force on Child Abuse and Neglect Plan of Safe Care Protocol.	MDHHS agrees. MDHHS is actively partnering with MPHI and other critical partners to implement the enhanced Plan of Safe Care, with the support of a comprehensive training series and toolkit, to improve outcomes for infants and their families. The training series is expected to roll out in 2025/2026. The department’s training unit will also train on the enhanced protocol moving forward.
The child advocate recommends MDHHS develop and implement additional training for case managers on how to conduct birth match investigations, and how to appropriately apply and assess threatened harm policy, PSM 713-11.	MDHHS agrees in part. While the Department recognizes the opportunities for improvement in birth match investigations, the recommendation will be reviewed further to determine if this is a systemic issue and how best to mitigate the area of concern.
The child advocate recommends MDHHS develop and implement additional training for case managers on how to appropriately apply the substance exposed infant policy, PSM 716-7.	MDHHS agrees in part. While the Department recognizes the opportunities for improvement in the case, the recommendation will be reviewed further to determine if this is a systemic issue and how best to mitigate the area of concern.
The child advocate recommends MDHHS amend PSM 713-01 to require case managers immediately provide the family with a pack n play or other approved safe sleep environment when one is not observed in the home.	MDHHS agrees. PSM 713-01 will be amended to reflect the following: If items needed for safe sleep are not available in the home, case managers must ensure assistance is provided to obtain the necessary items.

PDF Version of Report:  Cases 23-0593, 23-0866, 24-0618

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
July 30, 2025	November 13, 2025	December 12, 2025	2023-0827

Summary of recommendations:

The Child Advocate recommends strengthening AWOLP and placement protocols by amending FOM 722‑03A to require court notification within one business day when a missing child is located and to provide guidance for responding when a child remains in an unapproved placement, including notifying the court for protective action. Additional recommendations include providing staff training on the updated definition of “relative,” amending FOM 722‑03B to require documentation of how an unrelated caregiver meets that definition, and ensuring appropriate placement exception requests are completed for the identified cases.

Case Summary:

The Office of the Child Advocate (OCA) is tasked with making recommendations to positively effect change in policy, procedure, and legislation by investigating and reviewing actions of the Michigan Department of Health and Human Services (MDHHS), child placing agencies, child caring institutions, or certain facilities offering Juvenile Justice services. The Child Advocate Act, Public Act 204 of 1994, also requires the OCA to ensure laws, rules, and policies pertaining to Children’s Protective Services (CPS), Foster Care, Adoption and Juvenile Justice are being followed. The OCA is an autonomous entity, separate from the MDHHS.  
  
This OCA review included reading confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), service reports and social work contacts. The OCA also interviewed MDHHS staff, and reviewed law and policy surrounding children who go Absent Without Legal Permission (AWOLP). Due to the confidentiality of OCA investigations, the OCA cannot disclose the identity of witnesses or complainants or sources of statements and evidence.  
 
The objective of this review is to identify areas for improvement in the child welfare system by looking at how the case involving Child and his siblings was handled by Wayne County MDHHS, Hands Across the Water and Wolverine Human Services, and the involvement of MDHHS staff. This report is not intended to place blame, but to highlight areas of concern regarding the case; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children.  
 
This case came to the attention of the OCA after a complaint was received and a preliminary investigation found concerns for Child’s sibling, Sibling One’s AWOLP status, the condition of the home Sibling One was living in, and the number of children in the home. A full OCA investigation was opened on February 2, 2024, to review why Sibling One was still listed as AWOLP when the agency was aware of where he was residing. 

Family History and Case Background:

Date of Birth: 12/29/2005

Mother and Father are the birth parents of Child, Sibling One, Sibling Two, and Sibling Three. The children were removed from their parents on June 24, 2022, for physical neglect, improper supervision, educational neglect, and parental drug use. Child, Sibling One and Sibling Two were placed in an unrelated, unlicensed caregiver’s home. Sibling Three was placed in a separate unrelated, unlicensed caregiver’s home. Both unrelated unlicensed foster homes were documented by MDHHS as unrelated caregivers at initial placement. A court order from a hearing on July 28, 2022, documents the court was made aware “today” (July 28, 2022) that the children were in a fictive kin placement¹ without court approval or order. The referee denied the request for the fictive kin placement. A request was made for the Judge to review the referee’s recommendation of this decision. The order following a review of the referee’s decision was issued on August 10, 2022, and ordered the fictive kin placements.  

On October 7, 2022, MDHHS updated the placements in MiSACWIS to relative homes from unrelated caregivers. The children had not been moved from the unrelated, unlicensed caregivers’ homes. They remained in their original placement. Their status in MiSACWIS was the only thing that changed. This change enabled the caregivers to receive payment, as MDHHS policy was revised in October 2022 to allow unlicensed relative caregivers to be compensated. The foster care case was monitored by North Central Wayne County MDHHS (MiSACWIS ID: 691596). 

On June 26, 2023, Sibling One was reported to the Ecorse Police Department as a juvenile run away from his foster home placement by his foster mother. A CPS complaint was later received, on June 29, 2023, which stated Sibling One went AWOLP from his placement three days earlier. The complaint was transferred to foster care, the Placement Collaboration Unit (PCU), and the Division of Child Welfare Licensing (DCWL). On July 2, 2023, Sibling One was brought to the River Rouge Police Department by a friend’s mother. Ecorse Police Department was contacted due to the missing juvenile report and Sibling One was later transported back to the foster home by law enforcement. On July 4, 2023, Sibling One went AWOLP again. 

According to court records, an AWOLP petition concerning Sibling One was drafted by the foster care case manager on July 6, 2023, and approved by the section manager on July 12, 2023. A court order was issued on July 13, 2023, for an ex-parte order granting MDHHS or “its agent” the ability to take Sibling One into custody when located. The court order documents the Ecorse Police Department was notified as well as the National Center of Missing and Exploited Children (NCMEC). A second AWOLP docket hearing was held on August 16, 2023. According to the jurist’s report and order, reasonable efforts to locate Sibling One were being made and should continue. Sibling One’s AWOLP status would continue, and the next hearing was scheduled for September 13, 2023. 

On September 5, 2023, Sibling One was found at the home of his friend’s grandmother, Unrelated Adult. Unrelated Adult is an individual who is unrelated to Sibling One and does not fit the updated definition of a relative.

The foster care case manager met with Sibling One at school and completed a home visit at Unrelated Adult’s home on September 5, 2023. Following this contact, MDHHS did not notify the court or law enforcement authorities that Sibling One had been located. The next court hearing was a review hearing on October 2, 2023. The goals for Child and Sibling One were updated to Another Planned Permanent Living Arrangement (APPLA). The court order does not speak to Sibling One’s AWOLP status and there was no evidence in the case file the court was made aware Sibling One was located.

On October 23, 2023, a relative/fictive kin home assessment, a MDHHS-5770, was started by the North Central Wayne County fictive kin case manager. This home assessment is required by MDHHS prior to placing a child in a relative, unlicensed foster home. The fictive kin case manager submitted the MDHHS-5770 to their supervisor as a denial on October 25, 2023, and this was approved by the supervisor on November 8, 2023. Unrelated Adult’s home was denied for placement of Sibling One due to the cleanliness and suitability of the home. After denial of placement, Sibling One remained in Unrelated Adult’s home and his placement status remained listed as AWOLP in MiSACWIS. The AWOLP status was factually inaccurate as MDHHS was aware of Sibling One’s location and status.

A separate foster care case (MiSACWIS ID: 789963) was opened regarding Unrelated Adult’s grandchildren and was monitored by Western Wayne County MDHHS. On December 11, 2023, Western Wayne County MDHHS approved Unrelated Adult’s home for the relative placement of her five grandchildren, (ages 5 to 12 at the time of placement). Sibling One remained in the home, but this was not reflected in the approved MDHHS-5770 relative/fictive kin home assessment completed for Unrelated Adult’s grandchildren. After placement of Unrelated Adult’s five grandchildren, Unrelated Adult had seven minor children in her home, including her biological minor child. 

According to the jurist’s report and order for Sibling One’s AWOLP docket, a hearing was held on January 17, 2024. The court was provided an update on Sibling One’s location with Unrelated Adult. The court ordered MDHHS to assist Unrelated Adult with cleaning her home to get it approved for Sibling One to be placed there. A second relative/fictive kin MDHHS-5770 assessment was completed on Unrelated Adult’s home on February 7, 2024, approving Unrelated Adult’s home for placement of Sibling One. Sibling One’s placement record was later updated on February 21, 2024, after the OCA’s investigation began and interviews were being conducted. 

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_{[1] Fictive Kin- individuals who are close to the family but not blood relatives or related to the family through marriage. Examples of fictive kin are long-time neighbors, Godparents, close family friends or mentors. A non-relative or fictive kin placement cannot be used by the agency unless the home is licensed or the court orders placement.}

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OCA Investigation:

During the OCA’s investigation, the investigator asked MDHHS about the initial placements for the children and how the children knew the families. The OCA was informed both unrelated unlicensed foster homes were provided to MDHHS by Mother as “friends of friends.” It was explained the homes were assessed for placement after the placement unit could not locate placement for the children. Neither family fit the definition of a relative at the time of placement and the agency did not have a court order. Additionally, the OCA spoke with both unrelated families who confirmed having no prior relationship with the children prior to taking placement of them in their homes. 

MDHHS was asked to explain the delays in reporting Sibling One’s AWOLP status to the court, however, the case manager and assigned supervisor did not provide a reason for the delay in reporting the AWOLP status. The OCA asked MDHHS staff what the process is once a child is found after being AWOLP. The OCA investigator was informed case managers are required to notify the courts, notify law enforcement, and contact the child after the child is found. After Sibling One was located, the courts and law enforcement were not notified timely. The OCA asked why the placement record was not updated until months after Sibling One was found and why he was not moved from Unrelated Adult’s home after she was not approved for his placement. The OCA was informed by several MDHHS staff members that because Sibling One’s placement with Unrelated Adult was not approved, they could not update his placement record in the system. It was explained once a child is found from AWOLP, their placement must be approved before the MiSACWIS system placement section can be updated to accurately reflect where the child is located. Since Unrelated Adult’s home study was denied, they left him in AWOLP status. The OCA was further informed Sibling One was not moved as he refused to return to his prior foster home placement and refused to go to any other home. MDHHS staff said they could not force him to leave and did not want him to go AWOLP again. The decision was made to leave him in the home, where they knew his whereabouts and could maintain contact with him. 

When conducting interviews with Western Wayne County staff involved with the removal and placement of Unrelated Adult’s grandchildren, it was discovered they were unaware Sibling One was living in Unrelated Adult’s home. Unrelated Adult did not inform staff at that time that she had another minor temporary court ward (TCW), Sibling One, residing in her home. The OCA was informed that Unrelated Adult’s placement record in MiSACWIS also did not reflect that she had any placements in her home, leaving them no reason to believe that any other children resided in her home outside of her own minor child. The OCA was informed by Western Wayne County staff, having the information regarding Sibling One residing in Unrelated Adult’s home may have impacted their decision to place all five of Unrelated Adult’s grandchildren in her home. Western Wayne staff would have needed to further assess Unrelated Adult’s ability to care for a total of seven minor children, ensure proper sleeping arrangements, and space in the home with an additional child involved. Additionally, Western Wayne County staff would need to assess any additional risks related to (Sibling One) that could negatively impact Unrelated Adult’s grandchildren being placed in her home.

The OCA investigator spoke with the NCMEC regarding Sibling One after noticing two different case numbers in the foster care file concerning Sibling One. The OCA was informed two reports were filed concerning Sibling One. One was filed by MDHHS on August 8, 2023, with Sibling One going AWOLP on July 4, 2023. This report had an incorrect spelling of Sibling One’s name. The OCA was informed this report was closed on November 27, 2023, with a recovery date of November 7, 2023. NCMEC told the OCA, MDHHS provided information regarding Sibling One’s recovery. The OCA was informed the second report was filed by the foster parent on October 29, 2023, and was still open at the time of the OCA’s discussion (May 2024). The OCA learned, that after MDHHS spoke with the OCA investigator, MDHHS notified NCMEC of Sibling One’s location and the second report was closed.

The OCA held a meeting on July 17, 2024, with MDHHS, Wolverine Human Servies, and Federation for Youth staff. The OCA discussed concerns regarding the status of placement exception requests (PERs). A PER is required per policy, Foster Care Manual (FOM) 722-03E, due to the number of children placed in Unrelated Adult’s home. During this discussion, Wolverine Human Services and MDHHS staff advised the PERs would be completed. As of the writing of this document, the PERs have not been completed.

In summary, the OCA found the initial placements for the children were out of compliance with both statute and policy due to the unrelated caregivers not fitting the definition of a relative. It was also found that MDHHS did not notify the court or law enforcement of Sibling One’s AWOLP status within the legal timeframe. Furthermore, Sibling One's placement was not updated within MiSACWIS due to him being in an unapproved placement for four and a half months leaving his whereabouts unknown despite his case manager knowing where he was.  This caused the Department to be out of compliance for not only Sibling One’s case but also for the caregivers five grandchildren who were placed in the home with no knowledge of Sibling One being there.

Law and Policy Review:

As part of the OCA investigation, the OCA investigator reviewed MDHHS policy manuals regarding the issues identified in the case involving Sibling One. The following section is a review of what MDHHS policy says regarding relative/fictive kin placements, AWOLP protocol, and the MDHHS-5770 Relative Placement Safety Screen. 

Relative/Fictive Kin: MCL 712A.13a(1)(j) defines a relative as an individual who is at least 18 years of age and is either of the following: 

(i) related to the child within the fifth degree by blood, marriage, or adoption, including the spouse of an individual related to the child within the fifth degree, even after the marriage has ended by death or divorce, the parent who shares custody of a half-sibling, and the parent of a man whom the court has found probable cause to believe is the putative father if there is no man with legally established rights to the child.

(ii) Not related to a child within the fifth degree by blood, marriage, or adoption, but who has a strong positive emotional tie or role in the child’s life or the child’s parent’s life if the child is an infant, as determined by the department or, if the child is an Indian Child, as determined by the Indian child’s tribe.

Current FOM 722-03B, Placement Selection and Standards, defines a relative as “an individual who is at least 18 years of age and is any of the following: 

1. Related to the child within the fifth degree by blood, marriage, or adoption, as a grandparent, great-grandparent, great-great-grandparent, aunt or uncle, great-aunt or great uncle, sibling, stepsibling, nephew or niece, first cousin or first cousin once removed, and the spouse of any of the above, even after marriage has ended by death or divorce. 

2. A stepparent, ex-stepparent, or the parent who shares custody of a half-sibling is considered a relative for the purpose of placement. 

3. The parent of a man whom the court has found probable cause to believe is the putative father if there is no man with legally established rights to the child. A placement with the parent of a putative father is not to be construed as a finding of paternity or to confer legal standing on the putative father. (MCL 712A.13a(1)(j).

4. Not related to a child within the fifth degree by blood, marriage, or adoption but who has a strong positive emotional tie or role in the child’s life or the child’s parent’s life if the child is an infant, as determined by the department or, if the child is an Indian child, as determined solely by the Indian child’s tribe.  As used in this section, "Indian child" and "Indian child's tribe" mean those terms as defined in section 3 of chapter XIIB; see NAA 215, Placement/Replacement Priorities for Indian Child(ren). 

Note: Placements made with an unrelated caregiver cannot be changed to a relative placement while the child is in their home.”

Prior to October 2022, the definition of a relative in both MCL 712A.13a(1)(j) and FOM 722-03B did not include unrelated individuals who have a strong positive emotional tie or role in the child’s life or the child’s parent’s life if the child is an infant. Additionally, FOM 722-03 states the supervising agency must not place a child with an unrelated caregiver unless the unrelated caregiver is licensed, or the court orders the placement. Neither of these things were true when the children were placed in unrelated unlicensed homes at the time of initial removal. 

AWOLP: FOM 722-03A, Absent Without Legal Permission (AWOLP), states the supervising agency must immediately file a missing person report classifying the child as missing and endangered, after being notified of a child running away from a placement. Policy further outlines the requirement for notification to be provided within 24 hours to the court, the parents if applicable, the LGAL, the NCMEC, complete the ‘DHS 3198-A Unauthorized Leave report to Court/Law Enforcement’ and send copies to law enforcement and the court. The agency is also to ensure the child is entered into LEIN as missing and endangered. Policy further states that within one business day, the agency is to update the child’s placement to AWOLP and update their identifying information and description in their record. Actions to locate the child should be documented in the MiSACWIS case file. Following Sibling One going missing, law enforcement, and NCMEC were not notified within the time requirements outlined in policy.

When a child is located, FOM 722-03A states that as soon as possible, but no later than one business day after locating the child/youth, the supervising agency must notify the NCMEC the child/youth has been located and notify local law enforcement the child/youth has been located. The case manager should provide information pertaining to the circumstances of the youth’s recovery. In addition, the case manager must meet with the youth as soon as possible, but no later than five business days after locating the youth to determine the factors that contributed to the youth running away, the ways in which placement should respond to those factors, and the activities the youth participated in while missing and/or exploited.  The conversation must be documented in the social work contacts in the electronic case record, as “Interview with child/youth on Return from AWOLP.” Following Sibling One being located, MDHHS staff did not notify NCMEC or the local law enforcement agency within one business day that he had been located. Additionally, the interview with Sibling One at his school after he was located was not marked as an interview with child/youth on return from AWOLP, and did not cover policy requirements.

Relative Approval & Placement Safety Screen (MDHHS-5770): FOM 722-03B defines an emergency relative placement as an initial placement made by CPS, or a subsequent placement made by a supervising agency when a child has experienced an unplanned placement disruption or is placed in an unrelated home on an emergency basis and there is an immediate need for a placement resource. Emergency relative placements are made based on the results of the MDHHS-5770 Relative Approval & Placement Safety Screen. The MDHHS-5770 must be completed prior to an emergency placement.

If CPS denies placement with a relative caregiver and the child is placed in an unrelated/licensed foster home, then the foster care case manager must review the denied MDHHS-5770 with their supervisor to determine if placement would be appropriate upon further assessment via the MDHHS-3130A. The result of this review must be documented in the initial case service plan.

If further assessment is warranted, the MDHHS-3130A must be completed within 45 calendar days of removal. If the placement recommendation on the MDHHS-3130A is approved, the child must be placed with the relative. If the placement recommendation on the MDHHS-3130A is denied and the child is currently placed in the relative home, then the child is required to change placements, unless the court orders the placement against MDHHS' recommendation. MDHHS did not complete a DHS-3130a after the MDHHS-5770 denied Unrelated Adult’s home. Furthermore, Sibling One remained living at Unrelated Adult’s home, in an unapproved, unlicensed home.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The child advocate finds MDHHS did not follow FOM 722-03B and MCL 712A.13a at the time the children were removed and placed into their initial foster homes. At the time of placement, law and policy did not include fictive kin within the definition of a relative. A court order was required to place children in unrelated, unlicensed homes, otherwise known as fictive kin. The court was not made aware the children were in fictive kin placements without a court order until July 28, 2022, over a month after the children were placed in these homes. There was no legal relationship between the families and there was no prior relationship between the caregivers and the children prior to the children being placed in the homes.	MDHHS agrees. The siblings included the Child, Sibling One, Sibling Two, and Sibling Three.
The child advocate finds when Sibling One went AWOLP on June 26, 2023, and July 4, 2023, AWOLP policy requirements were not met. MDHHS did not file an AWOLP petition concerning Sibling One. MDHHS did not notify NCMEC until June 30, 2023, four days after he went AWOLP. Sibling One returned to the home on July 2, 2023, and left again without permission on July 4, 2023. The AWOLP petition and notification to the court occurred on July 6, 2023, two days after Sibling One went AWOLP. Notification to NCMEC occurred on August 8, 2023, 33 days after Sibling One went AWOLP from his placement.	MDHHS agrees.
The child advocate finds Sibling One was found and interviewed by foster care at his school on September 5, 2023. The interview with Sibling One at his school was not marked as an interview with child/youth on return from AWOLP, and did not cover policy requirements outlined in FOM722-03A.	MDHHS agrees.
The child advocate finds MDHHS became aware on September 5, 2023, Sibling One was living at the home of Unrelated Adult, an unrelated and unlicensed home. Unrelated Adult’s home was visited by the foster care case manager on September 5, 2023. An MDHHS-5770 for fictive kin/relative placement was completed on Unrelated Adult for Sibling One’s placement on October 23, 2023. This assessment was denied on October 25, 2023, due to the suitability of the home. Per FOM 722-03B, this was considered a subsequent emergency placement, and the MDHHS-5770 should have been completed immediately.	MDHHS agrees.
The child advocate finds MDHHS did not complete an MDHHS-3130a after the MDHHS-5770 denied Unrelated Adult’s home.	MDHHS agrees
The child advocate finds Sibling One was left in an unapproved placement by MDHHS for 169 days. Between September 5, 2023, and February 21, 2024, his placement status in MiSACWIS remained AWOLP.	MDHHS agrees
The child advocate finds the court was not notified of Sibling One’s location and status until January 17, 2024. MDHHS was then ordered to assist Unrelated Adult in cleaning the home to make it suitable for placement of Sibling One.	MDHHS agrees
The child advocate finds Western Wayne County MDHHS was not aware of Sibling One’s placement in Unrelated Adult’s home at the time her grandchildren were approved for placement with her. Additional assessments were required and could have been completed had staff been aware of Sibling One’s placement in the home. Multiple placement exception requests (PERs) were required for Barabara Cagle’s home due to the number of children in the home (seven minor children). Per FOM 722-03e, the local county office is required to route the placement exception requests to DCWL. As of the writing of this document, the placement exception requests remain pending and unapproved.	MDHHS agrees in part. MDHHS agrees that FOM 722-03A does not include a timeframe for notification to the court, but there is guidance regarding engagement with the youth when they are located. While there is no current written guidance in policy for when a child refuses to leave an unapproved placement, foster care specialists may consult the Child Locator Unit for support. MDHHS will consider updating policy or issuing other written guidance to direct staff to the Unit when AWOLP incidents fall outside existing parameters.
The child advocate finds FOM 722-03A concerning AWOLP protocol lacks clear guidance and instruction for case managers. FOM 722-03A does not include a timeframe on when the court should be notified following a child being located when AWOLP. FOM 722-03A does not provide guidance/instruction on how to handle situations when a child refuses to leave an unapproved placement.	MDHHS agrees in part. It does not give a quick and accurate location of the child in the placement screen; however, the specialist should be including information on the youth’s current unapproved placement in social work contacts when discussing meeting with the youth upon return from AWOLP. Current MiSACWIS functionality does not allow a specialist to enter an unapproved placement; therefore, placement cannot be updated from AWOLP until an approved placement is identified. This is something that has been identified as a needed function in CCWIS as it is being built.
The child advocate finds that leaving a child(ren) in AWOLP status when MDHHS or private agency staff become aware of where a child is living, places the child(ren) at risk and potentially increases risk to other children in the home.	MDHHS agrees.

 

Recommendations:

Recommendation	MDHHS Response to Recommendation
The child advocate recommends MDHHS amend FOM 722-03A concerning AWOLP protocol to include a requirement for the court be notified within one business day when a child is found.	MDHHS agrees.
The child advocate recommends MDHHS amend FOM 722-03A to include guidance/instruction for case managers on what steps to take if a child is in an unapproved placement and refuses to leave. a. This should include notification to the court which would allow the court to make proper orders to safeguard the child.	MDHHS agrees. The department agrees to explore other avenues and available legal resources to support our specialists when faced with situations in which youth refuse to leave an unapproved placement.
The child advocate recommends MDHHS provide additional training to staff on the updated definition of relative to provide a better understanding of who qualifies under the new definition.	MDHHS agrees. MDHHS has already addressed training needs on the updated definition of a relative to provide a better understanding of who qualifies under the new definition. No additional trainings are required. In May 2025, CI 25-043: Determining a Relative Status Through a Fictive Kin Relationship was released to guide placement decisions. The issuance provides key assessment criteria, considerations, and policy clarifications for determining relative status and remains available to staff. The updated definition of a relative and the communication issuance itself were also reviewed during an MDHHS leadership and all-staff meeting. The Office of Workforce Development and Training (OWDT) share all communication issuances with Pre-Service Institute trainers to ensure training materials stay current with policy changes and clarifications.
The child advocate recommends MDHHS amend FOM 722-03B to require case managers to document how the unrelated caregiver meets the definition of a relative.	MDHHS agrees in part. MDHHS agrees to consider future technological solutions that potentially could be implemented within CCWIS to identify the relationship of a caregiver when meeting the definition of relative. MDHHS is also exploring updates to the MDHHS5770 Relative Approval and Placement Safety Screen forms to include an assessment question documenting the relationship between the caregiver and the child being placed. Updates to the MDHHS-5770 will not occur until implementation of CCWIS as MiSACWIS updates are limited.
The child advocate recommends the appropriate placement exception requests be completed as required for ongoing case IDs 789963 and 691596.	MDHHS agrees.

PDF Version of Report:  Case 2023-0827

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
July 30, 2025	November 13, 2025	December 12, 2025	2022-0821

Summary of recommendations:

The Child Advocate recommends strengthening Michigan’s child welfare system by improving legal oversight, expanding experiential courtroom‑testimony training, and ensuring statewide access to fully funded simulation labs. These recommendations call for policy updates requiring notification to CSLD when the department disagrees with court‑ordered respondent removals; legislative codification and funding of a Child Welfare Training Academy and regional simulation facilities; mandatory, recurring simulation‑based courtroom‑testimony training integrated with petition writing and conducted jointly with legal partners; and enhanced supervision through mentor support for inexperienced case managers during court proceedings.

Introduction to the OCA:

The Office of the Child Advocate (OCA) is tasked with making recommendations to positively effect change in policy, procedure, and legislation by investigating and reviewing actions of the Michigan Department of Health and Human Services (MDHHS), child placing agencies, child caring institutions or residential facilities providing juvenile justice services. The Child Advocate’s Act, Public Act 204 of 1994, also requires the OCA to ensure laws, rules, and policies pertaining to Children’s Protective Services (CPS), Foster Care, Juvenile Justice and Adoption are being followed. The OCA is an autonomous entity, separate from MDHHS. 

This OCA review included reading confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), service reports, medical records, social work contacts, and law enforcement reports. The OCA also interviewed MDHHS staff, medical professionals, and law enforcement personnel. Due to the confidentiality of OCA investigations, the OCA cannot disclose the identity of witnesses or complainants or sources of statements and evidence. 

Case Objective:

The objective of this review is to identify areas for improvement in the child welfare system by looking at how CPS investigations involving Child were handled by Genesee County MDHHS, and the involvement of MDHHS staff, the court, medical professionals, and law enforcement. This review reinforces the idea that the safety and well-being of a child is a shared responsibility of the family, community, law enforcement, and medical professionals aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of the investigations; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children. 

Case Summary:

Date of Birth: April 8, 2021

Date of Death: August 6, 2022

Child was one year old when he died on August 6, 2022. Pursuant to MCL 722.627k, MDHHS notified the OCA of the child fatality. On September 12, 2022, the OCA opened an investigation into the administrative actions of CPS and courts prior to Child’s death. The following report summarizes the information and evidence found during the OCA investigation.

Background and History: 

Mother and Father are the parents of Child. Mother has four other children: Sibling One, Sibling Two, Sibling Three, and Sibling Four. Sibling’s Father One is Sibling One’s father. Sibling’s Father Two is Sibling Two and Sibling Three’s father. Sibling’s Father Three is the father of Sibling Four, and they reside in another state. Father has one additional child, Sibling Five, who primarily resides with his mother, Sibling’s Mother.

Mother has extensive CPS history dating back to 2007 involving improper supervision, physical neglect, physical abuse, and sexual abuse investigations. Outside of the scope of this investigation, Mother was substantiated in multiple prior cases, including a Category I removal in 2019 for improper supervision due to substance abuse. Throughout CPS’ involvement with Mother, she was provided a variety of services including parenting classes, Families Together Building Solutions, Families First, Access services, YWCA services and services with the Genesee Health System.

As it relates to the scope of this investigation, the OCA review included history pertaining to Mother and Father. 

Mother’s CPS History:

In the two years proceeding Child’ death, there were four CPS investigations. The first investigation (MiSACWIS ID: 105943405) began on April 16, 2021, following Child being born positive for marijuana, hydromorphone, and hydrocodone. Child did not experience withdrawals. However, CPS had concerns for Child’ health and well-being due to Mother not taking Child for his well-child examinations following his birth. During the investigation, Mother advised CPS Child’ father was unknown. Mother was substantiated for physical neglect as a Category II and an ongoing services case was opened on May 28, 2021. The ongoing case (MiSACWIS ID: 221639) was closed on July 16, 2021, after Child was seen for a well-child examination and there were no concerns for abuse or neglect. Mother was offered services through CPS ongoing, but she refused to cooperate. 

During the ongoing case, a new CPS complaint was assigned for investigation on June 12, 2021, with concerns of physical neglect (MiSACWIS ID: 107522931). The complaint expressed concern Mother was using substances and had unstable housing. CPS found Mother had appropriate housing and there were no concerns expressed by the children for Mother’s ability to parent. Mother identified Father Bulter as Child’ father, stating Father was not involved and she was unaware of his contact information. CPS located possible addresses for Father but were not able to reach Father during this investigation. The investigation was closed as a Category IV on July 20, 2021. 

The next investigation began on September 12, 2021, with concerns for physical neglect and improper supervision of Sibling Three by Mother (MiSACWIS ID: 109494467). A neighbor found Sibling Three soiled and dirty. The complaint also expressed concern for Mother using substances and having poor home conditions. During the investigation, Mother admitted Sibling Three snuck out of the home to play with a friend, but the friend was not home, and she ended up at a neighbor’s home. Mother agreed to get locks/chimes for the doors. CPS documented the home had plenty of food and working utilities. When interviewed by CPS, Sibling Three confirmed she left the home while everyone else was asleep. When asking standard parent questions, CPS inquired about the fathers of the children. Mother refused to identify Child’ father and told CPS he was not involved. Although CPS should have had knowledge of who Child’ father was from the prior investigation, CPS did not make any documented efforts to contact him during this investigation. Mother tested positive for amphetamines during this investigation, but no additional information was gathered relating to Mother’s drug use. CPS encouraged Mother to participate in prevention services. The case was closed as a Category IV with high risk stating there was not a preponderance of evidence Mother’s drug use was impairing her ability to care for the children, the home was appropriate, and the incident with Sibling Three appeared isolated. 

On June 28, 2022, MDHHS Centralized Intake received a new complaint for concerns of improper supervision and physical neglect of the children by Mother. The complaint stated law enforcement dropped the family off to a shelter because they were in an abandoned home, the children were dirty with no shoes, matted hair, and they had not eaten. Child was described in the complaint to be completely naked without a diaper, and a lot of the families’ belongings had to be thrown away due to being covered in human feces. This complaint was accepted and assigned to Genesee County for investigation (MiSACWIS ID: 132434694). 

During the CPS investigation, CPS struggled to locate Mother and the children as the family was kicked out of the shelter because of Mother’s use of profanity and threatening behavior. Shelter staff informed CPS the Flint Police Department escorted the family from the shelter. CPS spoke with the Flint Police Department who advised they assisted Mother in getting a few things out of the shelter, and the family advised they were going camping. No further information was provided to CPS by the Flint Police Department. From June 29, 2022, to July 6, 2022, CPS made several unsuccessful attempts to locate Mother at her last known addresses.

On July 9, 2022, CPS received an additional complaint that was accepted and linked to the current complaint. This complaint stated the family was picked up from a property in Flint where the family was not authorized to be, the family was homeless, and the home they were in was deplorable. Additional concerns were expressed that Mother left the home, leaving Sibling One (age 15) in charge of the younger children (ages 7, 4, and 1).

CPS met with Mother and the children at the police station. It was confirmed the family was homeless and they had been staying in an abandoned house with no food, water, or electricity, for an unknown amount of time. Mother provided CPS with information for a friend, Mother’s Friend, who agreed to allow Mother and the children to stay with her for the weekend. On July 11, 2022, CPS was contacted by Mother’s friend’s husband who had concerns for statements Mother had been making. He was unsure if she was on substances and said she could only stay short term. On July 15, 2022, CPS was informed Mother and the children were no longer able to stay with the Berry family as they were destroying their property. 

During the investigation, CPS completed a home assessment on Sibling’s Father One’s home (Sibling One’s father). He was able and willing to care for her, and his home was found to be appropriate. On July 18, 2022, CPS spoke with Sibling’s Father Two by phone (father of Sibling Three and Sibling Two). He informed CPS he was living in Tennessee and had room for his girls if placement was needed. On July 18, 2022, CPS completed a home visit at Father’s home. The home was documented by CPS to be appropriate. According to the CPS report, Father advised having domestic violence history with Mother, both as the aggressor and as the victim. He denied having any mental health diagnosis, substance abuse history or criminal history. However, the investigation report documents past CPS history pertaining to Father, including his placement on Central Registry for physical abuse.

An emergency petition was filed with the Genesee County court for removal on July 19, 2022, with Mother, Father, and Sibling’s Father Two as respondents. A preliminary hearing took place on July 20, 2022. The court authorized the petition against the mother, and removed the fathers as respondents, placing their respective children in their care. Following the hearing, Father informed CPS he had been pulled over by police and was informed he had a warrant for his arrest. Father was not arrested during the traffic stop. Father failed to provide CPS with the circumstances surrounding his arrest warrant. CPS later discovered the warrant for Father was related to felony dangerous drugs - possession of methamphetamine. 

The CPS case manager submitted the investigation for review on July 28, 2022, as a Category I with a preponderance of evidence supporting physical neglect and improper supervision by Mother. The supervisor approved and closed the investigation on August 11, 2022. The case was transferred to CPS ongoing to provide services for the family. 

Father’s CPS History:

As part of the OCA investigation, Father’s CPS history was reviewed. Father has the following substantiated CPS history:

2011:

On August 23, 2011, Father was involved with Girlfriend and was arrested for felonious assault. CPS received a complaint regarding the incident and an investigation was conducted. During the investigation, CPS discovered Father and Girlfriend were involved in several domestic violence incidents. During the incident that occurred on August 23, 2011, Girlfriend’s son, Son (8), was a witness to the domestic violence. Son informed CPS Father pulled his mom “off the couch and into the dining room, punching and kicking his mom in the face and ears.” Mt. Morris Police Department advised CPS Father had been arrested four additional times in the sixty days prior to August 23, 2011. Girlfriend filed a personal protection order (PP0) against Father and moved to Virginia. Father was substantiated for threatened harm as a result of domestic violence. The investigation was closed as a Category II on September 16, 2011. Father was not provided any services. 

2014:

In March of 2014, Father resided with Girlfriend Two and her son, Son Two (age 1). On March 25, 2014, CPS received a complaint stating Son Two was brought to the hospital with bruising and swelling to the side of his face, forehead, and cheek with fresh linear bruising to his neck and chest area. The complaint stated Father was caring for Son Two while Girlfriend Two was at work, and Son Two was in his crib when Father heard a “thump.” He found Son Two on the floor near his crib. Girlfriend Two was called to the home and observed bruising to Son Two, resulting in her taking him to the hospital. CPS spoke with Son Two’s examining physician at the hospital who advised the injuries were not consistent with a fall. Son Two was observed by CPS to have significant bruising to the left side of his face, a bruise on his left shoulder, a bruise in the middle of his back, scratches on the right side of his neck, and a scratch behind his right ear. Girlfriend Two said Father was very upset about what happened and that he had fallen asleep after putting Son Two in his crib. Son Two’s parents agreed not to allow Father to care for Son Two during the investigation. Girlfriend Two informed CPS a “Lego cart” matched the lines on Son Two’s face and she believed Father was telling the truth. While waiting for a second opinion from a child abuse expert, Girlfriend Two advised CPS she was moving back in with Father. The doctor advised CPS the injuries to Son Two were indicative of abuse. CPS found a preponderance of evidence for physical abuse of Son Two by Father, and Son Two was removed from Girlfriend Two’s care. During this investigation Father advised CPS he had a seven-year-old son who resided somewhere in Flint, but no documented efforts were made to identify or locate his child. Father was not provided any services.

Father was involved in two investigations concerning improper supervision and physical neglect involving Girlfriend Three and her children. The first investigation (MiSACWIS ID: 7324505) began on November 28, 2014, which stated Girlfriend Three had to be hospitalized for two to three days after Father beat her up, and the children were with their father while she healed. During this investigation, Girlfriend Three denied Father beating her up, advising CPS she was jumped outside a bar by two females. The children denied witnessing any domestic violence between their mom and Father, expressing no concerns at home. CPS found no preponderance of evidence and closed the case as a Category IV on January 8, 2015. On May 2, 2015, another complaint came in with concerns for improper supervision and threatened harm by Father (MiSACWIS ID: 7439889). Initially, Girlfriend Three denied domestic violence and stated Father accidentally hit her with a broom. During this investigation, Girlfriend Three’s children told CPS, Father and their mom fight every day and the police have been called. No further descriptions were provided of what their fighting looked like. During a subsequent home visit on June 4, 2015, Girlfriend Three advised CPS another incident occurred which included Father biting her ear, which led to Father getting arrested and her obtaining a PPO against him. Father was substantiated for threatened harm of Girlfriend Three’s children as a Category III and Girlfriend Three was offered services by CPS. The case was closed on June 25, 2015. Father was not provided any services.

2020:

On February 2, 2020, a CPS investigation began involving concerns of improper supervision, medical neglect, and physical neglect of Son Three, son of Girlfriend Four, by Girlfriend Four and Father (MiSACWIS ID: 80392531). At the time of this investigation, Girlfriend Four and Father were living together. Concerns were expressed Son Three had autism, was visually impaired, and was often left in soiled diapers. Additional concerns expressed Son Three was only fed one meal, Girlfriend Four and Father did not interact with Son Three, Father was selling methamphetamine out of the home, and both Girlfriend Four and Father were using methamphetamine and other substances. 

During this CPS investigation, Father was non-compliant with taking a drug screen, denied having any children of his own, and told CPS the allegations were not true. CPS identified Father had a 14-year-old son, Sibling Five, who resided with his mother, Sibling’s Mother. CPS spoke with Sibling’s Mother who advised she was not afraid of Father and would not allow Father to ever see Sibling Five. Sibling’s Mother told CPS Father was abusive in their past relationship. 

When CPS interviewed Girlfriend Four, she denied the allegations and initially refused to provide a drug screen for CPS. CPS later discovered Girlfriend Four was arrested for felony substance/delivery/manufacture, schedules 1, 2, 3 except marijuana, and she pled to misdemeanor substance use, narcotic/cocaine/methamphetamine/ecstasy. CPS was informed by medical professionals there was a concern for medical neglect of Son Three. Girlfriend Four refused to have him routinely seen by a medical professional. Fictive Caregiver, fictive caregiver for Son Three, informed CPS Girlfriend Four used methamphetamine, and it is manufactured in the home. CPS was further advised by Fictive Caregiver that Girlfriend Four called her on New Year’s Eve asking for her to come rescue her and Son Three, after Father had beat her. Fictive Caregiver told CPS Girlfriend Four had bruises on her body and had to walk through glass to get out of the home. Girlfriend Four’s drug screen came back positive for amphetamine, methamphetamine, benzoylecgonine, and cocaine, with the results for amphetamine and methamphetamine being “above the upper limit of linearity, indicating the levels were at or above this level for testing.” A petition was drafted and filed with the court on February 13, 2020.

The investigation was concluded as a Category I with a preponderance of evidence supporting improper supervision and physical neglect of Son Three by Father and Girlfriend Four, and medical neglect of Son Three by Girlfriend Four. The removal petition was authorized removing Son Three from his mother’s home on February 20, 2020. Father was not a respondent on the petition as he was not Son Three’s father. Father was not provided any services.

Additional Information:

In review of the petition filed against Mother, Father, and Sibling’s Father Two in July 2022, CPS included the substantiated CPS history for domestic violence and physical abuse concerning Father. The petition also included his criminal history which detailed numerous assault and domestic violence charges dating back to 2002 up until 2015. The warrant for Father’s arrest related to felony dangerous drugs was not included on the original petition filed by CPS in July 2022. 

In interviews conducted with MDHHS staff the OCA investigation was unable to determine why Father’s charge of and arrest warrant for felony dangerous drugs (methamphetamine) was missed. MDHHS staff expressed this was possibly overlooked and the recognized error. MDHHS staff also recognized their lack of training and experience for courtroom testimony. The assigned case manager had only filed a few petitions throughout their career, and the court hearing for the petition against Mother and Father was this staff member’s first in-person court hearing since proceedings had been virtual due to the COVID-19 pandemic. The in-person court hearing heightened their nerves, leading to concerns surrounding Father’s CPS history of physical abuse not being fully communicated to the court. MDHHS staff informed the OCA investigator that the assigned Assistant Prosecuting Attorney (APA) did not assist in ensuring the petition was fully communicated to the court, and did not ask the case manager any questions during the hearing to help elicit information. MDHHS staff believed asking for removal from Father was going to be difficult due to the most recent history being two years prior to this case. However, Father had never cared for Child, who was only one year old, and Father had never been serviced through his prior substantiations, which included a substantiation for severe physical abuse of an infant. 

On February 23, 2023, the OCA reviewed the video of the recorded court hearing that took place on July 20, 2022. In review of this video, the OCA observed the case manager testify to the reasons for removal and reasonable efforts in relation to Mother. The case manager did not testify to the full details of the petition and the concerns surrounding Father’s CPS history. The case manager was asked why the child should be removed from Father’s care and the case manager responded because of his criminal history and CPS history, which was unrelated to his child. The case manager testified Father’s CPS history involved domestic violence in the presence of children, stating this was the concern and why he was a respondent. The referee inquired if there were any current concerns for domestic violence written in the petition or if any PPOs were in effect concerning his child; the case manager denied both. There were no additional questions asked by the APA representing MDHHS to assist in bringing the concerns of the petition to the courts’ attention. The APA was observed on their phone throughout the hearing. As a result, the history presented, of prior domestic violence investigations, did not raise enough concern to the court to remove Child from Father’s care and custody. The court removed Father as a respondent from the petition, resulting in no orders being put into place regarding Father or Child. This further limited MDHHS’ ability to engage Father in services as he was not bound by court orders to participate. 

MDHHS staff and the OCA examined the available training options and provided guidance for MDHHS staff on court testimony. Staff members from around the state have advised the OCA that there is a significant lack of training in this area. Webinars are offered annually, such as “Testifying in Court” by the State Court Administrative Office (SCAO) and “I am a Witness, CATS Webinar.” However, these are limited and often repeat the same content each year. Additionally, there is an in-person training called “Crime Scene to Courtroom: The Multidisciplinary Approach to the Investigation and Prosecution of Abusive Head Trauma and Serious Physical Abuse in Children.” The OCA was informed that this training is intended more for the multidisciplinary team as a whole rather than specifically focusing on court testimony for Child Welfare staff. Moreover, MDHHS staff indicated that a mock trial is part of the Child Welfare Training Institute (CWTI) for new case managers entering child welfare programs. However, participation is voluntary, so not everyone gains hands-on experience. 

The OCA was informed during interviews with multiple MDHHS supervisors across several counties about the lack of available training on courtroom testimony, highlighting an area where MDHHS could improve. It was suggested that courtroom testimony training should be offered at least annually and required for all MDHHS case managers either every year, every other year, or every three years. It was recommended that this training be conducted jointly with the local prosecuting attorney’s office in each county to ensure the most relevant and effective training is provided for the area where most petitions are likely to be filed. This training should be a stand-alone session, similar to forensic interviewing, involving hands-on mock trials for all participants. 

Review of MDHHS actions following placement in Father’s home:

According to the Updated Services Plan (USP), report period July 29, 2022, to September 26, 2022, Mother and the children participated in a parenting time visit on July 29, 2022. Father was also present and spoke with CPS. Father advised CPS Child was scheduled for an appointment at the Clio Health Care Center for immunizations on August 11, 2022. Another parenting time occurred on August 5, 2022, with Child, Sibling One, and Mother. CPS documented Child was observed walking around, laughing, and interacting well with his sister. Mother was documented to be acting weird, telling Sibling One it was her responsibility to go to Child’ dad’s home to supervise him and make sure Child was ok. CPS documented that during parenting time, Mother said “the dad is using drugs, and I worry about him over there.” 

A parenting time was supposed to occur on August 10, 2022, with Child and Sibling One. Father did not bring Child to the visit. CPS documented Mother appeared anxious, concerned, and having a difficult time concentrating. CPS documented Mother would often express her concern for Child not attending the visit and was observed calling Father and his friends inquiring about Child. CPS spoke with Father on August 11, 2022, via text messages. Father apologized to CPS for not bringing Child to his parenting time with Mother, advising CPS he overslept due to working all week. CPS informed Father they needed to see Child and he advised he could meet after work that day around 3pm. When CPS inquired about where Child was while he worked, Father informed CPS a babysitter in Tuscola County watched Child but refused to provide the name or address of the babysitter. CPS documented Father did not understand why CPS was making a big deal about it, stating Mother has been harassing him about it and he was not the “one on trial.” CPS documented Father then ignored CPS’ call and text messages asking for him to arrange a Facetime, Zoom, Teams, or face to face with Child. It is further documented Father informed CPS a second time that he was not the one on trial, he was in the process of moving and doing what he needed to care for his son. 

On August 12, 2022, CPS texted Father requesting his new address and inquiring whether Child would be at the parenting time visit scheduled for that day. Father did not respond until later in the afternoon, stating he needed to change visit days due to his work schedule. He advised CPS Child was with a relative and when CPS requested the information on who Child was with and where, Father did not respond. The CPS supervisor documented leaving a voice message for Father. 

Father responded to the voice message via text, stating he was not the one with an open case, there was no jurisdiction over him, he has done everything asked of him, has received no help from CPS, and he did not have to continue to cooperate. CPS continued to attempt to see Child and reach Father at his last known addresses and relative homes. No successful contact was made. The supervisor responded to Father’s text advising that CPS had jurisdiction over Child and a judge ordered parenting time. The supervisor agreed he has done everything CPS asked of him and if he needed help with something, to ask so they can help. She confirmed switching parenting time days, but informed Father, Child still needed to be seen.

Additional requests were made on the same day, August 12, 2022, from CPS on call to continue attempted home visits to see Father and Child that evening and over the weekend. CPS coordinated with law enforcement on some of these visits and was informed Father had a felony warrant out for his arrest for methamphetamine. Multiple attempts were made without success. 

On August 15, 2022, CPS sent Father a text message advising Child needed to be seen by noon and if he failed to show or respond, a petition would be filed with the court for removal of Child from his care. No response was received. An emergency petition was filed by MDHHS on August 15, 2022, with no response from the court documented. Mother expressed concern Father would not provide her with proof that her son was ok, and she was concerned he had not been seen. CPS followed up with the APA on August 16, 2022, and were informed that the referee did not see the petition as an emergency, because there was no allegation that Child was at imminent risk.  CPS documented parenting time visits were missed and their unsuccessful attempts to see Child for the two-week time period before the petition was filed. CPS was notified a hearing will be scheduled for a later date as a regular preliminary hearing. CPS continued to make efforts to locate Father and Child, including home visits, phone calls, text messages, and calls with Father’s friends to determine if any information on his whereabouts could be provided. 

On August 16, 2022, CPS requested assistance from on-call workers to continue efforts into the evening to locate Father and Child. Additionally, on August 17, 2022, a courtesy request for Saginaw County was made requesting an attempted home visit with one of Father’s relatives. No attempts made were successful. 

On August 23, 2022, a dispositional review hearing was held in front of Judge Gadola in Genesee County concerning the petition filed removing the children from Mother. At this hearing, Mother pled to the petition and the court took jurisdiction over the children. The CPS case manager requested Judge Gadola hear the petition concerning Child and remove Child from Father’s care. Judge Gadola advised a preliminary hearing should be scheduled in front of a referee to hear that petition. 

On August 24, 2022, CPS attempted to see Father and Child at the home of Friend, a friend of Father’s. What appeared to be Father’s truck was in the driveway, however, no one answered the door. CPS went back to the home later that afternoon with the Michigan State Police (MSP) and Friend answered the door. Friend advised CPS and MSP that she had not seen Child in about a week or so and that Father told her he gave Child back to CPS three weeks ago. She allowed CPS and MSP to search her home; Father and Child were not located, and the truck observed earlier in the day was noted to be gone. 

On August 26, 2022, CPS received notification a preliminary hearing for the petition requesting removal of Child from Father was set for September 6, 2022. Unfortunately, the same day, August 26, 2022, CPS learned a child’s body was found in a ditch near the area CPS had been searching for Child since August 12, 2022. The body was later confirmed to be the body of one year old, Child.

Review of CPS’ Investigation of Child’ Demilo’s Death (MiSACWIS ID 134663118):

On August 26, 2022, a new complaint was received by MDHHS Centralized Intake concerning the death of Child. The complaint expressed concern for Father having a history of methamphetamine use, CPS having an active CPS case and recently filing another petition against Father. On this date (August 26, 2022), the body of Child was found in a ditch, badly decomposed. Child had been missing for approximately two weeks; the last time CPS saw him was on August 5, 2022. The complaint advised law enforcement located Father, and he advised “…Child hit his head on a large rock in their yard, he did not know what to do, and he dumped Child’ body in the ditch.” This complaint was assigned for investigation to Genesee County CPS.
 
CPS began their investigation by documenting all of the efforts to locate Father and Child over the two weeks prior to Child’ body being located. The detective from the Genesee County Sheriff’s Department advised CPS Father said he was at Heather Edwards’ home playing outside with Child, teaching Child how to run, when Child tripped over his feet or a rock and fell. Father said Child hit his head on a large landscaping rock in the yard. Father did not tell anyone what happened and put Child into the car. Father informed the detective Child was ok at first but later went in and out of consciousness, he drove around with Child in this state for two days, administered CPR, but Child passed away on the second day. The detective told CPS Father stated he freaked out knowing he was going to spend the rest of his life in jail and dumped his son’s deceased body into the ditch. The detective advised CPS Father kept telling others that CPS removed his son two Tuesdays ago and he continued to repeat this, which in the detective’s experience, was significant.

CPS met with Father at the Genesee County Jail. He refused to speak to CPS about Child or the circumstances of his death. Father admitted to using methamphetamine daily for the past two years and was unsure of the number of times he used per day. He was informed a mandatory petition would be filed concerning his son, Sibling Five. On August 30, 2022, Father was arraigned and notified he was being charged with first degree child abuse, felony murder, concealing a death, and domestic assault. 

On September 1, 2022, CPS participated in a critical incident debrief with law enforcement, ATF, forensic scene investigators and anthropology. The home where Father said the fall/injury to Child occurred was searched and no large rock existed as Father described. 

On October 22, 2022, the medical examiner’s office notified CPS the DNA results confirmed the child’s body to be Child. The autopsy revealed Child was positive for THC and methamphetamine.
 
During this investigation, CPS filed a mandatory petition requesting Father’s parental rights to Sibling Five be terminated. A trial occurred on November 30, 2022, where Father pled no contest to the petition in its entirety. Father’s rights were terminated to Sibling Five and Sibling Five was released to his mother.

The investigation was concluded by CPS as a Category I with a preponderance of evidence supporting medical neglect, improper supervision, and physical abuse of Child by Father Bulter.  Father was also substantiated for medical neglect and threatened harm of Sibling Five. The investigation was approved and closed by the supervisor on January 5, 2023. 

During the OCA’s investigation, the autopsy report was reviewed. Child’s cause of death was determined to be blunt-force head injuries, and Methamphetamine and Cannabis Intoxication Complicated by Medical Neglect. His manner of death was ruled a homicide. The autopsy concluded his approximate date of death was on or around August 7, 2022. 

On February 7, 2024, Father was found guilty by jury verdict of homicide-felony murder, 1st degree child abuse, concealing the death of an individual, and domestic violence-aggravated. Father was sentenced to life in prison on March 18, 2024.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The child advocate finds MDHHS appropriately included Father Bulter as a respondent on their initial removal petition in July 2022. The child advocate finds this petition did not include pertinent information including: Allegations regarding Father’s absence of a relationship and involvement in Child’ life, nor the fact that he had never provided for Child. Based on statements made by Mother during prior CPS investigations, Father was not involved in Child’ life. Per information gathered from the Friend of the Court by MDHHS, Father had never paid his court ordered child support. The child advocate finds MDHHS reviewed Father’s criminal history but missed a warrant for his arrest at the time the petition was filed in July 2022. The warrant was for felony dangerous drugs (methamphetamine) and would have added additional concern to the petition presented to the court.	MDHHS agrees in part. Although there were times when mother, said that Father was not involved in life in previous investigations, she also noted that Father was working to obtain a home for her and her children. The degree to which Father was involved in life was hard to determine based on contacts made in the report. MDHHS agrees that he did not pay his court-ordered child support. MDHHS also agrees that information regarding the warrant was not included in the petition filed in July 2022.
The child advocate finds the testimony provided to support the July 2022 petition and allegations regarding Father’s CPS history was not adequately presented to the court. There was no testimony provided regarding the serious injuries Father caused to an infant in 2014. There was no testimony provided regarding the severe physical neglect Father caused to a child in 2020. There was minimal testimony provided regarding the seriousness of Father’s domestic violence history and methamphetamine use. No services to rectify the concerns had been provided to Father by MDHHS.	MDHHS agrees in part. The petition documented Children's Protective Services (CPS) history, and that information remained in the court records, regardless of whether there was direct testimony or the reading of the petition was waived.
The child advocate finds MDHHS staff have limited training with court testimony.	MDHHS agrees. All new Children Protective Services, Foster Care, and Adoption staff receive training on court testimony during the Pre-Service Institute (PSI). MDHHS will evaluate whether additional training is needed regarding court testimony as an ongoing supplemental training for all service specialists.
The child advocate finds the assigned assistant prosecuting attorney provided no guidance or assistance to the MDHHS case manager during testimony.	No response.
The child advocate finds following testimony, the court removed Father as a respondent from the petition.	MDHHS agrees.
The child advocate finds there is an opportunity for improvement in training provided to case managers regarding petition writing and court testimony. Various webinars are available and offered yearly to case managers, however, these webinars do not provide hands on experience to adequately prepare a case manager for testimony. Webinars do not provide case managers with the opportunity to practice testifying in a court room setting. A mock trial is completed at the MDHHS Child Welfare Training Institute; however, this only allows for a handful of case managers to practice, and according to interviews performed by the OCA, does not provide adequate preparation for a court room setting.	MDHHS agrees in part. Training for court testimony could be enhanced with additional resources and will be explored. Training for petition writing has recently been enhanced for new specialists during Pre-Service Institute (PSI).
The child advocate finds that Father was a non-custodial parent in July of 2022.	MDHHS agrees.
The child advocate finds Protective Services Manual (PSM)715-3, Problem Court and Administrative Hearing Orders, lacks guidance for MDHHS staff on what to do when a court removes a non-custodial parent as a respondent. In situations such as this case, an amended petition requesting in-home jurisdiction could have been filed with the court to ensure services were provided to Father. Given the seriousness of Father Bulter’s CPS history, and Father never having care and custody of Child, court ordered participation in services would have provided additional support for Father and Child.	MDHHS agrees in part. While the Department recognizes the opportunities for improvement in this specific case, the finding will be reviewed further and to determine if this is a systemic issue and how best to mitigate the area of concern.

 

Recommendations:

Recommendation	MDHHS Response to Recommendation
The child advocate recommends Children’s Services Agency (CSA) amend PSM 715-3 Problem Court and Administrative Hearing Orders to include notification to the Children’s Services Legal Division (CSLD) when a court or referee removes a respondent from a petition and the department disagrees with the decision.	MDHHS agrees in part. Although CSA staff is required to contact CSLD in the event a petition is dismissed, and the respondent father’s removal from this petition may be considered a de facto dismissal in accordance with the policy, adding this type of scenario to the policy would clarify the requirement to contact CSLD for further review. MDHHS will explore opportunities to provide clearer guidance in policy.
The OCO recommends that the Michigan Legislature Codify the requirement for a Child Welfare Training Academy (CWTA) and simulation labs that incorporate experiential learning on courtroom testimony.	No response.
The OCO recommends that the Michigan Legislature adequately fund the purchase, equipping, staffing, and maintenance of MDHHS regional simulation labs for child welfare training.	No response.
The child advocate recommends MDHHS institute simulation training on courtroom testimony that would allow all new case managers to be trained and existing case managers to have ongoing training on providing courtroom testimony. The child advocate recommends MDHHS require all case managers complete the training as part of their initial child welfare training and then repeat it on a routine basis as determined by MDHHS. The child advocate recommends this training be conducted jointly with the local prosecuting attorney’s office, the Attorney General’s office and/or with the department’s retained counsel in each county to ensure the most relevant and effective training is provided in the jurisdiction where testimony is provided. The child advocate recommends this training be conducted in a simulation environment involving hands-on mock trials for all participants. The child advocate recommends petition writing be integrated into this training.	MDHHS agrees. The department has executed a contract with Michigan State University School of Social Work to implement a simulation pilot for child welfare specialists and implementation is anticipated in 2026. Due to cost and logistical constraints, the pilot is limited in scope and volume but will inform the feasibility of utilizing a simulation format for an expanded audience and range of content in the future. The implementation of statewide mock trials in a simulation environment would require additional funding to compensate legal experts and resources to coordinate logistics with local jurisdictions. MDHHS has recently enhanced the Pre-Service Institute to require all trainees to complete a petition during training and have it reviewed by their local office/agency supervisor. Additionally, ongoing training in testifying and petition writing is available as an in-service training for experienced specialists
The child advocate recommends supervision, or mentors attend court hearings with inexperienced staff.	MDHHS agrees. MDHHS will collaborate with regional and local office leadership to evaluate this recommendation and determine whether enhanced practice guidance is warranted and will issue it accordingly.

PDF Version of Report:  Case 2022-0821

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
April 17, 2025	November 13, 2025	December 12, 2025	2022-0102 2023-0002

Summary of recommendations:

The Child Advocate recommends strengthening foster care safety practices by clarifying past policy changes and enhancing requirements for monitoring foster homes. Key actions include explaining the 2019 revision to FOM 722‑06H and amending policy to mandate quarterly unannounced home visits, monthly private interviews with verbal children, full‑home walkthroughs, and targeted drug screening of caregivers when substance‑abuse concerns exist. Additional recommendations include requiring interviews with medical or mental‑health providers when a caregiver’s condition may affect their ability to provide care, and ensuring foster parents report hospitalizations so the department can assess any impact on child safety.

Introduction to OCA:

The Office of the Child Advocate (OCA) is tasked with making recommendations to positively effect change in policy, procedure, and legislation by investigating and reviewing actions of the Michigan Department of Health and Human Services (MDHHS), child placing agencies, or child caring institutions. The Child Advocate’s Act, Public Act 204 of 1994, also requires the OCA to ensure laws, rules, and policies pertaining to Children’s Protective Services (CPS), Foster Care, Adoption, and Juvenile Justice are being followed. The OCA is an autonomous entity, separate from the MDHHS.  
 
The OCA’s review included reading confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), MDHHS relative home studies, safety plans, investigative and service reports, court documents, criminal history checks, death certificates, autopsy reports, and law enforcement reports. The OCA also interviewed MDHHS and placing agency foster care (PAFC) staff. Due to the confidentiality of OCA investigations, the OCA cannot disclose the identity of witnesses or complainants or sources of statements.  

Case Objective:

Case Summary:

Child One and Child Two were both one-year-olds when they died on February 5, 2022, and December 29, 2022, respectively.  Pursuant to MCL 722.627k, MDHHS notified the OCA of the child fatalities. On January 23, 2023, the OCA opened an investigation into the administrative actions of MDHHS regarding Child Two’s death. On October 25, 2023, the OCA opened an investigation into the administrative actions of MDHHS regarding Child One’s death. Child One and Child Two’s cases shared a similar fact pattern. During both children’s foster care cases, no unannounced home visits were completed where the children were residing and there were incomplete assessments of each family's living situations. Additionally, both children died while under the care and supervision of MDHHS. The following report summarizes the information and evidence found during the OCA’s investigations. 

Child One

Family History and Background regarding Child One: 

According to CPS records, Mother One is Child One’s mother. CPS records also state Mother One is the mother of Child One’s twin sibling, Sibling One (4 at time of investigation), Sibling Two (17 at time of investigation) and Sibling Three (18 at time of investigation). Father One is Child One and Sibling One’s father. CPS records show Mother One had a CPS history involving neglect of Sibling Two and Sibling Three due to substance abuse and domestic violence issues. In 2018, CPS records indicate CPS staff, Mother One, Sibling Two and Sibling Three’s father, Sibling’s Father One, arranged for Sibling Two and Sibling Three to live with their maternal grandmother, Maternal Grandmother, under a power of attorney (POA). Foster care records show that foster children, Adopted Child One (13) and Adopted Child Two (18), were also living with Maternal Grandmother in 2018. Foster care records state Maternal Grandmother adopted Adopted Child One and Adopted Child Two in 2020. 

CPS records show that on February 1, 2021, Hurley Hospital personnel reported to CI staff that Child One and Sibling One were born at the hospital on January 29, 2021. CPS records state morphine was being administered to both children by hospital personnel to treat withdrawal symptoms from in utero opiate exposure. CPS records indicate Mother One admitted to hospital personnel that she used heroin and fentanyl during her pregnancy. CPS records also say Mother One identified the children’s father as Father One. Father One had been banned from visiting Mother One at the hospital because hospital personnel caught him trying to smuggle drugs into the hospital for Mother One. CPS records show CI staff assigned this complaint to Genessee County CPS staff for investigation on February 1, 2021. 

According to CPS records, Genessee County CPS staff’s investigation of the February 1, 2021, complaint resulted in CPS staff making a finding against Mother One for physically abusing Child One and Sibling One. CPS records show this finding was based on the children’s withdrawal symptoms and because opiates were detected by hospital staff in both children’s meconium drugs screens. CPS records indicate CPS staff then filed a removal petition for both children on February 19, 2021, with the Genesee County 7th Circuit Court. CPS records indicate Father One (Child One and Sibling One’s father) was not included as a respondent on the petition because he had not established legal paternity.

CPS and court records state the court authorized a removal petition on February 19, 2021, and Child One and Sibling One were removed from Mother One and placed by CPS staff in foster care on February 20, 2021, with their maternal grandmother, Maternal Grandmother.

Review of Child One’s foster care case:

According to the Shiawassee County Sheriff’s Office (SCSO) and foster care records obtained and reviewed by the OCA investigator, Child One died on February 5, 2022, while in foster care under the care and supervision of MDHHS. The OCA investigator obtained and reviewed Child One’s autopsy report, and it states his cause of death was acute fentanyl toxicity and his manner of death was indeterminate.

While reviewing foster care records and interviewing child welfare staff, the OCA investigator determined assessments performed by foster care staff, of the children’s placement with Maternal Grandmother, and Father One’s ability to care for the children, were incomplete. What the OCA investigator discovered is discussed in this section.

A MDHHS-5770: Relative Placement Safety Screen was completed on Maternal Grandmother on February 22, 2021, and a DHS-3130A: Children's Foster Care Relative Placement Home Study was completed on March 3, 2021. Both the safety assessment and home study outlined concerns for Maternal Grandmother following the DHHS policies and safety plans regarding Mother One. Mother One was living with Maternal Grandmother at the time of the removal. Mother One told MDHHS staff she would move across the street and live with her grandmother, however during both assessments Mother One was observed at the home.

SCSO and MDHHS records reviewed state that on February 5, 2022, Father One contacted 911 about finding Child One unresponsive on a couch in the “farmhouse” located on the property where Father One lived. SCSO records also state that when officers and emergency services arrived at Father One’s property, they found Father One, Child One, and Mother One in the farmhouse. This farmhouse is next to the home where Father One previously told foster care staff he lived. SCSO and MDHHS records further indicate this farmhouse was where Child One and Sibling One had been living with their parents since they were removed from Mother One’s care and placed in foster care with Maternal Grandmother on February 20, 2021.  

SCSO records reviewed revealed officers searched the farmhouse on February 5, 2022, and found methamphetamine, heroin, five pounds of marijuana, and six unsecured firearms. The records state some of the firearms were loaded. SCSO records also say the firearms and drugs were in areas the children could access. 

The OCA investigator learned from reviewing foster care records and interviewing child welfare staff, that on the day Child One died, the children were not supposed to be having unsupervised visits with Mother One. Foster care and court records indicate Mother One’s visits with the children were required to be supervised due to Mother One not being compliant with services. Foster care records further state Father One was not authorized by foster care staff or the court to supervise Mother One's visits.

Foster care records also indicate the children were not supposed to be living with Father One or Mother One. The OCA investigator learned from foster care staff they didn’t know Father One and Mother One were living together or the children were living with them. The OCA developed evidence showing foster care staff believed Father One was living in the home next to the farmhouse, and Mother One was living separately in a home with friends. Foster care and court records further indicate Father One began court ordered unsupervised visits with the children on January 20, 2022. Foster care records also state Father One was not court ordered, or voluntarily participating, in any services prior to the court ordering he be allowed unsupervised visits. On January 20, 2022, the court granted permission for Father One to have “unrestricted and unlimited” time with the children while in the process of establishing paternity. 

Child welfare staff did not provide the court with information about Father One smuggling drugs into the hospital for Mother One. The OCA learned foster care did not view this as important because CPS did not address the issue. Additionally, Father One was not listed on the petition so the court would not have heard this information. The OCA investigator discovered foster care did not know Father One had a criminal history despite foster care policy (FOM 722-06) stating "Law Enforcement Information Network (LEIN) checks must be conducted on all household members when a child will be having parenting time at the parent’s home”. The OCA investigator completed a criminal history check on Father One and found he had criminal convictions for misdemeanor use of narcotics and possession of marijuana, misdemeanor and felony operating a motor vehicle while impaired, and felony fleeing a police officer. The OCA investigator also discovered that Father One had an active arrest warrant during the open foster care case. This arrest warrant was active while Father One was caring for the children by himself. Foster care was unaware of Father One’s arrest warrant.

Foster care records reviewed show Mother One completed supervised visits with the children at Maternal Grandmother’s residence. Foster care records state Maternal Grandmother or Maternal Aunt supervised these visits. The records also state in September 2021 Mother One’s visits became less frequent. Foster care records indicate Mother One’s participation in, and completion of services to achieve reunification were “poor” throughout the open foster care case. 

The OCA investigator learned by reviewing foster care records and interviewing child welfare staff, during the open foster care case, staff completed eleven scheduled face-to-face home visits with the children at Maternal Grandmother’s residence. Foster care records indicate Mother One was present at five of the face-to-face home visits, and Father One was present at three home visits. Absent from foster care records are interviews with the four other teenage children residing in Maternal Grandmother’s home. It was confirmed through OCA interviews that foster care staff did not interview these children because it is not required by foster care policy.  

The OCA investigator learned through interviews no unannounced home visits were completed at Maternal Grandmother’s residence during the open foster care case because it is not required by policy. MDHHS staff interviewed informed the OCA investigator they don’t believe there is enough time to complete unannounced visits due to caseload sizes and other extenuating circumstances. Extenuating circumstances include, but are not limited to, the distance between their work location and homes needing unannounced visits.

According to interviews the OCA investigator completed, and the foster care records reviewed, foster care staff didn’t visit either parent’s residence during the open foster care case until January 21, 2022. That visit was at Father One’s home and was to determine if it was appropriate for placement of the children. According to interviews conducted with child welfare staff, the home that was looked at on January 21st was the main residence on the property, and it was appropriate. Child welfare staff said they observed the farmhouse, but Father One told them he was renting it to someone so foster care had no reason to see the inside of the farmhouse.   

The OCA investigator learned between September and November 2021, maternal aunt, Maternal Aunt, informed foster care staff Maternal Grandmother had been in and out of the hospital. During this time foster care staff were informed that Maternal Aunt was caring for Child One and Sibling One.

The OCA learned that no foster care staff contacted Maternal Grandmother’s medical providers to inquire about Maternal Grandmother’s hospitalizations and to determine if her conditions affected her ability to care for Child One and Sibling One. Foster care staff attempted to get Maternal Grandmother’s signature on a release of information form however Maternal Grandmother refused to sign. 

Review of CPS Maltreatment in Care (MIC) investigation of Child One’s death:

MDHHS records state foster care and CI staff were notified of the situation surrounding Child One’s death on February 5, 2022, and a CPS MIC investigation was opened and assigned. 

In addition to discovering further facts about the circumstances that led to Child One’s death, the OCA investigator also determined that foster care staff could have more thoroughly assessed Father One, Maternal Grandmother, and their living situations prior to Child One’s death. The facts and the outcome of the CPS MIC investigation are discussed in this section.     

CPS records show Father One and Mother One admitted to CPS staff that Child One and Sibling One had been living with them unsupervised in Father One’s farmhouse since the foster care case was opened in February 2021. 

CPS records indicate Mother One was drug screened by CPS staff on February 5, 2022, and she tested positive for methamphetamine and fentanyl. CPS records also state CPS staff offered Father One a drug screen the same day, but he refused to complete it.

CPS records state Father One and Mother One admitted to CPS staff that prior to Child One’s death, when foster care staff completed announced visits to Maternal Grandmother’s home, they would bring the children from the farmhouse to Maternal Grandmother’s. Records also show Father One and Mother One admitted they had been using methamphetamine, heroin, and fentanyl throughout the open foster care case and consistently for three days leading up to Child One’s death.

CPS and SCSO records indicate Maternal Grandmother also admitted to officers and CPS staff that she was using methadone, heroin, oxycodone, and fentanyl, throughout the open foster care case. The records state Maternal Grandmother further admitted the two times she was hospitalized in September and November 2021, were not due to illnesses and back issues, but from overdoses caused by using these substances. The records further show that Maternal Grandmother said if foster care staff completed unannounced home visits, they would have likely discovered the children were not living with her and she was using these substances. 

MDHHS records indicate that due to Maternal Grandmother’s admissions another CPS MIC investigation was opened on February 14, 2022, regarding the other children residing in Maternal Grandmother’s home. CPS records indicate Maternal Grandmother was substantiated during that investigation for neglecting the other children due to her substance abuse, and because she allowed Child One and Sibling One to live with their parents unsupervised. MDHHS staff arranged for Sibling One to be placed in a licensed foster home, and Sibling Two and Sibling Three to live with their father, Sibling’s Father One. CPS records show CPS staff allowed Maternal Grandmother’s adoptive children, Adopted Child One and Adopted Child Two, to continue to reside with Maternal Grandmother.

On February 22, 2022, CPS records state CPS staff were informed by officers that Child One’s cause of death was due to acute fentanyl toxicity. CPS records state CPS staff then submitted a petition to the court requesting that Mother One and Father One’s parental rights to Sibling One be terminated. Foster care records indicate Mother One and Father One’s parental rights to Sibling One were terminated on May 12, 2023, and Sibling One was adopted by an unrelated family on February 6, 2024.

Father One pled guilty to felony firearm and felony homicide–manslaughter-involuntary on March 18, 2024, in relation to Child One’s death. He was sentenced to prison. His earliest release date is October 20, 2042, and maximum release date is February 20, 2076.
 
Mother One was found guilty of felony possession of methamphetamine and felony homicide- manslaughter-involuntary on April 5, 2024, in relation to Child One’s death. She was sentenced to prison. Her earliest release date is April 17, 2035, and maximum is October 17, 2052.
 

Child Two

Child Two was 14 months old when he died on December 29, 2022. Below is a summary of the OCA’s investigation of MDHHS’s management of Child Two’s cases before his death.  

Family History and Background regarding Child Two: 

According to CPS records, Mother Two is Child Two’s mother. Legal Father is Child Two’ legal father, as he was married to Mother Two when Child Two was born. Biological Father was identified by Mother Two as Child Two’ biological father. The biological father did not establish legal paternity prior to Child Two’ death.

MDHHS records indicate Child Two was removed from Mother Two (Child Two’ mother) on November 9, 2021, due to her parental rights previously being terminated to her two other children. MDHHS records state Mother Two’s rights were terminated to those children because she physically neglected and improperly supervised them. She also failed to rectify the situation that led to those children’s removal. 

MDHHS records state when Child Two was initially removed from Mother Two, he was placed in a licensed foster home. MDHHS records further state Child Two was moved by foster care staff to his maternal aunt, Maternal Aunt’s, home on January 20, 2022. Foster care records state Maternal Aunt's daughter, Cousin (11), lived with Maternal Aunt when Child Two was placed with her.

OCA staff discovered seven years before placing Child Two into Maternal Aunt’s home, Maternal Aunt had one prior substantiated CPS complaint made against her. This complaint and investigation occurred in September 2015, and it was regarding Maternal Aunt’s daughter, Cousin. That complaint involved circumstances relevant to Child Two’ death. That complaint said Maternal Aunt was shooting up an unknown drug and smoking crack-cocaine while Cousin was present. The complaint also stated Maternal Aunt was leaving the syringes she was using out and accessible to Cousin. 

Based on CPS staff’s investigation, CPS found a preponderance of evidence for child neglect. Maternal Aunt improperly supervised Cousin and placed her in a situation of threatened harm. CPS records say the preponderance of evidence was found because Maternal Aunt tested positive for marijuana and cocaine during the investigation. CPS records state CPS staff created a safety plan with Maternal Aunt. The safety plan said Maternal Aunt agreed not to use substances when Cousin was present, or to have a sober caregiver watch Cousin when Maternal Aunt used. CPS records indicate CPS staff then closed their investigation on October 20, 2015.
 

Review of Child Two’s foster care case:

According to the Flint Township Police Department (FTPD) and foster care records obtained and reviewed by the OCA investigator, Child Two died on December 29, 2022, while in foster care under the care and supervision of MDHHS. The OCA investigator obtained and reviewed Child Two’ autopsy report, and it states his cause of death was due to complications of methamphetamine toxicity and hyponatremia, and his manner of death was a homicide. 

In addition to discovering the facts that led to Child Two’ death, the OCA investigator determined that MDHHS staff’s initial and ongoing assessment of Child Two’ placement and safety with Maternal Aunt were incomplete. What the OCA investigator discovered is discussed in this section.   

Foster care records show that prior to Child Two’ placement with Maternal Aunt, Lapeer County MDHHS licensing staff completed the MDHHS Relative Placement Home Study (3130-A) for Maternal Aunt on January 19, 2022. The OCA investigator obtained and reviewed the 3130-A, and it states child welfare staff addressed the September 22, 2015, CPS investigation with Maternal Aunt. The 3130-A states Maternal Aunt admitted to using substances when the September 22, 2015, CPS investigation occurred. The 3130-A also states Maternal Aunt told the child welfare specialist she stopped using all other substances but currently uses marijuana. The child welfare staff did not have concerns about Maternal Aunt’s substance use. At the time the 3130-A was completed no safety plan surrounding marijuana use and parenting was established.
 
The 3130-A additionally states Maternal Aunt told child welfare staff she used those substances in 2015 due to peer pressure by a boyfriend. The report says Maternal Aunt told child welfare staff she ended her relationship with that boyfriend in 2015. The 3130-A further states Maternal Aunt told staff she went to therapy to develop healthier coping skills after the September 22, 2015, CPS investigation concluded. 

The 3130-A also states Maternal Aunt told child welfare staff she was currently taking Prozac and Klonopin for anxiety, but these things didn’t interfere with her ability to parent. The 3130-A doesn’t state whether child welfare staff contacted Maternal Aunt’s prescribing doctor to verify if what Maternal Aunt said was accurate. There was recognition from child welfare staff that making collateral contacts about Maternal Aunt’s medication would have been a better way to assess this situation. The 3130-A states recommended Child Two be placed with Maternal Aunt. 

Foster care records show Child Two was placed in Maternal Aunt’s home by foster care staff on January 30, 2022. These records also show that from January 30, 2022, to May 10, 2022, foster care staff completed four scheduled home visits at Maternal Aunt’s residence. Records reviewed show Child Two and Cousin were both present at each visit. OCA interviews indicated foster care staff did not view Maternal Aunt’s entire home.

During interviews conducted by the OCA investigator, it was learned foster care staff spoke to Cousin during each home visit however these discussions were not documented in MiSACWIS. The OCA was informed that the conversations with Cousin were not documented because it is not a policy requirement to interview other children who reside in the home that are not children in care.
 The child welfare staff interviewed expressed their belief that policy regarding home visits should require staff to privately interview all children residing in the foster home. 

On May 10, 2022, foster care records state Maternal Aunt, Cousin, and Child Two moved to a new home. The records indicate Maternal Aunt told the foster care staff it was only her, Cousin, and Child Two living in the new home. Records show Maternal Aunt told foster care staff her mother was watching Cousin and Child Two when she worked. Foster care records also show staff completed nine announced visits to Maternal Aunt’s home to see Child Two between May 10, 2022, and December 19, 2022. 

Foster care records show that Child Two’ mother’s parental rights were terminated on June 29, 2022. Records state when this happened, Adoption and Foster Care Specialists, Inc., began the adoption process with Maternal Aunt. Beginning in August 2022, these records state adoption staff began expressing concerns to foster care staff that they were having a difficult time contacting Maternal Aunt. The records indicate adoption staff expressed these concerns to foster care staff again in October and November 2022. The records show foster care staff spoke with Maternal Aunt about this each time, and Maternal Aunt said her lack of contact was due to being busy with work. 
 
According to MDHHS records foster care staff completed their last announced home visit to Maternal Aunt’s home on December 1, 2022. On December 19, 2022, MDHHS records show CI staff received a complaint that Maternal Aunt found Child Two unresponsive and pale at her home. These records also stated Maternal Aunt’s boyfriend, Boyfriend, was present at the home when this happened. On December 19, 2022, Maternal Aunt left Child Two with Boyfriend when she went to work. When Maternal Aunt returned home from work on December 19, 2022, she found Child Two unresponsive with Boyfriend, called 911, and took Child Two to Hurley Hospital.

MDHHS records further state Child Two had multiple bite marks on his left hand and several bruises on his head, arms, legs, buttocks, and lower back. The records also indicate Child Two had burn marks on his left hand, and “a lot of water coming out of his stomach and mouth.” Doctors suspected he drowned while in Boyfriend’s care. CI staff assigned this complaint to CPS MIC for investigation on December 19, 2022.

Review of CPS MIC’s investigation of Child Two’s death:

In addition to discovering further facts about the circumstances surrounding Child Two’ death, the OCA investigator found evidence to show Maternal Aunt’s home was a safety concern. These things were not previously known to foster care staff. The facts discovered by the OCA investigator and the outcome of the CPS MIC investigation of Child Two’ death are discussed in this section.       

CPS records state Child Two was drug tested at Hurley Hospital on December 19, 2022, and the results were positive for methamphetamine. Records also state due to his methamphetamine exposure and injuries; hospital staff admitted him for treatment.

CPS records state on December 19, 2022, Maternal Aunt admitted to CPS staff she went to work earlier that day and left Child Two alone with Boyfriend. Maternal Aunt admitted to CPS staff she used methamphetamine during the week of December 12, 2022. On December 19, 2022, CPS staff asked Maternal Aunt to complete a drug screen, she refused.

CPS records show that on December 19, 2022, CPS staff discovered Boyfriend had an active CPS investigation in Lapeer County regarding a complaint made to centralized intake on December 5, 2022. That complaint stated Boyfriend struck his seven-year-old son in the face with a closed fist, causing a split lip and bruising. CPS records say this incident occurred while at Maternal Aunt’s home. CPS records further show neither the complaint nor the CPS investigation mention that Maternal Aunt was a relative caregiver for a foster child. CPS records reviewed, and interviews conducted by the OCA investigator with CPS staff, also show the CPS staff assigned to the December 5, 2022, investigation had not made successful contact with Maternal Aunt prior to Child Two’ death. CPS staff did not know Maternal Aunt had placement of a foster child.  

The CPS records reviewed indicate CPS staff were informed by FTPD officers that a search of Maternal Aunt’s residence was performed and FTPD found methamphetamine, marijuana, and a drug scale in Maternal Aunt’s home. Officers also told CPS staff they completed a search of Boyfriend and Maternal Aunt’s phones and found that during the week of Child Two’ death there were text messages between them about quitting methamphetamine use. CPS records further show officers told CPS staff Boyfriend had four children of his own, who were all present at Maternal Aunt’s home when Child Two was found unresponsive. 

CPS records state on December 21, 2022, FTPD officers contacted CPS staff and told them medical personnel at Hurley Hospital didn’t believe the bites on Child Two’ hand were self-inflicted. Officers also said hospital personnel told them there was a bruise on the same wrist as Child Two’ bites indicating someone was holding his hand while they bit him.

CPS records also state medical personnel told officers the bites and burns on Child Two were old and caused before December 19, 2022. FTPD officers told CPS staff Boyfriend Googled “meth exposure” on his phone on December 15, 16, and 17, 2022. The records go on to say officers told CPS staff that doctors believe Child Two was probably exposed to methamphetamine on December 15, 2022. Officers told CPS staff that medical personnel believed Boyfriend and Maternal Aunt were trying to flush Child Two’ body out with water all weekend. Medical personnel came to this conclusion because Child Two’ sodium levels were extremely low.  

On December 21, 2022, officers told CPS staff when they interviewed Boyfriend, he admitted he bit Child Two and shoved methamphetamine down his throat to try to wake him up because he was “sleeping too much.” CPS records indicate Maternal Aunt completed a drug screen for CPS staff on December 21, 2022, and the results were positive for methamphetamine. 

On December 21, 2022, CPS staff filed a removal and termination petition against Maternal Aunt with the 7th Circuit Court in Genessee County. On December 22, 2022, Lapeer County CPS staff filed a termination petition against Boyfriend with the 40th Circuit Court in Lapeer County. CPS records show Cousin was placed in foster care with her maternal grandparents and Boyfriend’s children were to remain with their mothers. 

On December 22, 2022, Boyfriend and Maternal Aunt were criminally charged with 1st degree child abuse, assault with intent to murder, torture, and delivery of methamphetamine to a minor. 
  

Child Two died at Hurley Hospital on December 29, 2022. 

On June 5, 2023, Boyfriend was bound over to Genesee County Circuit on charges of felony homicide, 1st degree child abuse, felony torture, and felony-controlled substance delivery of methamphetamine to a minor.

CPS records note on January 9, 2022, CPS staff received the FTPD report regarding Child Two’ death. CPS staff entered into their records that FTPD officers completed additional searches of Boyfriend and Maternal Aunt’s phones. When officers did this, they found Maternal Aunt and Boyfriend’s Facebook accounts contained messages between them about Child Two’ injuries, how Child Two didn’t look ok, that Boyfriend was not authorized by foster care staff to watch Child Two, and their methamphetamine use.

According to CPS records, CPS staff determined Maternal Aunt and Boyfriend had been seeing one another since May 2022, but Maternal Aunt didn’t tell foster care staff about Boyfriend. CPS records also state Boyfriend had been watching Child Two since they met, frequently visited Maternal Aunt’s home and sometimes spent the night. Additionally, the records state Boyfriend’s family and friends knew he had a history of methamphetamine use. 

On March 28, 2022, CPS records state CPS staff learned from FTPD officers the medical examiner ruled Child Two’ cause of death to be methamphetamine toxicity, and his manner of death was homicide. 

The CPS investigation into Child Two’ death was concluded on May 15, 2023. The records state a preponderance of evidence was found that Maternal Aunt and Boyfriend physically abused and improperly supervised Child Two, which led to his death. CPS records also state Maternal Aunt improperly supervised her daughter, Cousin. CPS records further state Maternal Aunt and Boyfriend were placed on the child abuse and neglect Central Registry for this.  

Boyfriend released his parental rights to his children on July 20, 2023, and Maternal Aunt had her parental rights terminated to Cousin on October 8, 2024. 

The OCA investigator was informed by MDHHS staff, following the death of Child Two, Lapeer County implemented a revised best-practice standard for foster care case management. All case managers are now required to conduct unannounced home visits to the placements of children in foster care.

Boyfriend pled no contest to second degree murder, first degree child abuse, torture, and delivery of a controlled substance to a minor because of his involvement in Child Two’s death. He was sentenced to 31 to 53 years in prison on July 1, 2025.

Maternal Aunt pled no contest to first degree child abuse and delivery of a controlled substance to a minor because of her involvement in Child Two’s death. She was sentenced to 9 to 40 years in prison on July 8, 2025.

Review of MDHHS policy:

As part of the OCA investigation, the OCA investigator reviewed historical and current MDHHS policy manuals regarding the issues identified in the cases involving Child One and Child Two. The following section is a review of what MDHHS policy says about these issues. 

On June 1, 2007, the requirement for foster care staff to complete quarterly unannounced visits to homes where foster children reside was added to FOM 722-6. On July 1, 2019, this section was moved to FOM 722-06H and changed to; “unannounced visits are not required but may be made at the discretion of the case manager or supervisor”. 

Since July 1, 2019, FOM 722-06H has stated foster care staff must have at least one face-to-face contact with a legal parent in their home during the first month after their child has been removed and placed in foster care. FOM 722-06H further states that after the first contact, one face-to-face contact with the parent in their home should occur quarterly. 

Since December 1, 2017, SRM 700 has stated that criminal history checks should be completed prior to a parent having parenting time in their home. 

MDHHS foster care policy doesn't require foster care staff to:

• Complete private interviews with other children residing in a home, unless they are foster children.
• View the entire home during each visit with a foster child. 
• Drug screen a person being considered for placement of a foster child when there is reasonable cause to suspect substance abuse. 
• Interview medical or mental health providers when there is a condition reported that could affect a person’s ability to care for a child.       

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The child advocate finds that both Genesee and Lapeer County foster care staff only completed scheduled visits to the homes were Child One and Child Two were placed while they were in foster care.	MDHHS agrees.
The child advocate finds that MDHHS policy doesn't require foster care staff to conduct certain activities that would help ensure the safety of foster children. These activities include unannounced home visits; private interviews with all children residing in or frequently visiting a home where a foster child resides; viewing the entirety of the home when conducting visits; drug screening caregivers or other adults in the home when there is a reasonable cause to suspect substance abuse; and interviewing medical or mental health providers when a condition is reported that could affect a caregiver’s ability to care for a child.	MDHHS agrees in part. This consideration must be balanced with foster family rights, recruitment/retention of foster homes, and consideration that some families may have larger number of children that are older and engaged in extracurricular activities, making connection more incorporation into policy. MDHHS does agree that quarterly unannounced home visits to a home where a foster child resides should be required and policy will be amended to reflect this change. MDHHS also agrees that viewing the entirety of the home where a foster child resides when conducting each required home visit should be required and policy to be amended to reflect this change. MDHHS does not have the authority to require drug screens as part of the placement assessment or ongoing placement outside of a Children’s Protective Services investigation. Staff are not prohibited from requesting a release and speaking to a health professional or asking for medical documentation if there is a medical or mental health concern that warrants that level of followup. Staff are also not prohibited from requesting a release to speak with a health professional when there is a health concern. This allows the case manager to follow up appropriately and, if needed, safety plan, or assess the viability of the placement. The current process and requirements are consistent with federal guidance and recommendations for relative caregivers and provide the necessary flexibility to address concerns on a case-by-case basis. Unlicensed relative foster homes do not fall under licensing rules or requirements, so there is no mechanism to enforce this as a policy requirement. There is no immediate correlation between the relative caregiver’s hospitalization and their ability to provide safe care. Relative placements should also be afforded the presumption of competence to care unless the specialist finds evidence to indicate otherwise.
The child advocate finds additional efforts are needed to ensure the safety and well-being of children placed in foster care.	MDHHS agrees. There is value in continually reviewing policies and procedures to support safe placements and outcomes for our children in care.

 

Recommendations:

Recommendation	MDHHS Response to Recommendation
The child advocate recommends MDHHS provide an explanation for why FOM 722-06H was changed on July 1, 2019, to say unannounced home visits to foster children’s placements is at the discretion of the case manager or supervisor.	MDHHS agrees. This change was made based on feedback from foster care staff. Michigan is a vast and diverse state, and it was challenging for case managers to drive extended distances to foster homes to find the family was not home. This combined with the consideration that many foster families often have other children and obligations, making it difficult for them to be available for unannounced visits.
The child advocate recommends MDHHS enhance foster care policy to require foster care staff to complete additional activities that would help ensure the safety of foster children. These activities should include the following: Amend FOM 722-06H to require a minimum of quarterly unannounced home visits to a home where a foster child resides Amend FOM 722-06H to require monthly private face-to-face interviews with all verbal children residing in, or frequently visiting, a home where a foster child resides Amend FOM 722-06H to require viewing the entirety of the home where a foster child resides when conducting each required home visit Amend FOM 722-03B (section: obtaining required information) to require drug screening any caregiver or other adult in a home where a foster child will reside, when there is a substantiated CPS history involving substance abuse by the adult or if there is a reasonable cause to suspect current substance abuse Amend FOM 722-06H (section: contact with child’s caregivers) to require drug screening any caregiver or other adult in a home where a foster child resides, when there is a reasonable cause to suspect substance abuse Amend FOM 722-03B (section: obtaining required information) to require interviewing medical and mental health providers when a caregiver reports a condition that could affect their ability to care for a foster child(ren) Amend FOM 722-03 (section: unusual incident reporting) to require foster parents to notify the child placing agency when a foster parent has been hospitalized. This should also include a requirement for MDHHS staff to interview the medical and mental health providers to determine if their condition affects their ability to care for a foster child(ren)	MDHHS overall agrees in part. Amend FOM 722-06H to require a minimum of quarterly unannounced home visits to a home where a foster child resides. MDHHS agrees. Amend FOM 722-06H to require monthly private face-to-face interviews with all verbal children residing in, or frequently visiting, a home where a foster child resides. MDHHS agrees in part. This consideration must be balanced with foster family rights, recruitment/retention of foster homes, and consideration that some families may have larger number of children that are older and engaged in extracurricular activities making connection more challenging. MDHHS agrees to evaluate this further and consider for incorporation into policy. Amend FOM 722-06H to require viewing the entirety of the home where a foster child resides when conducting each required home visit. o MDHHS agrees. Amend FOM 722-03B (section: obtaining required information) to require drug screening any caregiver or other adult in a home where a foster child will reside, when there is a substantiated CPS history involving substance abuse by the adult or if there is a reasonable cause to suspect current substance abuse. MDHHS disagrees. MDHHS does not have the statutory authority to require drug screens as part of the placement assessment or ongoing placement outside of a Children’s Protective Services investigation. Amend FOM 722-03B (section: obtaining required information) to require interviewing medical and mental health providers when a caregiver reports a condition that could affect their ability to care for a foster child(ren). o MDHHS disagrees. Staff are not prohibited from requesting a release and speaking to a health professional or asking for medical documentation if there is a medical or mental health concern that warrants that level of follow-up. The current process and requirements are consistent with federal guidance and recommendations for relative caregivers and provide the necessary flexibility to address concerns on a case-by-case basis. Amend FOM 722-03 (section: unusual incident reporting) to require foster parents to notify the child placing agency when a foster parent has been hospitalized. This should also include a requirement for MDHHS staff to interview the medical and mental health providers to determine if their condition affects their ability to care for a foster child(ren). MDHHS disagrees. Unlicensed relative foster homes do not fall under licensing rules or requirements, so there is no mechanism to enforce this as a policy requirement. Furthermore, there is no immediate correlation between the relative caregiver’s hospitalization and their ability to provide safe care. Relatives should be afforded the presumption of competence to care unless the specialist finds evidence to indicate otherwise. Staff are also not prohibited from requesting a release to speak with a health professional when there is a health concern. This allows the specialist to follow up appropriately and, if needed, safety plan, or assess the viability of the placement.

PDF Version of Report:  Cases 2022-0102 2023-0002

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
February 4, 2025	July 22, 2025	August 25, 2025	2022-0315

Summary of recommendations:

The Child Advocate recommends strengthening Michigan’s child protection framework by clarifying statutory definitions, improving investigative practice for substance‑exposed infants, and enhancing CPS training. Key recommendations include amending MCL 722.622(p) to classify medically treated withdrawal in newborns as serious abuse or neglect; updating MCL 722.637(1) to align terminology and statutory references; revising PSM 716‑7 to clearly define qualified medical providers and require CPS specialists to consult treating clinicians when infants show withdrawal symptoms; and ensuring all CPS case managers receive training on the Governor’s Task Force Plan of Safe Care protocol.

Introduction to OCA:

The Office of the Child Advocate (OCA) is tasked with making recommendations to positively effect change in policy, procedure, and legislation by investigating and reviewing actions of the Michigan Department of Health and Human Services (MDHHS), child placing agencies, residential facilities providing juvenile justice services, or child caring institutions. The Child Advocate Act, Public Act 204 of 1994, also requires the OCA to ensure laws, rules, and policies pertaining to Children’s Protective Services (CPS), Foster Care, Adoption, and Juvenile Justice are being followed. The OCA is an autonomous entity, separate from the MDHHS.  
 
The OCA’s review included reading confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), CPS complaints and investigation reports, the child’s autopsy report, medical records, police reports, and substance abuse treatment records. The OCA also interviewed MDHHS staff, medical staff at the medical examiner’s office and the hospital where the child was born, law enforcement, and service providers. Due to the confidentiality of OCA investigations, the OCA cannot disclose the identity of witnesses or complainants or sources of statements and evidence.  

Case Objective: 

The objective of this review is to identify areas for improvement in the child welfare system by looking at how CPS complaints and investigations involving Child were handled by Wayne County CPS, medical professionals, service providers, and law enforcement. This review includes an analysis of Child Protection Law (CPL) and MDHHS policy regarding substance-exposed infants. The OCA discusses and provides citations to research that exists regarding the impact in-utero substance-exposure has on a neonate and a child throughout their lifetime. This review reinforces the idea that the safety and well-being of a child is a shared responsibility of the family, community, law enforcement, and medical professionals aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of Child’s case; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children.   

Given the nature of our responsibilities, the OCA review is inherently prompted by a worst-case scenario. The investigation and review aim to give a voice to the children involved. It is important for readers to understand the majority of cases investigated and managed by children’s protective services, foster care, and adoption, do not lead to the 'worst-case scenario.' The OCA has also reviewed countless instances where MDHHS’ child welfare programs have been successful for children and families, and where dedicated child welfare professionals help families remain strong and together in the face of adversity. While the OCA reviews specific cases, the items identified in the findings of this document highlight missed opportunities often observed by the OCA. If addressed by MDHHS, the OCA believes it can help prevent future instances of harm. 

Case Summary:

Date of Birth: February 24, 2022

Date of Death: April 1, 2022 

Child was five weeks old when he died on April 1, 2022.  Pursuant to MCL 722.627k, MDHHS notified the OCA of Child’s death. On December 13, 2022, the OCA opened an investigation into the administrative actions of MDHHS leading up to and regarding Child’s death. The following report summarizes the information and evidence found during the OCA’s investigation.

Family History and Background regarding Child:

Mother is Child’s biological mother. Child is her only known child. Mother identified Biological Father as Child’s biological father; however lawful paternity was never established. Mother was living at an America’s Best Value Inn motel and Biological Father was incarcerated when Child was born. Child was born premature at thirty-six weeks by caesarian section at Henry Ford Hospital on February 24, 2022. 

When Child was born, Mother was administered a urine drug screen by Henry Ford Hospital staff, and she tested positive for opiates and cocaine. Mother admitted to Henry Ford Hospital staff she was unemployed and had been using crack cocaine and heroin for more than a decade. She admitted using crack and heroin daily throughout her pregnancy with Child. She said her most recent use was on February 23, 2022. She did not receive prenatal care and left the hospital against medical advice on February 24, 2022. She initially planned to place Child up for adoption but changed her mind on March 8, 2022.  
 
Cocaine and opiates were detected in Child’s meconium drug screen. Child experienced withdrawal symptoms from his substance exposure and was diagnosed with Neonatal Abstinence Syndrome (NAS). This caused Child to be hospitalized for twenty-three days while he was treated with morphine. Child also had Hepatitis C. 
 
MDHHS Centralized Intake (CI) received a complaint about Child’s birth and withdrawal symptoms on February 24, 2022. That day, CI staff assigned the complaint to Wayne County CPS for investigation.  

The OCA’s investigation of the February 24, 2022, CPS investigation:

According to records the OCA investigator reviewed and the interviews they conducted, the CPS specialist and supervisor assigned to the February 24, 2022, CPS investigation, told Henry Ford Hospital staff Child could be discharged to Mother. As part of this decision, Mother verbally agreed to participate in substance abuse services through the Star Center (STAR), the Wayne County Early On program, Crystal Home Health’s Maternal Infant Health Program (MIHP), and MDHHS prevention services. She also verbally agreed to follow safe sleep practices, obtain baby supplies, and take Child to a pediatrician.  
 
In addition to the verbal agreements there was a written safety plan. The written safety plan asked Mother to use substances only when a sober caregiver was present to care for Child, not to transport Child when using substances and to make all controlled substances inaccessible to him. 
 
According to interviews the OCA investigator conducted, Child was discharged from Henry Ford Hospital to Mother on March 24, 2022. CPS records, and interviews conducted by the OCA investigator, indicated when Child was discharged to Mother, she was still living in the America’s Best Value Inn motel, had begun substance abuse treatment with STAR, and had obtained baby supplies. Mother also had one contact with the Early On program on March 10, 2022. 
 
CPS and Livonia Police Department (LPD) records reviewed indicate that on March 31, 2022, a resident at America’s Best Value Inn motel contacted the LPD and said Child was found unresponsive. Emergency services responded to the motel and transported Child to St. Mary Mercy Hospital, where he was declared deceased on April 1, 2022. 
 
CPS records show that CI staff were notified of Child’s death via telephone on April 1, 2022. On the same day, CI staff assigned the death complaint for investigation to the CPS specialist managing the February 24, 2022, CPS investigation.   
 
CPS records indicate the February 24, 2022, investigation was concluded after Child’s death on April 1, 2022. CPS staff found that Mother physically abused Child. CPS staff wrote in their investigation report this finding was made because Mother was unable to demonstrate the ability to “consistently nurture and supervise Child according to his developmental needs.” CPS staff also wrote in their report the withdrawal symptoms Child experienced weren’t severe as this is what Henry Ford Health’s social worker relayed to CPS. 
 
During interviews with CPS staff, it was discovered CPS didn’t speak with any doctors, nurses, or other medical personnel about whether Child’s withdrawal symptoms caused him serious injury. During interviews with Henry Ford Hospital staff, the OCA investigator was told the hospital social worker would not be able to tell CPS whether Child’s withdrawal symptoms were a severe injury or not. Henry Ford Hospital staff told the OCA investigator hospital social workers aren’t qualified to make that determination.  
 
The OCA investigator interviewed two Neonatologists, Dr. K and Dr. M. Both attended to Child while he was being treated for withdrawal symptoms at Henry Ford Hospital. The OCA was informed withdrawal symptoms by an infant caused by substance exposure, if not treated, may lead to seizures and an inability to eat. The physicians interviewed stated these can lead to death if medical treatment isn’t provided. The physicians also said even though Child didn’t experience seizures during his withdrawal, he began to show signs he might, and so pharmacological treatment had to be provided. The physicians informed the OCA fetuses exposed to substances while in utero can lead to short-term and long-term physical health, developmental, and intellectual challenges. According to these treating physicians, the more substances a fetus is exposed to, the more difficult the withdrawal symptoms are to treat. Further adding an infant who has been exposed to opiates and is having withdrawal symptoms is especially difficult to treat.

The OCA’s investigation of the April 1, 2022, CPS investigation of Child’s death:

CPS records indicate LPD officers found drug residue and paraphernalia in Mother’s motel room the same day Child died. Officers told CPS staff that Mother, and a resident staying in the room next to Mother named Resident, kept falling asleep after the LPD arrived. The LPD detective investigating Child’s death told CPS staff that Resident admitted to using heroin on March 31, 2022, prior to Child’s death. The detective said officers administered Mother a blood test on March 31, 2022, and it was positive for methadone, fentanyl, and benzodiazepines. 
 
CPS records, and the medical records the OCA investigator obtained and reviewed from St. Mary Mercy Hospital, indicated heroin paraphernalia was found near Child’s crib. 
 
The LPD report concerning Child’s death was reviewed by the OCA investigator. It states Child was already in rigor mortis when officers arrived. The report goes on to state that Mother told officers she found Child unresponsive in his crib on March 31, 2022. It also states Mother wasn’t following safe sleep practices. Officers interviewed other residents at the motel, and they said Mother and Resident appeared to be under the influence before and after law enforcement arrived.
 
The LDP report further states Mother fell asleep at the hospital after being told by officers and Henry Ford Hospital staff that Child was deceased. Officers arrested Mother after this for possession of the drug paraphernalia found in her motel room. 
 
According to CPS records, the April 1, 2022, investigation was concluded on June 17, 2022. CPS staff found that Mother improperly supervised Child. They documented this finding was made because Mother was under the influence of substances and was not able to respond to Child’s needs the night he died. The OCA investigator learned from interviews with CPS staff that Child’s autopsy report wasn’t complete until after the April 1, 2022, investigation was closed. CPS did not obtain Child’s autopsy report for their investigation.
 
The OCA investigator obtained and reviewed Child’s autopsy report during the OCA investigation. The report states Child’s cause and manner of death were both indeterminate. The report also states that one nanogram of cocaine and fentanyl were found in Child’s urine and blood, respectively. 
 
The OCA investigator interviewed the medical examiner (ME) who completed the autopsy. The ME stated they could not say whether the cocaine and fentanyl contributed to Child’s death. The ME added livor mortis found during Child’s autopsy did not align with the position Mother said Child’s body was in when she found him unresponsive. The ME informed the OCA this may indicate Child died from unsafe sleep practices, but this could not be confirmed as his cause of death.  

The OCA review of the Michigan Child Protection Law (CPL) (MCL 722.621-722.638):

MCL 722.623a requires mandated reporters to contact MDHHS CI when they have “reasonable cause to suspect, that a newborn infant has any amount of alcohol, a controlled substance, or a metabolite of a controlled substance in their body…[unless] the person knows [it’s]…the result of medical treatment administered to the newborn or their mother.” The remainder of the CPL does not specify what MDHHS is supposed to do with such complaints when they are made, or whether a newborn infant with such substances in their body is considered abuse or neglect. The CPL also does not specify whether a substance exposed newborn infant who is experiencing withdrawal symptoms that require medical treatment is considered serious physical harm. The CPL refers readers to the Michigan penal code, MCL 750.136b(1)(f) to define serious physical harm. 

The OCA review of MDHHS policy regarding substance exposed newborn infants:

MDHHS policy PSM 716-7 currently states positive toxicology of substances in a newborn infant, in and of itself, isn’t proof of child abuse or neglect. PSM 716-7 then states whether substance exposure means an infant was abused or neglected is to be determined by CPS staff based on the evidence they collect during their investigation from “medical staff”. For such exposure to be considered serious child abuse or neglect, CPS must have a “medical practitioner” confirm the infant’s exposure meets the definition of serious physical harm per MCL 750.136b(1)(f). MDHHS policy does not define what is meant by medical staff or practitioner.  

MCL 750.136B(1)(f) defines "Serious physical harm" as any physical injury to a child that seriously impairs the child's health or physical well-being, including, but not limited to, brain damage, a skull or bone fracture, subdural hemorrhage or hematoma, dislocation, sprain, internal injury, poisoning, burn or scald, or severe cut.

The OCA review of research on substance exposed newborn infants:

The detrimental short-term and long-term effects of maternal substance use during pregnancy on the fetus, neonate, and child are well documented in the research on this issue.¹ This includes, among other substances, the use of cocaine, alcohol, nicotine, amphetamines, cannabinoids, and opioids.² The use of such substances during pregnancy can cause prematurity and Neonatal Abstinence Syndrome (NAS)³.  It can also cause growth deficits, cognitive delays and impairments, and attention, behavioral, and emotional issues throughout a child’s lifetime.⁴

Neonatal Abstinence Syndrome (NAS) is a spectrum of clinical manifestations seen in neonates due to withdrawal symptoms secondary to intrauterine exposure to various drugs, including opioids, alcohol, benzodiazepines, and cocaine.⁵ Short-term withdrawal symptoms from such drugs can include high-pitched crying, irritability, tremors, feeding difficulties, respiratory distress, gastrointestinal and vasomotor issues, sleep disturbances, and seizures.⁶ In some instances, if such symptoms are not treated using pharmacology it can result in the infant’s death.⁷ NAS has also been found to cause long-term consequences for children that include neurodevelopmental delays, behavioral challenges, and premature death.⁸ 

When a newborn infant is suspected to have NAS, a scoring system called the Finnegan Score (FS), or Neonatal Abstinence Syndrome Score (NASS) are used to determine whether different withdrawal symptoms are present and whether medication (morphine, phenobarbital, clonidine, or methadone) should be administered to the newborn infant to treat the symptoms.⁹ The scoring assessment is recommended to be done every few hours during admission when the initial score is below 8.¹⁰ If the score becomes greater than eight (worsening of symptoms) the assessment must be done more frequently.¹¹ If two subsequent scores after the initial score are greater than eight, then medication should be used to stabilize the symptoms.¹² 

Presently, eighteen states have laws stating that substance use during pregnancy is child abuse, three states have laws that say substance use during pregnancy is a crime, and sixteen states have laws that health care workers must report drug abuse during pregnancy to the proper authorities.¹³

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<sub>[1] Chang G. “Maternal Substance Use: Consequences, Identification, and Interventions.” Alcohol Research. 40(2): (2020). Maternal Substance Use: Consequences, Identification, and Interventions | Alcohol Research: Current Reviews (nih.gov); Bailey, Nicole A., Diaz-Barbosa, Magaly MD. “Effects of Maternal Substance Abuse on the Fetus, Neonate, and Child.” Pediatric in Review. 39(11): 550-559 (2018). https://doi.org/10.1542/pir.2017-0201; Ross, E., Graham, D., Money, K. et al. “Developmental Consequences of Fetal Exposure to Drugs: What We Know and What We Still Must Learn.” Neuropsychopharmacology 40, 61–87 (2015). https://doi.org/10.1038/npp.2014.147; Behnke, Marylou MD, Smith, Vincent, C. MD, et al. “Prenatal Substance Abuse: Short- and Long-Term Effects on the Exposed Fetus.” Pediatrics 131 (3): e1009-e1024 (2013). https://doi.org/10.1542/peds.2012-3931  

[2] Chang, “Maternal Substance Use: Consequences, Identification, and Interventions.” Alcohol Research. 40(2): (2020); Bailey, “Effects of Maternal Substance Abuse on the Fetus, Neonate, and Child.” Pediatric in Review. 39(11): 550-559 (2018); Ross, “Developmental Consequences of Fetal Exposure to Drugs: What We Know and What We Still Must Learn.” Neuropsychopharmacology 40, 61–87 (2015); Behnke, “Prenatal Substance Abuse: Short- and Long-Term Effects on the Exposed Fetus.” Pediatrics 131 (3): e1009-e1024 (2013).

[3] Chang, “Maternal Substance Use: Consequences, Identification, and Interventions.” Alcohol Research. 40(2): (2020); Bailey, “Effects of Maternal Substance Abuse on the Fetus, Neonate, and Child.” Pediatric in Review. 39(11): 550-559 (2018); Ross, “Developmental Consequences of Fetal Exposure to Drugs: What We Know and What We Still Must Learn.” Neuropsychopharmacology 40, 61–87 (2015); Behnke, “Prenatal Substance Abuse: Short- and Long-Term Effects on the Exposed Fetus.” Pediatrics 131 (3): e1009-e1024 (2013).

[4] Chang, “Maternal Substance Use: Consequences, Identification, and Interventions.” Alcohol Research. 40(2): (2020); Bailey, “Effects of Maternal Substance Abuse on the Fetus, Neonate, and Child.” Pediatric in Review. 39(11): 550-559 (2018); Ross, “Developmental Consequences of Fetal Exposure to Drugs: What We Know and What We Still Must Learn.” Neuropsychopharmacology 40, 61–87 (2015); Behnke, “Prenatal Substance Abuse: Short- and Long-Term Effects on the Exposed Fetus.” Pediatrics 131 (3): e1009-e1024 (2013).

[5] Wachman EM, Schiff DM, Silverstein M. “Neonatal Abstinence Syndrome: Advances in Diagnosis and Treatment.” JAMA. 319(13):1362–1374. (2018). 1940-0640-9-19.pdf (springer.com); Ghazanfarpour M, Najafi MN, et al. “Therapeutic approaches for neonatal abstinence syndrome: a systematic review of randomized clinical trials.” Daru. 27(1):423-431. (2019). Therapeutic approaches for NAS.pdf; Lisonkova, S., Richter, L., et al. “Neonatal Abstinence Syndrome and Associated Neonatal and Maternal Mortality and Morbidity.’ Pediatrics 144(2): e20183664. (2019). https://doi.org/10.1542/peds.2018-3664; Merhar S.L., McAllister J.M. et al. “Retrospective review of neurodevelopmental outcomes in infants treated for neonatal abstinence syndrome.” J Perinatal. 38(5):587-592. (2018) Retrospective review of neurodevelopmental outcomes in infants treated for neonatal abstinence syndrome (nih.gov); Ordean A. & Chisamore B. “Clinical presentation and management of neonatal abstinence syndrome: an update.” Research and Reports in Neonatology 4, 75-86. (2014). https://doi.org/10.2147/RRN.S46441; McQueen K. & Murphy-Oikonen J. “Neonatal Abstinence Syndrome.” The New England Journal of Medicine 375;25. 2468-2479. (2016). Neonatal Abstinence Syndrome (nejm.org)

[6] Wachman. “Neonatal Abstinence Syndrome: Advances in Diagnosis and Treatment.” JAMA. 319(13):1362–1374. (2018); Ghazanfarpour. “Therapeutic approaches for neonatal abstinence syndrome: a systematic review of randomized clinical trials.” Daru. 27(1):423-431. (2019); Lisonkova. “Neonatal Abstinence Syndrome and Associated Neonatal and Maternal Mortality and Morbidity.” Pediatrics 144(2): e20183664. (2019); Merhar. “Retrospective review of neurodevelopmental outcomes in infants treated for neonatal abstinence syndrome.” J Perinatal. 38(5):587-592. (2018); Ordean. “Clinical presentation and management of neonatal abstinence syndrome: an update.” Research and Reports in Neonatology 4, 75-86. (2014); McQueen. “Neonatal Abstinence Syndrome.” The New England Journal of Medicine 375;25. 2468-2479. (2016).

[7] Lisonkova, S., Richter, L., et al. “Neonatal Abstinence Syndrome and Associated Neonatal and Maternal Mortality and Morbidity.” Pediatrics 144(2): e20183664. (2019). https://doi.org/10.1542/peds.2018-3664

[8] Wachman. “Neonatal Abstinence Syndrome: Advances in Diagnosis and Treatment.” JAMA. 319(13):1362–1374. (2018); Ghazanfarpour. “Therapeutic approaches for neonatal abstinence syndrome: a systematic review of randomized clinical trials.” Daru. 27(1):423-431. (2019); Lisonkova. “Neonatal Abstinence Syndrome and Associated Neonatal and Maternal Mortality and Morbidity.” Pediatrics 144(2): e20183664. (2019); Merhar. “Retrospective review of neurodevelopmental outcomes in infants treated for neonatal abstinence syndrome.” J Perinatal. 38(5):587-592. (2018); Ordean. “Clinical presentation and management of neonatal abstinence syndrome: an update.” Research and Reports in Neonatology 4, 75-86. (2014); McQueen. “Neonatal Abstinence Syndrome.” The New England Journal of Medicine 375;25. 2468-2479. (2016).

[9] Bagley, S.M, Wachman E.M., et al. “Review of the assessment and management of neonatal abstinence syndrome.” Addiction Science & Clinical Practice 9:19 (2014). http://www.ascpjournal.org/content/9/1/1

[10] Bagley. “Review of the assessment and management of neonatal abstinence syndrome.” Addiction Science & Clinical Practice 9:19 (2014).

[11] Bagley. “Review of the assessment and management of neonatal abstinence syndrome.” Addiction Science & Clinical Practice 9:19 (2014).

[12] Bagley. “Review of the assessment and management of neonatal abstinence syndrome.” Addiction Science & Clinical Practice 9:19 (2014).

[13] Newborn Drug Test States 2024. (2024-07-07). World Population Review. https://worldpopulationreview.com/state-rankings/newborn-drug-test-states</sub>

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Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The child advocate finds that Michigan law, specifically the child protection law, does not adequately address the harm caused to newborn infants when they are experiencing withdrawal symptoms from non-prescribed substance exposure while in utero.	MDHHS disagrees. MCL 722.623 (a) requires a mandated reporter who knows or has reasonable cause to suspect based on the infant’s symptoms, that the infant has any amount of alcohol, a controlled substance, or a metabolite of a controlled substance in their body, not attributed to medical treatment, to make a referral of suspected child abuse/neglect to Centralized Intake. Withdrawal not attributed to medical treatment is considered a symptom requiring a referral. The law appears clear regarding which referrals must be reported to Centralized Intake. MDHHS then operationalizes the statutory requirement further by outlining which referrals must be screened in for investigation, which includes infants born exposed to substances not attributed to medical treatment when symptoms suggesting exposure, which may include withdrawal, are present. Children’s Protective Services (CPS) investigates referrals alleging an infant was born exposed to substances not attributed to medical treatment when exposure is indicated by any of the following: Positive urine screen of the infant. Positive result from meconium testing. Positive result from umbilical cord tissue testing. A medical professional report(s) the child has symptoms that indicate exposure. If screened in for investigation, CPS must assess child safety and family well-being throughout the course of the investigation and determine the case outcome based on the evidence gathered, including whether further intervention is needed by the department or the court. In addition, a Plan of Safe Care (POSC), a family-centered plan designed to ensure the safety and well-being of infants who have experienced prenatal substance exposure and their families, should be co-developed with the family during an investigation and revisited throughout the duration of any ongoing child welfare involvement.
The child advocate finds child protection law MCL 722.637(1) refers to a severe physical injury and references section 8 for definitions. This is the only section of child protection law containing the word “severely” or a derivative of the word severe. “Severe” physical injury is not defined in child protection law. MCL 722.637(1) refers the reader to section 8 for a definition of severe physical injury. Definitions are provided in section 2 (MCL 722.622) of the child protection law.	MDHHS agrees. This error was identified following Central Registry reform legislation in 2022. Any references to severe physical injury should have been updated to reflect serious physical harm to align with other references in statute. Serious physical harm is referenced in MCL 722.622 and defined in MCL 750.136b.
The child advocate finds that current MDHHS policy surrounding substance exposed infants who are experiencing withdrawal symptoms is insufficient. Current MDHHS policy instructs CPS to contact “medical staff” to determine if the evidence available is indicative of abuse or neglect. In order to determine if serious physical abuse has occurred, policy instructs CPS to contact “a medical practitioner” to confirm the exposure or related symptoms meets the definition of serious physical harm. Policy does not define what individuals constitute “medical staff” or “a medical practitioner.”	MDHHS disagrees. Medical practitioner is defined in PSM 711-4. A medical practitioner is one of the following: A physician or physician’s assistant licensed or authorized to practice under part 170 or 175 of the public health code, MCL 333.17001 to 333.17088 and MCL 333.17501 to 333.17556. A nurse practitioner licensed or authorized to practice under section 172 of the public health code, MCL 333.17210. MDHHS agrees to consider aligning the language in PSM 716-7 to require consultation with a medical practitioner.
The child advocate finds that during the February 24, 2022, CPS investigation, CPS staff didn't contact the correct medical “staff” or “practitioner” to determine the level of harm caused or likely to be caused by the withdrawal symptoms Child was experiencing. Anecdotally the OCA’s review of child death cases has revealed a pattern where, in prior CPS investigations, CPS staff fail to make contact with the medical providers who have specific knowledge about a child’s medical condition, how it developed, and how it is being treated.	MDHHS agrees. MDHHS acknowledges review of the anecdotal statement.
The child advocate finds there is no requirement in CPS policy to speak with the treating medical provider who has specific knowledge of the child’s medical condition, how it developed, and how it is being treated.	MDHHS disagrees. PSM 716-7 requires that investigations involving infants exposed to substances or alcohol also include the following: Contact with medical staff to obtain the following information, if available: Results of medical tests indicating infant exposure to substances and/or alcohol. The health and status of the infant. Documented symptoms of withdrawal experienced by the infant. Medical treatment the infant or birthing parent may need. Observations of the parent's care of the infant and the parent's response to the infant's needs. To be considered serious physical abuse, a medical practitioner must confirm the infant's exposure, and any related symptoms, meet the definition of serious physical harm. Interview with the infant's parents and any relevant caregivers to assess the need for a referral for substance use disorder prevention, treatment, or recovery services.

Recommendations:

Recommendation	MDHHS Response to Recommendation
The child advocate recommends the Michigan Legislature amend the child protection law to add the following language to MCL 722.622(p) regarding what constitutes a confirmed case of serious abuse or neglect: 722.622 Definitions. Sec. 2. (p) adding a new subsection MCL 722.622(p)(vi): A newborn infant experiencing withdrawal symptoms from alcohol, a controlled substance, or a metabolite of a controlled substance, they were exposed to while in utero that needs to be medically treated, unless the alcohol, controlled substance, metabolite of a controlled substance, or the child's symptoms are the result of medical treatment administered to the newborn infant or his or her mother.	MDHHS disagrees. Department policy operationalizes the statutory definitions of child abuse and child neglect and the required elements to reach a confirmed finding. Policy also permits case managers to assess whether the criteria for serious physical harm are met, which may result in the need for court intervention. Further, penalizing a parent struggling with substance use during and after pregnancy by placing them on Central Registry, following any confirmed finding of this nature, may have unintended consequences and a disproportionate impact on marginalized communities. An approach that prioritizes prevention, treatment, and support for pregnant and parenting individuals with substance use disorders is the department’s current focus and is supported by implementation of the federally mandated Plan of Safe Care (POSC) Protocol. MDHHS is actively partnering with the Michigan Public Health Institute (MPHI) and other critical partners to implement an enhanced POSC, with the support of a comprehensive training series and toolkit, to improve outcomes for infants and their families. The POSC is designed to ensure the safety and well-being of infants who have experienced prenatal substance exposure and their families with an emphasis on prevention, treatment, and support.
The child advocate recommends the Michigan Legislature amend child protection law MCL 722.637(1) by removing the term “severely” and replacing it with “seriously” and removing the reference to section 8 and referring readers to section 2. Suggested language: Sec. 17. (1) Except as provided in subsection (2), within 24 hours after the department determines that a child was seriously physically injured as defined in section 2, sexually abused, or allowed to be exposed to or have contact with methamphetamine production, the department shall submit a petition for authorization by the court under section 2(b) of chapter XIIA of 1939 PA 288, MCL 712A.2.	MDHHS agrees. Child Protection Law should be updated throughout to reflect serious physical harm/seriously physically harmed for consistency.
The child advocate recommends MDHHS amend PSM 716-7 regarding investigations involving infants exposed to alcohol or substances. PSM 716-7 should define medical staff, or practitioners, to mean the child’s treating medical provider who has received formal training to practice medicine. This should include individuals such as a physician, nurse, or other medical provider who are qualified to report about the infant’s physical health, medical treatment being provided to the child for withdrawal symptoms, and what that medical treatment involves.	MDHHS agrees. Medical practitioner is defined in PSM 711-4 as follows: A physician or physician’s assistant licensed or authorized to practice under part 170 or 175 of the public health code, MCL 333.17001 to 333.17088 and MCL 333.17501 to 333.17556. A nurse practitioner licensed or authorized to practice under section 172 of the public health code, MCL 333.17210. MDHHS will enhance PSM 716-7 to mirror or link the language reflected in PSM 711-4.
The child advocate recommends MDHHS amend PSM 716-7 to add new language requiring CPS specialists to contact and speak with the substance exposed infant’s treating medical provider when a newborn infant is experiencing withdrawal symptoms from that exposure. When doing so, CPS specialists should determine the status of the infant’s physical health, if they are receiving any medical treatment for the withdrawal symptoms, what that medical treatment involves and if the infant's exposure and any related symptoms meet the definition of serious physical harm.	MDHHS disagrees. PSM 716-7 requires that investigations involving infants exposed to substances or alcohol also include the following: Contact with medical staff to obtain the following information, if available: Results of medical tests indicating infant exposure to substances and/or alcohol. The health and status of the infant. Documented symptoms of withdrawal experienced by the infant. Medical treatment the infant or birthing parent may need. Observations of the parent's care of the infant and the parent's response to the infant's needs. To be considered serious physical abuse, a medical practitioner must confirm the infant's exposure, and any related symptoms, meet the definition of serious physical harm. Interview with the infant's parents and any relevant caregivers to assess the need for a referral for substance use disorder prevention, treatment, or recovery services.
The child advocate recommends all CPS case managers be trained on the Michigan Governor’s Task Force on Child Abuse and Neglect plan of safe care protocol.	MDHHS agrees. MDHHS is actively partnering with MPHI and other critical partners to implement the enhanced POSC, with the support of a comprehensive training series and toolkit, to improve outcomes for infants and their families. The training series is expected to roll out in 2025. The department’s training unit will also train on the enhanced protocol moving forward.

PDF Version of Report:  Case 2022-0315 

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
April 28, 2025	July 22, 2025	August 25, 2025	2023-0379

Summary of recommendations:

The Child Advocate recommends strengthening Michigan’s response to child strangulation by developing a dedicated medical and investigative policy, expanding staff training, and ensuring all allegations receive expert review. Key actions include partnering with TISP or a similar entity to create evidence‑based guidance; training all MDHHS and centralized intake staff on the lethality and often invisible nature of strangulation; discontinuing intake‑level judgments about the “excessiveness” of reported incidents; requiring all strangulation complaints to be assigned for investigation; and incorporating non‑fatal strangulation content into mandated reporter training.

Introduction to OCA:

The Office of the Child Advocate (OCA) is tasked with making recommendations to positively effect change in policy, procedure, and legislation by investigating and reviewing actions of the Michigan Department of Health and Human Services (MDHHS), child placing agencies, or child caring institutions. The Child Advocate’s Act, Public Act 204 of 1994, also requires the OCA to ensure laws, rules, and policies pertaining to Children’s Protective Services (CPS), Foster Care, Adoption, and Juvenile Justice are being followed. The OCA is an autonomous entity, separate from MDHHS.  
 
The OCA investigator’s review included reading confidential records and case documentation located in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), the MDHHS Centralized Intake (CI) Portal, police reports, peer reviewed published research articles, brochures, diagrams, power points, handouts, and other educational documents related to strangulation and child abuse. The OCA also conducted interviews with CI staff and subject matter experts regarding strangulation and child abuse. The subject matter experts are employed at the Training Institute on Strangulation Prevention (TISP), C.S. Mott Children’s Hospital, Children’s Hospital of Michigan, and the Michigan Commission on Law Enforcement Standards (MCOLES). In total, sixteen different individuals were interviewed. Due to the confidentiality of OCA investigations, the OCA cannot disclose the identity of witnesses or complainants or sources of statements and evidence.  

Case Objective:  

The objective of this review is to identify areas for improvement in the child welfare system by looking at how CPS complaints involving the strangulation of Child were handled by CI and CPS staff, and law enforcement. This review reinforces the idea that the safety and well-being of a child is a shared responsibility of the family, community, MDHHS, law enforcement, and medical professionals aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of complaints about strangulation; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children. 

The investigation and review aim to give a voice to the child, or children involved. The OCA has undertaken a comprehensive review of various cases where MDHHS has successfully implemented child welfare programs, demonstrating the dedication of professionals who support families in maintaining their resilience and unity during difficult periods. While the OCA's analysis centers on specific cases, the insights presented in this document highlight common areas for improvement that have been consistently observed. The OCA respectfully suggests that by addressing these recurring issues, MDHHS could significantly contribute to preventing potential harm in the future.

Case Background: 

Date of Birth: October 16, 2008

Child was fourteen years old when the first complaint about her adoptive father, Adoptive Father, strangling her was made to CI on May 12, 2023. On August 23, 2023, the OCA opened an investigation into the administrative actions of MDHHS concerning eight different CPS complaints made about Adoptive Father strangling Child. The following report summarizes the information and evidence found during the OCA’s investigation. 

Family History and Background:

Biological Mother is the biological mother of Child (14 at time of investigation) and Sibling One Geer (10 at time of investigation). Adoptive Father is the biological father of Sibling One and the adoptive father of Child. Biological Mother and Adoptive Father are married. Child’s biological father’s identity is unknown. According to CPS records, his parental rights were voluntarily terminated to Child. Biological Mother, Adoptive Father, Child, and Sibling One live together in a home in Clinton County.

Summary of the complaints made, and the CPS investigation completed regarding Adoptive Father strangling Child:

On May 12, 2023, a mandated reporter made a complaint to CI stating Adoptive Father hit Child in the back of her head during a disagreement and later “choked” her. According to the complaint Child did not have marks, bruises, or injuries from this incident. CI staff didn’t assign this complaint for a CPS investigation. CI staff documented the complaint didn’t meet the definition of child abuse or neglect because there was no indication Child was injured.

On May 25, 2023, a mandated reporter made a complaint to CI stating when Biological Mother picked up Child from school today Biological Mother confronted Child about a vape device she found in Child’s room. Because of this, Biological Mother told Child she would have to walk fifteen miles home from school. Biological Mother then left the school. Child’s grandfather showed up while Child was walking home, and he took her to his home. Several weeks prior to this, Adoptive Father “choked” Child and slapped her on the top of her head. No marks or bruises were reported, but Child was afraid of Adoptive Father. CI staff didn’t assign this complaint for a CPS investigation. CI staff documented the complaint didn’t meet the definition of child abuse or neglect because there was “[n]o indication of harm.” 

On May 26, 2023, five complaints were made to CI regarding Child being “choked” by Adoptive Father. The first complaint was made at 11:32 am. This complaint stated on May 25, 2023; Child’s parents made her walk home from school. Child was one mile into the walk and her grandfather showed up and took her to his home. A week prior to this, Adoptive Father put his hands around Child’s neck and hit her on the back of the head. CI staff documented the referral source didn’t say that Child had any marks, bruises, or injuries, but the relative was concerned about the safety and well-being of Child. CI didn’t assign this complaint for a CPS investigation. CI staff documented the complaint didn’t meet the definition of child abuse or neglect because Child didn’t have any marks, bruises, or injuries.

Another complaint was made to CI on May 26, 2023, at 6:00 pm. This complaint stated there were ongoing issues between Child and Sibling One that has led to verbal arguments and physical altercations. The relative stated Adoptive Father and Child will wrestle, and one time Adoptive Father hit Child on the shoulder. The relative didn’t know if Child was injured.

At 6:12 pm on May 26, 2023, a mandated reporter contacted CI to make another complaint. They stated two weeks ago Adoptive Father put his hands around Child’s neck and law enforcement was called. The mandated reporter said law enforcement was involved with the family again on May 26, 2023. They said on this date law enforcement was called to do a child welfare check on Child. When law enforcement completed the check, they didn’t have any concerns. The mandated reporter also stated Child’s parents drink alcohol and smoke marijuana in her presence. CI staff added the mandatory reporter and information they provided to the complaint made at 6:00 pm. 

At 6:14 pm on May 26, 2023, a third relative made another complaint to CI. This complaint stated that two weeks ago Adoptive Father got upset with Child and responded by putting his hands around her neck and she could not breathe. The relative didn’t know how long this had occurred but Child had red marks around her neck after the incident. The relative stated Child was afraid of Adoptive Father and scared to be at home with him. Child stayed the night with the relative on May 25, 2023, but on May 26, 2023, Adoptive Father picked her up. When Adoptive Father picked her up, Child hid from him. This caused Adoptive Father to become “belligerent,” and he made her leave with him. The relative also reported Child’s parents made her walk home from school on May 25, 2023, but while she was walking home a relative picked her up. The relative making the complaint said Biological Mother is threatening to make Child sleep in a tent outside as a form of punishment.

The fifth and final complaint made on May 26, 2023, was made by one of the relatives who had made a complaint to CI earlier that day. Their new complaint was made at 6:26 pm and it stated Adoptive Father slapped Child across the back of the head a few days ago and she had a headache for several days. They said Adoptive Father also “choked” Child two weeks ago and this left bruises around her neck. They further stated Adoptive Father calls Child names like “retard” and “bitch,” and both parents lock Child in her room at night. Child said she would rather kill herself than live with her parents. The relative was concerned because Child had access to her parents’ guns.

Excluding the first complaint made on May 26, 2023, at 11:32 am, all the other complaints made to CI on May 26, 2023, were assigned to CPS for investigation as one complaint. CI staff documented they assigned this complaint because Child sustained red marks on her neck, couldn’t breathe due to being “choked” by Adoptive Father, and Adoptive Father slapped Child repeatedly on the back of her head, which resulted in Child having a headache for several days.

No preponderance of evidence of abuse or neglect was found by CPS staff during their investigation of the assigned May 26, 2023, complaint. CPS documented this decision was based on Child telling them Adoptive Father never grabbed her around her neck and Child telling Forest View Hospital staff she and her grandfather lied to police about Adoptive Father “choking” her.  

On May 27, 2023, a complaint was made to CI. The complaint stated on May 24, 2023; Biological Mother was threatening to make Child sleep in a tent because she (Child) was no longer welcome in the home.  The complaint also said Adoptive Father put Child in a “chokehold,” was threatening to put her head through a wall, and smacks her on the back of the head all the time. The complaint also documented that Biological Mother had to stop Adoptive Father from shaking Child while he was “choking” her. The family friend didn’t know if Child had any type of injuries from these incidents. CI staff didn’t assign this complaint for a CPS investigation. CI staff documented the complaint didn’t meet the definition of child abuse or neglect because there were no known marks, bruises, or injuries.

Interviews with medical and legal experts and research regarding strangulation:

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The child advocate emphasizes that all instances of strangulation carry the potential to be life-threatening.	MDHHS acknowledges review of this statement.
The child advocate finds all reports of strangulation to a child by an adult should be considered alleged child abuse, regardless of the presence of visible injuries.	MDHHS agrees in part. To screen in a referral involving allegations of strangulation, the department must consider whether the adult alleged to have strangled the child is considered a person responsible. The Structured Decision Making (SDM) Centralized Intake Assessment utilized by Centralized Intake (CI) staff at the point of intake does not require an injury be visible to select, and assign for, physical injury. If there are allegations of strangulation and no visible injuries, Centralized Intake will assess the elements captured in the following sub-item for physical injury: Dangerous behavior or excessive action toward the child AND current behavior could cause serious physical injury, including unsafe use of physical restraint. If the adult alleged to have strangled the child is considered a person responsible and allegations meet the criteria for physical injury, whether an injury is visible or not, the referral should be screened in for investigation assuming the allegations have not been, or are not currently being, investigated.
The child advocate finds the only way to determine the extent of an injury from strangulation is for a full, thorough, and complete investigation to be conducted by CPS and law enforcement.	MDHHS agrees in part. To screen in a referral involving allegations of strangulation, the department must consider whether the adult alleged to have strangled the child is considered a person responsible. If the adult alleged to have strangled the child is considered a person responsible and the allegations meet the criteria for physical injury, whether an injury is visible or not, the referral should be screened in for investigation. At that point, a full, thorough, and complete investigation should be conducted by CPS and law enforcement
The child advocate finds that when a child has allegedly been strangled, that child should be evaluated by a medical professional who has training on strangulation, its seriousness and lethality. The medical evaluation completed should include a neurological examination.	MDHHS agrees in part. In instances where strangulation is alleged and a medical exam is obtained, CPS relies on the medical provider to assess the needs of, and any injury to, the child, and what additional evaluation, testing, and/or referrals may be needed. To determine the feasibility that every child who has allegedly been strangled can be evaluated by a medical professional who has training on strangulation, its seriousness, and lethality, including a neurological examination, MDHHS will discuss this finding with the Children’s Services Administration’s (CSA) Medical Advisory Committee (MAC). The MAC is comprised of child abuse pediatricians and other medical experts from across the state who help inform the department’s policy and procedures from a medical perspective. The MAC will also have additional insight into access, especially in rural areas, and how timely neurological examinations can be completed.
The child advocate finds CI staff members and law enforcement officials interviewed during this investigation were unaware of the difference between choking and strangulation.	Agree in part. MDHHS agrees that Centralized Intake employees were not trained in the difference between choking versus strangulation at the time that OCA was collecting data for this report in 2023. MDHHS cannot speak to what law enforcement officials may have known regarding choking or strangulation.
The child advocate finds CI staff are attempting to determine the excessiveness of a strangulation through discussions on the phone with reporting sources.	MDHHS agrees in part. The goal of Centralized Intake is to focus on initial fact gathering and evaluation of information to determine not only the validity but the severity of the intake, whether it meets statutory criteria for investigation, and to assess the level of risk to the child. Evaluation of the referral information determines the nature and priority of the initial response.
The child advocate finds CI staff are not assigning strangulation complaints for investigation by CPS unless the child loses consciousness, can’t breathe, or has a visible injury.	MDHHS disagrees. Centralized Intake staff are trained to determine if the allegations of abuse/neglect, which would include choking/strangulation allegations, meet assignment criteria under the Michigan Child Protection Law and MDHHS Children Protective Services intake policy. The Structured Decision Making (SDM) Centralized Intake Assessment, utilized by Centralized Intake staff at the point of intake, does not require an injury to be visible to select, and assign for, physical injury. If there are allegations of strangulation and no visible injuries, Centralized Intake will assess the elements captured in the sub-item for physical injury: Dangerous behavior or excessive action toward the child AND current behavior could cause serious physical injury, including unsafe use of physical restraint.
The child advocate finds that strangulation can cause damage to a person’s voice box or windpipe, the main arteries of the neck, psychological trauma, neurological injury, laryngeal fractures, upper airway edema, vocal cord immobility, short and long-term memory problems, traumatic brain injuries, and/or death.	MDHHS acknowledges review of this statement.
The child advocate finds only one of two CI offices were trained on strangulation, its seriousness and lethality.	MDHHS disagrees. Centralized Intake staff located in both offices were provided with the hard-copy training materials. The training was further reviewed and discussed during staff meetings.
The child advocate finds there is currently no plan to train the CI office who did not receive training on strangulation.	MDHHS disagrees. While one office was provided with in-person training, all Centralized Intake staff were provided with the hard-copy training materials, and those materials were reviewed during staff meetings.
The child advocate finds, per MCL 750.84, strangulation is a felony in Michigan which can, if found guilty, lead to up to ten years in prison, fines up to $5,000, or both.	MDHHS acknowledges the review and accuracy of this statute.

Recommendations:

Recommendation	MDHHS Response to Recommendation
The child advocate recommends MDHHS engage the TISP, or similar entity regarding development of a medical and investigatory policy surrounding intake and investigation of strangulation complaints.	MDHHS agrees to explore this recommendation further to determine whether enhancements are needed and will update policy accordingly.
The child advocate recommends all new and current MDHHS staff, including the entirety of centralized intake staff who have not been trained, be trained regarding strangulation, the seriousness and lethality of it, and how often strangulation results in observable or photographable injuries.	MDHHS agrees in part. Training in choking and strangulation should be developed and trained by the Office of Workforce Development and Training. However, as mentioned previously, the structured decision-making tool assists in delineating whether an action by a person responsible was excessive, regardless of the presence of marks or bruises.
The child advocate recommends centralized intake discontinue efforts to try to determine the “excessiveness” of a strangulation complaint based on whether the child lost consciousness, couldn’t breathe, or had marks, bruises, or other injuries. The decision whether a child was strangled and injured from the incident should be determined by those investigating it.	MDHHS agrees in part. It is Centralized Intake’s function to focus on initial fact-gathering and evaluation of information to determine whether it meets statutory criteria for investigation and to assess the level of risk to the child. Evaluation of the referral information determines the nature and priority of the initial response. The decision whether a child was strangled and injured from the incident should be determined by those conducting the investigation.
The child advocate recommends centralized intake assign all complaints about strangulation for investigation so child protection experts and specialists can determine what happened to the child, and whether they were harmed.	MDHHS disagrees. To screen-in intakes regarding strangulation, Centralized Intake must consider if the perpetrator is a person responsible for the child’s health and welfare. The intake must be vetted to determine the validity of the intake, to determine if it meets criteria outlined in the child protection law and identify the maltreatment types. MDHHS does agree to require more in-depth questioning at the intake level and to collaborate with external professionals to include suggested questions on the structured decision-making tool.
The child advocate recommends MDHHS train mandated reporters on non-fatal strangulation. This can be placed in MDHHS developed mandated reporter training.	MDHHS agrees to share this recommendation with the Michigan Public Health Institute (MPHI) for consideration in the development of enhanced mandated reporter training curriculum as part of an ongoing project.

PDF Version of Report:  Case 2023-0379

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
April 22, 2025	July 22, 2025	August 25, 2025	2024-0139

Summary of recommendations:

The Child Advocate recommends strengthening foster care practice and oversight by increasing staffing support, improving petition‑writing capacity, and enhancing the consistency and accountability of Temporary Voluntary Agreements (TVAs). Key actions include securing funding for additional administrative staff and dedicated petition‑writing specialists; implementing statewide TVA tracking and designating county‑level approvers for extensions; amending CPS policy 713‑01 to clarify TVA timelines, require management approval for extensions, and ensure parents are offered and documented for visitation; and requiring annual training for MDHHS staff on TVAs and safety planning.

Introduction to OCA:

The Office of the Child Advocate (OCA) is tasked with making recommendations to positively effect change in policy, procedure, and legislation by investigating and reviewing actions of the Michigan Department of Health and Human Services (MDHHS), child placing agencies, child caring institutions, or certain facilities offering Juvenile Justice services. The Child Advocate’s Act, Public Act 204 of 1994, also requires the OCA to ensure laws, rules, and policies pertaining to Children’s Protective Services (CPS), Foster Care, Adoption and Juvenile Justice are being followed. The OCA is an autonomous entity, separate from the MDHHS.  
 
This OCA review included reading confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), service reports and social work contacts. The OCA also interviewed MDHHS staff, and reviewed law and policy surrounding temporary voluntary arrangements (TVA). Due to the confidentiality of OCA investigations, the OCA cannot disclose the identity of witnesses or complainants or sources of statements and evidence.  

Case Objective:

The objective of this review is to identify areas for improvement in the child welfare system by looking at how the case involving Child was handled by Wayne County MDHHS. This report is not intended to place blame, but to highlight areas of concern regarding the case, inform policy, procedure, and practice of MDHHS and partners within the child welfare system, and advocate for changes within it on behalf of similarly situated children.

Case Summary:

Date of Birth: August 8, 2021

This case came to the attention of the OCA after a complaint was received regarding Child being kept in a TVA for approximately eight months. During this time, it was alleged that Child and his mother did not have services in place, and Child’s mother was being denied the ability to visit with Child. 

Prior to opening a full investigation on this case, a preliminary investigation was completed by OCA Public Education and Intake (PEI) Unit staff. At the time of the preliminary investigation, Child’s case was identified in MiSACWIS as a Category I¹ ongoing services case with no documented petition or documented TVA. Investigations categorized as a category I require the filing of a petition under Michigan law. Additionally, if the department requests a parent enter into a TVA, the TVA is required to be formally documented with signatures from the parents and case manager showing their agreement to the TVA. The TVA is required to be uploaded to the electronic case management system. Additionally, PEI staff could not locate evidence Child was visiting with his mother.  A full investigation was opened on April 24, 2024, to determine the reason for the extended TVA, why there was a delay in filing a petition, if Child was visiting with his mother, and if family services were offered to Child and his mother.

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CPS Policy Review: 

Review of August 2023 CPS Investigation:

Additional OCA Evidence:

Additional Cases with Similar Issues:

The OCA has observed the misuse of safety plans and TVAs in additional cases. The TVAs were used in lieu of filing timely petitions.

• OCA preliminary investigation, 2024-0264, concerned the death of Child Two. Child Two died as a result of natural causes. Prior to Child Two’s birth there was a CPS investigation (MDHHS investigation case #165933449) which addressed concerns for the mother’s substance use causing neglect in the home. TVAs were implemented for Child Two’s siblings, Sibling 2 and Sibling 3. Sibling 2 was placed in a TVA with his grandmother, while Sibling 3 was placed in a TVA with her legal father. These TVAs were initiated on April 5, 2024, and were documented to be in place until April 5, 2025.
• OCA investigation 2024-0076 concerning Child Three (MDHHS investigation case #156423373) came to the OCA’s attention over concerns of a petition not being filed, no visitation between the mother and the children, the children missing school, and no signed TVA in place. By April 2024, when the OCA opened its full investigation, the children had been with a relative since December 20, 2023. When asked about the delay in filing a petition for this case, MDHHS staff advised being “slammed” with multiple cases that had “high needs”, and the children were in safe placements at the time. The OCA was provided evidence to show Child Three’s mom was not having visits with the children during the extended safety plan.
• OCA investigation 2024-0254 concerning the death of Child Four (MDHHS investigation case #168803516) involved safety plans and TVAs being utilized in lieu of a petition being filed. On April 29, 2024, CPS responded to the home and found both parents were highly intoxicated. CPS was unable to create a safety plan with the parents due to their high level of intoxication. CPS contacted the police and had a family friend care for the children for the night. On April 30, 2024, CPS created a safety plan with the mother where she agreed to have a sober caretaker for her children. During this investigation, a new CPS investigation (MDHHS investigation case #176893476) was assigned after the mother was arrested for driving under the influence of alcohol with the minor children present in the vehicle. The mother was in jail, was not agreeable to a TVA and was hostile with CPS. The mother did sign the TVA form but vocalized not agreeing with the TVA. The original TVA was initiated on June 20, 2024. The children were to reside with their maternal grandmother in the mother's residence. The TVA was not readdressed until August 22, 2024, where it was noted, the TVA would be effective from August 9, 2024, to August 20, 2024. A court hearing was held on August 20, 2024, and the petition to remove the children was authorized by the court. 
  • During the investigation, the OCA observed the children's placement dates as June 20, 2024, two months prior to the court hearing. The OCA sought clarification from the Federal Compliance Division and was informed that because the TVA was not properly extended and was not agreed upon by the mother, the children were considered removed without a court order on June 20, 2024.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The Child Advocate finds MDHHS placed Child in a TVA with his great grandmother for eight months. During this time, although not directly restricted by MDHHS, Mother was unable to visit with Child. There was no signed copy of the TVA uploaded into the MiSACWIS case file.	MDHHS Agrees.
The Child Advocate finds MDHHS drafted the first petition and sent it to the Attorney General’s office for review on April 10, 2024, eight months after the incident occurred. Due to the amount of time that had passed, the lack of current risk, and the lack of services provided to the family, the petition was not supported by the Attorney General’s office and was not filed with the court.	MDHHS Agrees.
The Child Advocate finds MDHHS did not adhere to child protection law when placing Child without a court order to do so.	MDHHS Agrees.
The Child Advocate finds MDHHS is currently experiencing a staffing shortage crisis which was a factor in not having timely outcomes for Child and Mother.	MDHHS Agrees.
The Child Advocate finds in May of 2024 after Mother surrendered Child at the MDHHS office, MDHHS wrote a petition for removal. There was a 15-day delay between the date a petition was drafted by MDHHS until the petition was approved to move forward by an assistant AG.	MDHHS Agrees.

Recommendations:

Recommendation	MDHHS Response to Recommendation
The child advocate recommends MDHHS request allocations to hire additional support staff to assist case managers with obtaining records and service reports for investigations which would assist in providing some relief to case managers to attend to substantial matters involving their cases, such as filing petitions.	MDHHS disagrees. With the implementation of CCWIS, the department anticipates that family history and records will be more readily available to case managers and subsequently reduce the amount of time necessary to gather this vital information, providing time for petition writing and other essential duties. The new teaming model, that started with the first cohort in April 2025, includes family resource specialists and other supportive roles whose duties will include operational support such as assessing historical trends and prior services.
The child advocate recommends MDHHS request allocations to fund positions in larger counties at an analyst or specialist level for petition writing. The individuals hired should be experienced with court proceedings and petition writing or trained specifically for that purpose.	MDHHS agrees in part. We recognize the importance of clear and concise petitions. However, the Department finds that allocating full-time positions solely for petition writing is not an effective use of funds. Improved petition quality can be achieved through alternative methods, including: Providing hands-on training assistance. Facilitating collaboration with local court liaisons for pre- filing reviews. Establishing peer review processes within local offices. Furthermore, with readily available writing application tools, case managers have access to valuable resources that can enhance their petition writing and general communication skills, negating the need to divert money to new positions.
The child advocate recommends MDHHS track all TVAs throughout the State of Michigan to ensure TVAs are consistently reviewed. Tracking of TVAs will allow MDHHS to follow up with staff when a TVA is nearing the end of the timeframe to determine if the TVA needs an extension if a TDM needs to be scheduled with the family.	MDHHS agrees in part. In July 2024, the In Home Services Bureau assessed the number of TVAs in place at that point in time to determine the prevalence of TVAs across the state. At that time, there were approximately 132 TVAs in place across 27 counties. Tracking these from a statewide perspective would require a considerable amount of time and resources; however, MDHHS will explore what this could look like from a regional/Business Service Center (BSC) perspective and determine any next steps accordingly.
The child advocate recommends each county identify an individual to approve extensions of a TVA.	MDHHS agrees to discuss this recommendation with leadership across the state to assess the pros and cons of this approach and determine any next steps accordingly.
The child advocate recommends MDHHS amend CPS policy 713-01 as it pertains to TVAs and provide a clear timeline for case managers regarding appropriate length of TVAs and when an extension is necessary, require management approval.	MDHHS agrees and is actively working on enhancements to TVA policy, practice, and training to include that TVA’s are to be short-term in nature and only used when essential.
The OCA recommends MDHHS amend CPS policy 713-01 concerning TVAs to ensure parents are being afforded the opportunity to visit with their children while the TVA is in place. These visits should be documented within MiSACWIS to include when a parent has refused or is otherwise unable to visit their child(ren).	MDHHS disagrees. Policy and training currently state that during a temporary voluntary arrangement, case managers and/or temporary caregivers may not restrict a parent's physical custody or access to their child(ren). Parents are free to visit their children at any time during a TVA; therefore, MDHHS should not be requiring or facilitating visits and subsequently documenting them in a social work contact. This is also reiterated on the MDHHS-5433, Temporary Voluntary Arrangement form.
The OCA recommends MDHHS staff be required to complete training on TVAs and safety planning on a yearly basis.	MDHHS agrees in part. In 2024, 18 TVA trainings were provided across the state. In September 2024, a brief overview of TVAs was provided during the statewide supervisor call and CSA all-staff meeting. To date in 2025, four TVA trainings have been provided. Additionally, a TVA micro-learning is available to all staff on the Prevention, Preservation, and Protection SharePoint site and has been shared across the state on several occasions. TVA training is always available on request and should continue to be at the discretion of the BSCs and/or local office leadership based on the unique needs of staff within their offices. In addition, MDHHS has developed several micro-learnings around safety planning that are available to staff at any time. These are also maintained on the Prevention, Preservation, and Protection SharePoint site.

PDF Version of Report:  Case 2024-0139

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
November 13, 2024	Response received from MDHHS: February 7, 2025 Response received from Lincoln Park Police Department: February 13, 2025	March 14, 2025	2023-0062

Summary of recommendations:

The Child Advocate recommends strengthening Michigan’s response to child injuries and serious abuse by improving medical screening, expanding access to specialized expertise, and enhancing multidisciplinary coordination. Key actions include adding Ten‑4FACESp‑based questions to risk assessments, requiring medical evaluations within 24 hours for injuries in high‑risk locations, and establishing statewide regional child abuse medical centers staffed by Child Abuse Pediatricians. The recommendations also call for regular, prosecutor‑led MDT meetings; statutory amendments to ensure law enforcement participation as lead criminal investigators; dedicated funding for MDHHS MDT liaisons; and the creation of specialized liaison positions to support case reviews, policy alignment, and serious‑injury investigations.

The findings and recommendations in this report were shared with the Lincoln Park Police Department, the Wayne County Prosecutors
Office, and with the Michigan Department of Health and Human Services (MDHHS). Lincoln Park and MDHHS provided responses within
the 60-day response window. Wayne County Prosecutor's office did not respond. 

Prelude:

The Death of Child was caused by the two individuals Child should have received protection from. These individuals, Shane Shelton Sr. and Valerie Hamilton were held criminally liable for Child’s death. Michigan’s child advocate act requires the child advocate hold reports of findings and recommendations until there is no open criminal investigation. Shane Shelton and Valerie Hamilton were sentenced on October 11, 2024, thus ending the open criminal investigation.  The child advocate was not permitted to release this report until after the criminal sentencing of Shane Shelton Sr. and Valerie Hamilton.

Case Introduction:

Case Objective:

Case Summary:

Family History and Background:

Date of Birth: July 20, 2017

Date of Death: January 22, 2023

Mother is the birth mother of Sibling One (DOB:06/26/2013), Sibling Two (DOB: 07/20/2016), Child (DOB:07/20/2017), and Sibling Three (DOB: 12/26/2019). Sibling’s Father is the father of Sibling Three and was the live-together-boyfriend of Mother during both the 2021 and the 2023 CPS investigations. Sibling’s Father shares three children with Unrelated Adult: Non-relative Child One (DOB: 10/14/2013), Non-relative Child Two (DOB: 04/01/2016), and Non-relative Child Three (DOB: 07/16/2012). 

Sibling’s Father Two is the birth father of Sibling One. Biological Father is the birth father of Sibling Two and Child. 

At the time of Child’s death, Sibling One, Child, Sibling Two, Sibling Three, and Non-relative Child Two resided in the home with Mother and Sibling’s Father, Non-relative Child Three and Non-relative Child One resided with their mother and her other children. 

In 2021, within two years preceding Child’s death, CPS investigated allegations involving physical abuse of Child and Sibling Two by Sibling’s Father and Mother. The investigation resulted in an open services case. The scope of the OCA investigation solely involved this history, as there was no history between the 2021 services case and Child’s death. Sibling’s Father and Mother have CPS history as a couple and as individuals prior to their romantic relationship. 

Review of 2021 CPS Investigation:  

The focus of the OCA’s investigation starts in February 2021 with concerns for physical abuse of Child and Sibling Two due to bruising on their legs and buttocks. A CPS investigation was opened on February 26, 2021, and closed on April 27, 2021. 

On February 26, 2021, Sibling Two and Child were observed by their aunt with bruises all over their buttocks and legs. Child had a black eye and other bruising on his head. The children were first taken to Beaumont Hospital in Trenton by their aunt, Aunt. However, due to concerns about physical abuse, they were transferred to Detroit Children’s Hospital for specialized evaluations.

A complaint was made to CPS Centralized Intake (CI) as the bruising was suspected to be a result of physical abuse, and Sibling Two told hospital staff his mother’s boyfriend hits him and his brother. The complaint was assigned, and CPS began their investigation the same day (February 26, 2021). CPS sent a Law Enforcement Notification (LEN) to the Wayne County Prosecutor’s Office and the Brownstown Police Department. 

CPS contacted Child and Sibling Two at the hospital who were still with their aunt, Aunt. CPS documented Child was observed with bruises, swelling on his left hand, and a bruise on his left eye. CPS documented Sibling Two was observed with small red bruises on his left leg, a bruise on his right cheek, and discoloration of his left forearm. CPS attempted to interview Child, but all he verbalized was the bruises were from Sibling’s Father. Aunt (Child and Sibling Two’s Aunt) told CPS she had picked up the children from the maternal grandmother, Maternal Grandmother, who was caring for the children. Aunt further explained Sibling’s Father had dropped them off to Maternal Grandmother due to Mother being in the hospital with medical concerns. Aunt informed CPS Maternal Grandmother expressed concern to her about Child's hygiene and said she had noticed marks on him. Aunt saw the marks on Child herself while assisting him in the bathroom, leading her to take the children to the hospital for evaluation.

CPS spoke with the hospital social worker who advised CPS the children’s injuries were consistent with physical abuse. Child had more findings of physical abuse than Sibling Two. CPS documented calling and speaking with Maternal Grandmother (maternal grandmother) who said Sibling’s Father dropped Child, Sibling Two, and Sibling Three off to her home on February 25, 2021, because he needed help caring for them while Mother was hospitalized. Maternal Grandmother advised that prior to this, she had not seen her grandchildren in several weeks, and suspected Sibling’s Father of being physically abusive and controlling towards Mother. Maternal Grandmother informed CPS she observed marks on Child when giving him a bath. She inquired about how he got the marks and at first Child said he fell but then Sibling Two said, “Sibling’s Father did it.” 

CPS spoke with Mother by phone and confirmed she was hospitalized due to her own medical needs. CPS developed a safety plan with Mother where Mother agreed to have the children remain in the care of her mother, Maternal Grandmother. Mother also agreed to have Maternal Grandmother bring Sibling Three to the hospital for a medical examination. Maternal Grandmother also agreed to the safety plan and said she would care for the children as long as needed. 

CPS spoke with a police officer from the Brownstown Police Department who advised the incident did not take place within their jurisdiction, but that it occurred in Lincoln Park. CPS sent an updated LEN to Lincoln Park Police Department (PD). CPS requested well-being checks by law enforcement for Sibling’s Father’s other children who resided with their mother, Unrelated Adult. Law enforcement confirmed the well-being of the other children, who had no bruises or injuries. 

CPS conducted an in-person interview with Mother at the hospital on February 27, 2021. Mother was informed of the physical abuse findings from the children’s medical examination. The CPS investigation report documents due to Mother’s reaction and medical condition, further discussion could not occur, and CPS’ interview had to end.

On March 1, 2021, the assigned lieutenant from Lincoln Park PD left a message for CPS regarding the LEN received, to discuss the case and the need for Kids Talk interviews. CPS spoke with a detective from Lincoln Park PD on March 4, 2021, and advised Kids Talk interviews were requested but not yet scheduled. CPS informed the detective they would provide the dates once they were scheduled. 

The assigned CPS case manager spoke with Mother again on March 2, 2021, to discuss scheduling a home visit once Mother was out of the hospital. Mother remained hospitalized and did not know when she would be discharged. Mother told CPS she did not know what happened to her boys but that she also knew Sibling’s Father would never do anything to them. Mother had to cancel multiple home visits planned with CPS due to additional medical issues that caused hospitalization. 

CPS received photos of Child and Sibling Two’s injuries on March 5, 2021. These photos are documented to come from the children’s aunt, Aunt. The OCA investigator observed these photos during the OCA investigation. The photos are poor quality and hard to determine which child is which, however, the bruising observed on the children is patterned and significant. Bruising is observed on a child’s leg, buttocks, and abdomen area. There is also a photograph of a child’s hand which appears swollen, and a child with a swollen shut black eye. These were the only photos taken by anyone during the investigation.

On March 10, 2021, CPS attempted to speak with the doctor at Detroit Children’s Hospital who examined Sibling Two and Child. A message was left with another employee to have the doctor call CPS. CPS also contacted Sibling’s Father on March 10th who denied any abuse occurring in he and Mother’s home. Sibling’s Father then blamed the children’s injuries on Mother’s mother (the children’s grandmother), Maternal Grandmother. Sibling’s Father agreed to be interviewed once Mother was out of the hospital. 

Kids Talk forensic interviews were scheduled for March 18, 2021. CPS informed a Lincoln Park PD lieutenant of the interview, who advised CPS he would be present. Maternal Grandmother was also informed of the appointments for the children during a home visit on March 11, 2021. Maternal Grandmother agreed to transport the children to the interviews.

CPS conducted a home visit to Mother and Sibling’s Father’s residence on March 16, 2021. Mother and Sibling’s Father were interviewed again, this time in person, regarding the abuse allegations. Both denied any physical abuse. Mother did not believe Sibling’s Father, or her mother caused any injuries or harm to her children. Mother believed that Aunt could have been involved stating she and Aunt had not gotten along. Sibling’s Father denied disciplining the children and told CPS he believed this whole thing was a “set up”. Sibling’s Father informed CPS that Child was “accident prone”, always getting hurt, and would hurt himself with toys when he was angry. Sibling’s Father’s daughters, Non-relative Child One, Non-relative Child Two, and Non-relative Child Three, were in his care, advising CPS that Unrelated Adult (his daughter’s mother) was struggling with substance abuse and was “on the run.” CPS interviewed Non-relative Child One, Non-relative Child Two, and Non-relative Child Three separately and in a private setting. The girls made no disclosures of physical abuse or discipline in the home and told CPS they felt safe in the home with their dad and Mother. None of the girls knew how Child and Sibling Two were injured. Non-relative Child One, Non-relative Child Two, and Non-relative Child Three were documented to be free of any visible injuries.

Kids Talk interviews were conducted with Sibling Two and Child on March 18, 2021. Prior to the interviews, the Lincoln Park lieutenant informed CPS Sibling’s Father was arrested for unpaid parking tickets and was being held at the Lincoln Park police station until after the interviews. Maternal Grandmother was late arriving for the interviews and when asked questions, Maternal Grandmother could not provide the lieutenant with concrete answers regarding the timeline of events, regarding the bruising, when it was first observed, and when the children were taken to the hospital. Maternal Grandmother stated Mother cut ties with her when she began dating Sibling’s Father, that she did not approve of Sibling’s Father, and that she did not want her daughter with him. The Lincoln Park lieutenant told CPS he found this concerning and believed there could be possible coaching involved. 

Sibling Two (age 4 at the time) was interviewed first. Sibling Two is documented to “be walking around and would not sit in a chair.” When the interviewer was attempting to get Sibling Two to sit down, he randomly stated “Sibling’s Father did it.” He was asked what Sibling’s Father did. The CPS report documents Sibling Two then began motioning a punch and slapped his hands all over his body. Sibling Two is documented to say, “all over.” She asked who he did that to, and he responded with “his eye.” The interviewer attempted to get more information from Sibling Two, however he did not answer any further questions and attempted to leave the room. The interview was then ended. The CPS report documents Child (age 3 at the time) was interviewed next, but competency could not be established and two minutes after he entered the room, he was asking to leave.

Later the same day, (March 18, 2021), the Lincoln Park Lieutenant contacted CPS. The CPS report documents Sibling’s Father was interviewed and the Lieutenant told CPS he believed everything that was said to him. The Lieutenant advised CPS Sibling’s Father said he received a photo of the children from Maternal Grandmother after they were in her care without any marks. CPS was advised that during the interview, Sibling’s Father agreed to take a polygraph adding he would pass the polygraph. The Lincoln Park Lieutenant told CPS that Sibling’s Father was crying during the interview when he spoke about treating Sibling Two and Child as his own explaining he would not hurt them.

On March 24, 2021, the CPS specialist attempted, unsuccessfully, to make contact with the doctor at Children’s Hospital who examined Sibling Two and Child on February 26, 2021. CPS left a message asking for a return phone call. There is no documentation CPS ever received a return phone call from the doctor. Interviews with MDHHS staff did not yield any additional evidence showing the doctor returned the phone call.

CPS was informed by the Lincoln Park Lieutenant on March 30, 2021, that Sibling’s Father was scheduled for a polygraph, however, it was not believed he would come due to his lawyer advising him not to participate. On April 8, 2021, the Lincoln Park Lieutenant advised CPS that Sibling’s Father did not attend the polygraph. The lieutenant also advised CPS there could be several relatives interfering with the investigation due to wanting more interactions with the mother and the children. 

On April 13, 2021, CPS spoke with Mother and Sibling’s Father via phone. CPS advised the parents a case would be opened, and services would need to be participated in. Both Sibling’s Father and Mother agreed to participate in services. They agreed to a verbal safety plan of refraining from the use of physical discipline or excessive force with the children. The boys were then allowed to return to the care of Mother and Sibling’s Father 

A referral to Families First of Michigan was made on April 19, 2021. Both Sibling’s Father and Mother did not agree with an ongoing services case being open, however they verbally agreed to participate in the services provided by Families First. 

The investigation resulted in a substantiation of physical abuse of Sibling Two and Child and was dispositioned as a Category II. Sibling’s Father was identified as the abuser of Sibling Two and Child. The CPS disposition summary documents law enforcement would move forward with requesting charges for Sibling’s Father concerning physical abuse of Sibling Two and Child. An ongoing services case was opened and transferred to CPS ongoing for monitoring of services provided. 

Additional OCA Evidence Regarding February 2021 CPS Investigation:

During the OCA’s investigation, the OCA investigator reviewed the medical records concerning Sibling Two and Child. Child’s medical records note that Child told medical staff at Children’s Hospital his mother’s boyfriend hit him. The medical records documented Child had bruising all over his body and a bite mark on his right shoulder. Specifically, Child had bruising on his left eye, multiple linear (patterned) bruising in different stages of healing on his back, abdomen, thighs, and a rash on his lower extremity. Child was noted to have left periorbital ecchymosis¹, but his vision was intact. The medical documents show his left hand was swollen. Child also had multiple scabs and lumps on his head. Sibling Two was noted to have bruising on his legs, including pattern bruising over his left medial thigh. Both Sibling Two and Child’s medical records note suspected physical abuse. No photographs were taken at the hospital.

The Lincoln Park police report was also reviewed by the OCA investigator. The police report documents the case was transferred from Mott Children’s Hospital Police, which is inaccurate. The Lincoln Park police report documents an interview with the maternal grandmother, Maternal Grandmother, where it is documented Maternal Grandmother explained she took the boys to Mott Children’s Hospital in Ann Arbor and then they were transferred to Detroit Children’s Hospital. This is also inaccurate information. The OCA investigator confirmed the children were not seen at Mott Children’s Hospital in Ann Arbor nor were the Mott Children’s Hospital Police involved in this case. 

According to the Lincoln Park police report Sibling’s Father denied harming the children or causing any marks on the children, placing blame on Maternal Grandmother or Aunt. He also told law enforcement the boys play hard with one another. The Kids Talk interviews are also documented with no additional information from what was documented in the CPS report. The police report did not have any documented contact with Mother, medical staff, or any other witnesses. The records included photographs that were the same photos CPS received from Aunt during their investigation. The police report notes the investigation was turned over to the prosecutor on October 11, 2021 (approximately eight months after the incident occurred).

According to the Wayne County Prosecutor’s Office, the investigations was sent back to the Lincoln Park Police Department for more follow up. The investigations did not collect the children’s medical records and the Wayne County Prosecutor’s Office requested Lincoln Park Police Department acquire and submit the medical records with the investigation.

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_{[1] https://my.clevelandclinic.org/health/symptoms/raccoon-eyes} 

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Review of April 2021 CPS Ongoing Services Case:

The CPS ongoing case has one Updated Services Plan (USP), which is a closing report. The ongoing case was opened for the report period of April 17, 2021, to June 9, 2021. 

A Family Team Meeting (FTM) was held with Mother and Sibling’s Father by the CPS investigator on April 20, 2021. The case then transferred to an ongoing case manager on April 29, 2021. The assigned ongoing specialist contacted Mother on April 30, 2021, to arrange a home visit with the family that day. Due to the family having COVID-19, the home visit was completed virtually. Mother told the specialist that she had participated in a virtual visit with Families First as well. The specialist conducted another home visit with the family on May 13, 2021, and the children were documented to be free of injury. CPS documented going to the home but remaining outside and communicating with the family through the screen door and window due to COVID-19. Mother informed the specialist she was advised the services provided by Families First would be completed by the end of May. The USP documents, (during the report period of April 17, 2021, to June 9, 2021) that the case specialist advised Mother the ongoing services case would close after Families First services were completed. 

According to documentation in the USP, CPS did not have contact with Families First until June 8, 2021. The USP documents CPS was informed Mother completed services provided by Families First on May 16, 2021, that sessions were held three times per week via zoom, and Mother was compliant. The USP also documents Families First had no additional concerns about the family. 

The ongoing specialist held a closing FTM with Mother on June 8, 2021, documenting there were no additional safety concerns, and the case was safe to close due to Mother’s compliance with the services she was provided. Sibling’s Father was not present for this FTM. Documentation shows that the case specialist spoke with Mother and observed the children through a window and door screen at their residence, due to Mother stating she had COVID-19. The children were documented to be free of visible marks and bruises. During this time, it was approved to conduct these evaluations virtually due to the COVID-19 pandemic.

The safety assessment completed by the CPS ongoing case manager scored the family as safe with services, with safety interventions of family resources, neighbors, and other individuals in the community, and use of community agencies or services as immediate safety resources. The risk assessment completed by the CPS ongoing case manager was not properly scored as the assessment documented Mother as the only caregiver in the home. Sibling’s Father was also living in the home, was the father to one of the children living in the home and was considered a person responsible by law. The risk assessment statement regarding care providers is also inconsistent with the USP. The USP references both Mother and Sibling’s Father regarding the family’s income, employment, health, and stability, noting they were in a supportive relationship. In reviewing the “needs” section of the completed Family Assessment, ongoing needs were listed as parenting skills, stating Sibling’s Father should continue to work on his parenting skills and to maintain adequate discipline techniques. Sibling’s Father is the ‘person responsible’ listed for this goal, however, Sibling’s Father never participated in the services provided to Mother. 

The ongoing services case was closed on June 15, 2021, without Sibling’s Father’s participation.

Additional OCA Evidence Regarding April 2021 CPS Ongoing Services Case:

Interviews with MDHHS staff were conducted. Given the length of time from the OCA investigation and the 2021 CPS ongoing case, limited information was remembered by MDHHS staff. The OCA investigator was informed Families First did not know Sibling’s Father was the one to be serviced and he may not have been on the service referral. The OCA investigator was unable to determine if any additional contact with the service provider was made and not documented as MDHHS staff could not recall.  The ongoing services case concentrated on Mother and ignored Sibling’s Father’s lack of participation. The OCA was informed during interviews the reason why the ongoing case was closed was due to Mother’s successful completion of services, she did not have any other needs, and she was not substantiated for child abuse or neglect. 

The OCA investigator reviewed the Families First records for the services provided to Mother. The records document both Mother and Sibling’s Father were referred to participate in services due to concerns of physical abuse of Child and Sibling Two while in Sibling’s Father’s care. The referral documented Sibling’s Father was substantiated for physical abuse, and that neither parent was able to provide an explanation for how the injuries to Child and Sibling Two occurred. The records document the service provider was unable to fully complete Sibling’s Father’s assessment as he was not present in the home during the initial assessment visits. The service provider’s file documents that Sibling’s Father was present for two of the interactions with the service provider, and his level of participation is unclear from the reviewed documentation. The final Families First report documents only 30 of the contracted 40 hours of intervention was able to be made with the family. The lack of full participation was identified as the family canceling or missing appointments, noting “there was no specific assistance provided to the family yet.” It is documented Mother participated in services and made progress in learning new techniques for discipline and creating a routine schedule for the children, however, Sibling’s Father did not participate, interact, or provide any input. The Families First termination report documents the family will continue to be monitored through the CPS ongoing case. 

The OCA investigator interviewed Families First staff. Through these interviews it was confirmed Sibling’s Father did not participate in services, even though Sibling’s Father was referred to Families First to address parenting skills, specifically non-physical discipline techniques, creating structure and routine, how physical abuse can affect children, and proper supervision. The services provided by Families First occurred virtually due to the COVID-19 pandemic, and although he would be present in the background, Sibling’s Father did not participate. Those interviewed acknowledged it was hard to determine whether or not Mother benefitted from the services due to the visits being virtual.  
During the OCA’s investigation, the OCA investigator spoke with Dr. B, the Medical Director of the Child at Risk Evaluation (CARE) Team from Detroit Children’s Hospital about the medical evaluations completed on Child and Sibling Two in 2021. Dr. B was familiar with the case as he was a treating specialist for Sibling Three following Child’s death. 

Dr. B was not consulted by CPS during the 2021 CPS investigation and was not involved in Sibling Two or Child’s examinations or treatment.  Dr. B advised that after reviewing the medical records from the 2021 injuries, there was no doubt the injuries that Sibling Two and Child sustained were a result of physical abuse. He advised the documentation was clear that the children had several injuries indicative of child abuse. Dr. B further advised he considered the injuries significant because of the location of the bruising, explaining that the location of the bruising was not of typical childhood play and there was bruising all over their bodies. Dr. B advised that bruising in areas that you typically would not see, such as on the face, ears, and abdomen, can also indicate internal injury, and are significant. Dr. B expressed that Ten-4FACESp² could be a helpful tool to start considering significant bruising as serious physical harm/injury. Dr. B expressed the significance of CPS and/or law enforcement consulting with a medical child abuse expert when evaluating whether abuse or neglect has occurred. Dr. B reiterated that an expert should provide these medical assessments in cases involving physical abuse. 

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_{[2] TEN-4-FACESp stands for bruising to the Torso, Ears, Neck, Frenulum, Angle of the jaw, Cheeks, Eyelids or Subconjunctivae, “4” represents infants 4 months and younger with any bruise, anywhere, and “p” represents the presence of patterned bruising.}

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Review of CPS Investigation of Child’s Death, January 2023:

On January 22, 2023, Child was pronounced deceased after 911 was called to the family home. Mother stated Child had been sick the night prior and observed Child sleeping with brown puss coming from his nose and mouth. She attempted to move Child to the shower where he breathed deeply, snorted, and then stopped breathing. 911 was contacted and Child was transported to the hospital where he was pronounced deceased. Reports indicate Child’s entire body was covered in trauma, including deformities to his hip, left knee, skull, bruising all over his body, whip marks, and more linear bruises. His left toe was necrotic and falling off, with a full thickness slice between his toes, and puncture marks on his body. CPS complaints indicate Mother claimed the trauma to Child was from his siblings beating him up. Due to multiple involved parties having concerns of Child’s injuries and the mechanism of injury described by Mother, multiple complaints were made to Centralized Intake for concerns of physical abuse. 

On January 22, 2023, the CPS specialist conducted a visit to the hospital and interviewed Mother. Mother advised CPS Child had been sick, stopped breathing, and she called 911. Mother acknowledged seeing the bruising on Child but denied knowing where the bruising came from. When asked, Mother denied Sibling’s Father hits the children. She informed the CPS investigator she had been “working up the courage to bring Child to the hospital.” A safety plan was created for the other children to be cared for by Maternal Grandmother, the maternal grandmother.

CPS spoke with the doctor who examined Child. CPS was advised Child had a deformation of the skull, swelling of his neck, fracture of his vertebrae C-7, bruising around his rectum, bruising all over his body, and it looked like he had been thrown to the ground. CPS was informed by the examining doctor, that he believed Child died before January 22, 2023. Sibling Two and Sibling One were evaluated at St. John Hospital. Sibling Two had scratches on his forehead but no other obvious bruises. Sibling Two was not able to provide any information about what happened to Child. Sibling One informed CPS that Child had been sick lately, but he did not know what was wrong with him. He told CPS Child had puss coming out of his toes, and this happens because Child “pees on himself.” He further said his mom and Sibling’s Father had been giving Child a blue pill crushed up in water for his toe. He believed the pills were his grandmother’s. CPS relayed this information to law enforcement to add to the search warrant of Mother and Sibling’s Father’s home. 

CPS interviewed Unrelated Adult on January 22, 2023. Unrelated Adult is the mother of Sibling’s Father’s other children. Unrelated Adult explained Sibling’s Father dropped off Sibling Three and she was concerned with the number of marks on his body. Unrelated Adult advised CPS her children told her (Unrelated Adult) that Sibling’s Father hits the boys a lot. Unrelated Adult agreed to take her children for physical abuse examinations at Detroit Children’s Hospital. CPS learned Sibling Three had been brought to the hospital by Sibling’s Father’s sister, Aunt, after she discovered injuries on Sibling Three while at Unrelated Adult’s home. Sibling Three sustained cigarette burns, a descended abdomen, bruising on his hands and back, abrasions on his upper back, contusions to his chest, bruises on his right shoulder, limited motion in both of his hands, abrasions to his face, an abrasion on his left ear, red genitals, contusions on both lower legs, and his feet were frost bitten with a possible need for toe amputation. On January 23, 2023, Dr. B from the CARE team at Children’s Hospital confirmed all the injuries to Sibling Three were consistent with non-accidental trauma and were a result of abuse and neglect.

CPS collaborated with law enforcement during this investigation and all the children participated in forensic interviews at Wayne County Children’s Advocacy Center (CAC), Kids Talk CAC. Law enforcement provided CPS with 814 pages of text messages and Facebook messages between Sibling’s Father and Mother. These messages show ongoing maltreatment of the children by both Sibling’s Father and Mother. The text messages also showed Sibling One was forced to participate in the abuse of his younger siblings. 

During the Kids Talk interviews, Sibling One did not disclose any abuse and again told the interviewer about Child being sick and being given his grandmother’s pills. Non-relative Child Two (Unrelated Adult and Sibling’s Father’s daughter) disclosed getting hit with an open hand by her dad, and with a stick by Mother. Non-relative Child Two described the stick as a kitchen utensil, like a spoon but bigger. She also advised getting hit by Mother with an open hand on the butt, and with a belt by her dad. Non-relative Child Two disclosed Child would get hit by a belt a couple of times and she would see marks on his body. Her dad would use a belt and a cord on Child. Child would get hit on his butt and all over his body for “pooping on the floor, his bed, and stealing.” She advised Child would steal pop tarts, noodles, hot dogs, and all kinds of things. Non-relative Child Two said Mother also used a cord, a belt, and the same spoon she hits her with on Child. Non-relative Child Two said Sibling Three was also hit, she would hear both Child and Sibling Three scream, explaining that Sibling Three also had bruising all over his body. Non-relative Child Two said Child had been dead for two days as she heard her dad, Mother, and aunt talking about it. Non-relative Child Two continued to describe the conditions of how Child was treated, explaining that Child and Sibling Three would both get locked in the basement in a cold room in the house, with no blanket. During his forensic interview, Sibling Two described similar abuse. Sibling Two confirmed Sibling’s Father would hit Child and Sibling Three. Sibling Two said before Child died, he got in trouble. Sibling Two explained Child was hit with a belt or pipe by Sibling’s Father and he had bruising all over his body. 

On January 23, 2023, MDHHS filed a petition for removal of Sibling One, Sibling Two, and Sibling Three from Mother and Sibling’s Father with a request for termination of parental rights. A petition was later filed on February 09, 2023, for removal of Non-relative Child Two, Non-relative Child One, Non-relative Child Three and Unrelated Adult’s other children from the care of Unrelated Adult, requesting termination of her parental rights and Sibling’s Father’s parental rights. All the children were placed in relative foster care placements.

During the CPS investigation regarding Child’s death, CPS discovered that none of the boys were currently enrolled in school. Sibling One previously attended kindergarten but otherwise none of the boys had been in school. 

This investigation was placed in a Category I Open/Close with a preponderance of evidence supporting physical abuse and physical neglect of Sibling Three, Child, Sibling Two, Sibling One Belcher and Non-relative Child Two by Sibling’s Father and Mother. A preponderance of evidence was also found for Failure to Protect Sibling One Belcher by his father, Sibling’s Father Two, and abandonment of Sibling Two by his father Johnathan Belcher. Mother was also substantiated for medical neglect of Child. The CPS investigation was approved and closed by the supervisor on March 10, 2023. 

Sibling One and Sibling Two remain placed with relative caregivers. Sibling Three is placed in a non-relative home. 

Non-relative Child Two, Non-relative Child Three, and Non-relative Child One remain placed together with a relative caregiver.  All of the children became state wards on May 15, 2024.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The Child Advocate finds Shane Shelton Sr. and Valerie Hamilton were convicted of killing Child. Both were sentenced to life in prison on October 11, 2024.	MDHHS: Agree Lincoln Park PD: Agree
The Child Advocate finds in the 2021 child abuse investigation neither CPS or law enforcement contacted a medical child abuse expert to confirm the injuries on Sibling Two and Child were a result of non-accidental trauma.	MDHHS: Agree Lincoln Park PD: LPPD agrees that law enforcement did not contact a medical child abuse expert during the 2021 child abuse investigation. Since receiving the findings of this report, the entire patrol and investigative divisions of the department have and continue to receive training and case management protocols for child abuse and neglect investigations utilizing a multidisciplinary team approach. In addition, personnel have also received training in the TEN-4-FACESp rule.
The Child Advocate finds CPS, the treating hospital, and law enforcement did not take photographs of the injuries to Child and Sibling Two during the 2021 CPS investigation. The photographs were provided by a relative and provide no evidentiary value.	MDHHS: Agree that CPS did not take photographs Lincoln Park PD: LPPD agrees that during the 2021 investigation Law Enforcement did not take photographs of the injuries to the children and the only photographs the LPPD received were from a relative.
The Child Advocate finds the Lincoln Park police report concerning the 2021 incident documents the wrong hospital and wrong prior police agency. Additionally, law enforcement did not interview the mother, the paternal aunt, or the medical professional who examined the children.	MDHHS: No Response Lincoln Park PD: The patrol officer who interviewed and collected the information for the initial report from the maternal grandmother, is no longer employed with the department, therefore limited information is known as to what was reported to him regarding which hospital the children were taken to for evaluation by the paternal aunt. The Law Enforcement Notification (LEN) from CPS was initially sent to the Brownstown Police Department, who later sent it to LPPD after determining it was not in their jurisdiction. The CPS LEN fax cover sheet received by LPPD from Brownstown PD has "Motts Children Hospital" printed on it along with "21-3831". 21- 3821 has since been identified to be Brownstown PD's incident number which was started after they received the CPS LEN. The mother and the paternal aunt, were both separately contacted and spoke with law enforcement; however, it was not documented in a report. The mother was initially cooperative, but stopped communicating with Law Enforcement after she and the sibling's father allegedly spoke with an attorney. Interviews were not conducted by law enforcement with the medical professional who examined the children.
The Child Advocate finds a warrant packet was sent to the Wayne County Prosecutor’s Office in 2021 by Lincoln Park Police Department. This warrant packed was reviewed by the Wayne County Prosecutor’s Office on February 24, 2022. According to the Wayne County prosecutor’s office the case was returned to Lincoln Park Police Department for further investigations. The Wayne County Prosecutor requested Lincoln Park Police Department gather medical records of the abused children.	MDHHS: No response Wayne Co. Prosecutor: No response Lincoln Park PD: LPPD agrees that the 2021 case was returned by the Wayne County Prosecutor's Office requesting the medical records be collected. No further follow-up or communication occurred between law enforcement and the Wayne County Prosecutor's Office.
The Child Advocate finds the 2021 CPS ongoing services case did not ensure the substantiated perpetrator, Sibling’s Father, participated in services to address the identified needs.	MDHHS: Agree Lincoln Park PD: No response
The Child Advocate finds that closing Category II cases due to lack of cooperation from families or perpetrators is not supported by law or policy, potentially endangering children. The Child Advocate also recognizes that it is impossible to determine if Child's death could have been avoided had the case remained open and Sibling’s Father received the required services and participated in them. In 2024 the OCA closed 45 full investigations. Of those 45, 9% or four cases were identified as a Category II case closure without the persons responsible successfully completing or participating in services. Three of those four cases resulted in a child’s death.	MDHHS: Agree in part. DHHS agrees that closing a Category II solely due to non-cooperation with services, absent other factors, is not a valid reason for a case closure. MDHHS agrees that Sibling's Father's lack of cooperation should have been considered before closing the case. Other factors were considered when closing the case, including compliance with the department, and the reduced risk assessment. Lincoln Park PD: No response
The Child Advocate finds that in the 2021 investigation, although CPS and law enforcement had contact with one another, a joint multidisciplinary team (MDT) investigation did not occur. Law enforcement was unaware of the outcome of the CPS investigation. The CPS ongoing services case was closed without knowing if charges were issued against Sibling’s Father.	MDHHS: Agree Lincoln Park PD: LPPD agrees that although during the 2021 investigation, law enforcement and CPS had communication with one another, they did not coordinate their investigations collectively or with a joint MDT approach. Neither Law Enforcement nor CPS were aware of one another's outcome.
The Child Advocate finds that the Belcher children were purportedly homeschooled and thus had limited or no exposure to mandated reporters of child abuse.	MDHHS: Agree Lincoln Park PD: No response
The Child Advocate finds prior recommendations were made to MDHHS and the legislature to amend policy and law regarding the use of multi-disciplinary teams, however the recommended changes have not been made.	MDHHS: Agree in part. MDHHS recognizes the need for stronger use of multi-disciplinary teams across Michigan. MDHHS is a member of the Governor’s Task Force on Child Abuse and Neglect Child Death Investigation Protocol Utilizing a Multidisciplinary Approach subcommittee to strengthen multidisciplinary partnering and improve practice. Lincoln Park PD: No response

Recommendations:

Recommendation	MDHHS Response to Recommendation
The Child Advocate recommends MDHHS add a question to the risk assessment and the vulnerable child assessment surrounding Ten-4FACESp to help identify cases where children have injuries and help ensure proper medical examinations are completed.	MDHHS: MDHHS agrees in part. Based on the intent of the risk assessment and vulnerable child assessment, it does not appear adding a reference to TEN-4-FACESp in these assessments would meet the need identified by the OCA. Based on the identified need, MDHHS will explore an enhancement to PSM 713-04, Medical Examination and Assessment, to capture the specific areas/considerations highlighted in the TEN-4-FACESp acronym, in addition to the other circumstances outlined in PSM 713-04 that require a medical exam. Lincoln Park PD: No response
The Child Advocate recommends MDHHS require a medical assessment within 24 hours if a child presents with injuries in the locations identified in Ten-4FACESp, and that the case specialist have direct contact with the medical provider who examines the child(ren).	MDHHS: MDHHS agrees in part. Before committing to a 24-hour timeframe to complete a medical exam, MDHHS would like to consult with the department’s Medical Advisory Committee, comprised of child abuse pediatricians and providers from across the state, local child welfare leaders, and other partners to discuss the recommendation in detail to help make an informed decision. PSM 713-04 requires the following: Case managers must make efforts to speak directly with the examining medical practitioner; however, if the medical practitioner is not available, the case manager may provide the information to a professional at the medical facility and provide case manager contact information for any questions the medical practitioner may have. Attempts must be made throughout the duration of the investigation to speak to the examining medical practitioner. Efforts must be documented in social work contacts. Lincoln Park PD: No response
The Child Advocate recommends that the legislature allocate funding to establish statewide regional child abuse medical centers. These centers would be required for the MDHHS and placing agency foster care (PAFCs) to utilize for medical examinations when injuries are identified in children. The purpose of these centers is to assist CPS in directing children to the appropriate facilities for their examinations. Furthermore, it will ensure that these examinations are conducted under the guidance of a specialist, specifically a Child Abuse Pediatrician, who is trained to accurately diagnose and manage injuries. Additionally, the centers will facilitate follow-up discussions and findings with CPS workers, enhancing collaboration and care for affected children.	MDHHS: MDHHS agree in part. External partners would have to agree with this decision. Regional centers would present geographical challenges with getting the children to the facilities timely depending on the nature of their injuries. Lincoln Park PD: No response
The Child Advocate continues to recommend county prosecuting attorneys, or their designee, conduct regular MDT meetings to increase communication among members. The OCA has seen positive outcomes when the MDT is actively involved in case-by-case decision-making to facilitate and support the work of its members. The MDT can include members of law enforcement, medical personnel, mental health personnel, and Child Advocacy Centers.	MDHHS: MDHHS agrees in part. CSA agrees that there are positive outcomes when an MDT is utilized. However, CSA lacks authority over a prosecuting attorney’s willingness to conduct regular MDT meetings. Lincoln Park PD: LPPD has contacted our local Child Advocacy Center, and our investigative personnel have all and will continue to receive training, updates and case assistance through our local MDT meetings. Case management protocols from start to finish for child abuse and neglect investigations are in place and being used.
The Child Advocate recommends the Michigan Legislature amend Child Protection Law, MCL 722.628(6), to require that, as the lead criminal investigators, law enforcement be added to the MDT, along with the prosecuting attorney and the department.	MDHHS: MDHHS agrees that law enforcement is a necessary component of the MDT. Lincoln Park PD: LPPD would support this amendment.
The Child Advocate recommends the Michigan Legislature provide funding for MDHHS liaisons to the MDT for each county MDHHS office.	MDHHS: Agree. Lincoln Park PD: LPPD would support this recommendation.
The Child Advocate recommends MDHHS create positions that are solely responsible for MDT Liaison duties, which can include but are not limited to, serving as a bridge between MDT members, assisting the MDT leader in facilitating monthly MDT case review meetings, collaboration with MDHHS central office on policy changes, and actively participate in serious abuse and neglect investigations as an advisor to the MDT. Serious investigations include, but are not limited to, when a child presents with abnormal or suspicious bruising or injury, severe injury, sexual assault, or death.	MDHHS: MDHHS agrees with this recommendation, provided that the necessary funding is afforded. Lincoln Park PD: No response

PDF Version of Report:  Case 2023-0062

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
September 19, 2024	December 4, 2024	February 3, 2025	2023-0297

Summary of recommendations:

The Child Advocate recommends strengthening Michigan’s efforts to maintain sibling connections by requiring case managers to identify and document previously adopted siblings when a new child enters care, supported by regular staff communication and updates to FOM 722.03. Additional recommendations include establishing policies in both protective services and foster care to obtain information needed to locate and contact adoptive families; creating a process to assist adoptive parents who proactively reach out to be considered as placements; assessing the need for additional central adoption registry and post‑adoption inquiry staff; and ensuring all related processes are accessible to PAFCs conducting sibling searches.

Introduction to OCA:

The Office of the Child Advocate (OCA) is tasked with making recommendations to positively effect change in policy, procedure, and legislation by investigating and reviewing actions of the Michigan Department of Health and Human Services (MDHHS), child placing agencies, child caring institutions, or certain facilities offering Juvenile Justice services. The Child Advocate’s Act, Public Act 204 of 1994, also requires the OCA to ensure laws, rules, and policies pertaining to Children’s Protective Services (CPS), Foster Care, Adoption and Juvenile Justice are being followed. The OCA is an autonomous entity, separate from the MDHHS.  
 
This OCA review included reading confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), service reports and social work contacts. The OCA also interviewed MDHHS staff, and reviewed law and policy surrounding adoption. Due to the confidentiality of OCA investigations, the OCA cannot disclose the identity of witnesses or complainants or sources of statements and evidence.  

Case Objective:

 
The objective of this review is to identify areas for improvement in the child welfare system by looking at how the case involving Child was handled by Oakland County MDHHS, the Judson Center Child Safe, and the involvement of MDHHS staff. This report is not intended to place blame, but to highlight areas of concern regarding the case; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children. 

Case Summary:

This case came to the attention of the OCA after a complaint was received from an adoptive parent of one of Child’s siblings, with concerns they were not considered for placement of Child despite contacting the agency and expressing interest. A full investigation was opened on August 7, 2023, to review why Child was not placed with her siblings and why the OCA complainant’s home was not considered. 

Family History and Background: 

Date of Birth: March 15, 2022

Mother is Child’s biological mother. Before having Child, Mother lost her parental rights to four other children for reasons of child neglect. Mother’s parental rights were terminated to two children in 2006, and two children in 2018. Records indicate that two of the children were adopted by a relative in 2007. The other two children were adopted by two separate unrelated foster homes, in 2019, one of which, was the OCA complainant who remains a licensed foster parent.  

Child was removed from her parents in April 2022 for neglect and was initially placed with a relative. Shortly after being placed with the relative a new placement had to be found for Child as the relative was moving out of state. According to documentation in MiSACWIS of a Team Decision Meeting (TDM) held on April 27, 2022, the foster care case manager was searching for the families who had previously adopted Child’s siblings, for possible placement. Documentation was found in MiSACWIS that contact was made with two out of the three prior adoptive families. The two families contacted were not able or willing to take placement of Child. There were no documented contacts or efforts found in the case file to locate or contact the third adoptive family. 

Information Discovered During OCA’s Investigation:

The OCA investigator reviewed an undated initial genogram uploaded to MiSACWIS regarding Child and her family. This genogram did not have any information regarding any of Child’s siblings. A second genogram was completed and dated May 16, 2022, which identified Child had four siblings but did not list their names or who adopted them. The OCA investigator continued reviewing Updated Service Plans (USPs) for Child and no new information was found concerning any attempts to contact previous adoptive homes for Child’s siblings. 

The complainant informed the OCA that they first learned about Child’s birth and entry into foster care in September 2022 through social media. The OCA complainant reached out to their Foster Care licensing agency, Oakland Family Services, who had no information about Child and instructed the complainant to reach out to MDHHS. In an interview with the complainant the OCA investigator learned that the complainant contacted Oakland County MDHHS but could not be provided any information as the child welfare case was confidential. The OCA complainant also attempted to contact Centralized Intake on at least two occasions to let MDHHS know she was interested in placement of Child. According to the OCA complainant she was advised to go back to the local county MDHHS with her request. 

During the OCA’s investigation, the OCA investigator confirmed with Centralized Intake management that they do not handle county specific questions and requests as they are a hotline for abuse and neglect reporting. The OCA investigator was informed the Centralized Intake specialist would refer the individual back to the local county, and they would be informed that no information could be disclosed due to privacy/confidentiality. 

The OCA investigator also spoke with Oakland County MDHHS reception staff who advised they cannot give out any case information but some of the reception staff, depending on their knowledge, may review MiSACWIS to try to locate the name of the Purchase of Service (POS) monitor and give that information to the caller without confirming if a case was open or not. Reception staff may also refer the caller back to the private agency they worked with. MDHHS does not maintain statistics regarding these types of calls.

The OCA investigator spoke to MDHHS staff members who advised that initially Child was placed with a family member, therefore the placement team did not have any further contact on the case. The CPS case manager recalled knowing one of Child’s siblings was previously in care and adopted. The CPS case manager reached out to the adoptive family, but they declined to provide foster care for Child. Beyond that, the CPS case manager explained that the foster care case manager should continue trying to locate Child’s siblings.

The OCA investigator conducted interviews with private agency staff from Judson Center Child Safe, who handled Child’s foster care case management. The OCA investigator was informed when placement needs to be explored with past adoptive homes, they must go through the Central adoption registry/post adoptive inquiry analyst from MDHHS. Those interviewed explained this was done to preserve the privacy of the adopted children. Judson Center Child Safe knew that there were other siblings previously adopted as one of the supervisors had worked on one of Child’s siblings’ adoptions. The analyst from MDHHS was able to identify contact information for two out of the three families and spoke with the two families regarding Child. The adoptive families who the analyst spoke with later informed the foster care case manager that they declined to provide care for Child. Neither family was interested in sibling visits.

The OCA was informed the third adoptive family (the OCA complainant) had been identified, and attempts were made to contact them. However, the phone number on record was inaccurate, and thus, no contact was established. Therefore, when Child was replaced in May 2022, she was placed in an unrelated licensed foster home, where she remained during the OCA's investigation.

The OCA investigator asked Judson Center Child Safe staff if any of them attempted to contact the third adoptive family. Staff explained in the interviews that due to privacy reasons this is not encouraged. It was further explained, if the previous adoptive family contacts the private agency staff directly, they can discuss potential placements and visits. However, if there is no direct contact, any communication should be routed through the MDHHS analyst to prevent any inadvertent disclosure due to sealed adoption files. The private agency staff also mentioned the constraints faced as a Placement Agency Foster Care (PAFC) in MiSACWIS. They are restricted from accessing the complete case history, including past court and placement records, searching for providers, or viewing full CPS investigations. 

After learning the phone number of the third adoptive family saved in MiSACWIS was not valid, the OCA investigator confirmed this by placing a phone call to the number. The OCA investigator recognized the phone number listed in MiSACWIS had the wrong area code. Further research showed the area code for the third adoptive parent had changed in recent years and was not updated in MiSACWIS.

During interviews with MDHHS staff, the OCA learned the process for contacting families post adoption is not in policy and some MDHHS staff believe it is a violation of the law for the department to reach out and contact an adoptive family after an adoption has been finalized. Currently, when a child enters care, requests come to the MDHHS Central adoption registry/post adoptive inquiry analyst, and they are the individual who tries to track down past adoptive homes of siblings. Information is gathered from both MiSACWIS and the adoption subsidy specialists for the most updated contact information. The OCA learned the process for making these contacts is time consuming. The OCA was informed there should be an avenue for adoptive homes to identify whether they would be interested in future placement of any new siblings and this documentation should be available in local county offices to access, with limits regarding who can access the information. 

MDHHS staff expressed concern that when an individual reaches out to an adoptive family of a sibling, that this is breaching confidentiality by disclosing the identifying information about the adopted sibling’s birth and adopted name, identifying information about the biological parents and the adoptive parents. Additional concern was expressed that by breaching confidentiality, they could be breaking the adoption law.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The Child Advocate finds initial case planning performed to locate siblings when Child first entered care was not thorough. The undated genogram, created by CPS, did not identify Child had four siblings who were previously adopted. Except for one sibling, CPS did not make any efforts to locate information on Child’s three other siblings who were previously adopted. The dated genogram, created by foster care, did not identify any sibling names, only that Child had four siblings.	The Department neither agrees nor disagrees with this finding. Under Wilson v King, 298 Mich App 378 (2012), the court determined that the legal relationship between all the former biological siblings was severed when they were adopted. Absent consent from the adoptive parents, there is no legal authority for the department to contact them. However, because the department believes it is often in the best interests of children to be placed with their biological siblings, MDHHS will seek statutory changes to allow the department to open adoption files for the purposes of discovering biological siblings. The changes will include allowing the department to contact the parents of biological siblings. The genogram was complete, as prior adopted biological siblings are not siblings for legal purposes. MDHHS did not seek information about prior adopted siblings because they are not legal siblings, and statute strictly limits adoption information. MCL 710.67 restricts access to adoption files, only allowing access when a court has found good cause and issues an order. Because there is no legal relationship between the new child and his adopted biological siblings, there is no good cause to open the adoption file. MDHHS did attempt to contact as many legal relatives as possible for placement.
The Child Advocate finds that inaccurate or incomplete casework can cause negative effects. The information that was not captured at the start of the case, decreased the chances of Child being placed and/or adopted in a home with one or more of her siblings.	Disagree. Children's Protective Services (CPS) staff completed the relative documentation form, DHS-987 Relative Documentation, on 04/06/2022, with one relative listed. The relative listed on the form took initial placement of the child. There were no additional relatives listed on the form. The child was initially placed with a relative from 04/19/2022 through 05/16/2022 by CPS; this relative was not interested in long-term placement due to an out-of-state relocation. Additionally, Judson CPA contacted a relative in May 2022 who resided in Minnesota. An Interstate Compact on the Placement of Children (ICPC) referral was completed; however, the father's legal counsel was not in support of an out-of-state placement. The court agreed. MDHHS did attempt to contact as many legal relatives as possible for placement.
The Child Advocate finds Foster Care Manual (FOM) 722.03 Placement Selection and Standards states, “Although not required, best practice suggests efforts be made to identify biological siblings who may have been adopted by reviewing prior case records and documenting information about biological siblings in the child’s foster care case file. Placement and visitation are not required but encouraged when the adoptive parent is interested in placement or visitation…” Additionally, FOM 722.03 states “termination of parental rights does not dissolve a child's relationship to their siblings. Efforts to place siblings who are in out-of-home care together must continue as described above after termination of parental rights.” There is no formal policy that states efforts shall be made and documented within the case file to locate previously adopted siblings. Policy identifies efforts to locate previously adopted siblings as “best practice.”	Agree. Efforts to identify biological siblings who may have been adopted is best practice, and the department supports it remaining a best practice. MDHHS’s Children’s Services Administration (CSA) has consulted with the MDHHS Children’s Service Legal Division on this issue. Given current law, the opening of adoption records is not authorized. However, the department agrees there could be a process that does not violate an adoptive parent’s privacy by obtaining the adoptive parents consent to be contacted should a sibling of their child come into care. The department will address all logistical details when implementing the process.
The Child Advocate finds the department’s current practice may aid in maintaining the separation of siblings when younger siblings enter care where older siblings have been adopted. CPS, Foster Care and Placement Agency Foster Care (PAFC) case managers cannot directly access adoption records within MiSACWIS. MDHHS has designated one person, the central adoption registry/post adoptive inquiry analyst, when searching for and contacting adoptive families with siblings of a child in care who were adopted. PAFCs are restricted from accessing complete case history, including past court and placement records, searching for providers, or viewing full CPS investigations within MiSACWIS.	Agree and disagree as indicated below. a. Agree: They are not provided access due to the confidentiality requirements under MCL 710.67. b. Agree: There is one designated staff person who handles adoption registry and post inquiries as required by MCL 710.27 b. Disagree: That the adoption registry staff should search and contact adoptive parents with siblings of a new child in care. c. Disagree in part: If the Office of Child Advocate is suggesting that MDHHS and PAFC staff should have access to all files in MiSACWIS, that is prohibited due to the confidentiality of the records and who has an exception to see those records. However, a PAFC is entitled to CPS records with the proper exception under MCL 722.627(1)(k), and a PAFC is entitled to records under MCL 722.120(3).

Recommendations:

Recommendation	MDHHS Response to Recommendation
The Child Advocate recommends MDHHS require case managers to make efforts to identify and locate prior adopted siblings when a new sibling enters care. Additionally, the Child Advocate recommends a requirement to document these efforts in the child’s foster care case. This can be accomplished by adding the requirement to FOM 722.03 which is the foster care manual for placement selection and standards. The Child Advocate recommends MDHHS disseminate a communication issuance on a regular basis to inform staff of this process.	The department agrees with the recommendation to the extent it does not require opening of adoption records in violation of MCL 710.67 as indicated previously. The department agrees this process could be clearer; however, efforts to identify and locate prior adopted siblings when a new sibling enters care should remain a best practice rather than a requirement given the prior legal research conducted on sibling relationships after adoption. As stated in King, in pertinent part: “Thus, even if a claim for sibling visitation could theoretically exist, it wouldn't apply because the older children were no longer considered Mac's siblings under the law.”
The Child Advocate recommends MDHHS establish policy and procedure to obtain the information needed to identify and contact the families of previously adopted siblings. The recommendation is to place the policy and procedure in both protective services and foster care manuals.	Should MDHHS’s efforts to seek statutory changes allowing the department to open adoption files for the purposes of discovering biological siblings and allowing the department to contact the parents of biological siblings be successful, the department will establish necessary policy in accordance with the law. The policy will be added to the appropriate manuals. The department does agree that there needs to be a better process for dissemination of information to the PAFCs and clear direction in policy regarding how to access that information.
The Child Advocate recommends MDHHS develop a process to assist an adoptive parent of a previously adopted sibling who has reached out to any area within the children’s services agency (County MDHHS, Centralized intake, etc.), to aid that adoptive parent in becoming identified as a potential placement for the sibling who just entered care.	As noted above, the department will consider implementing a form for consent of the adoptive parent to be contacted regarding placement of biological siblings pending statutory changes.
The Child Advocate recommends MDHHS conduct research, including PAFCs, to determine the extent to which adding more central adoption registry/post adoptive inquiry analysts is needed.	MDHHS Agrees.
The Child Advocate recommends MDHHS make all these processes available to PAFCs who are searching for previously adopted siblings.	The department agrees that a process should be developed for PAFCs to establish communication with an adoptive parent by consent and without opening/dissemination of confidential adoption records.

PDF Version of Report:  Case 2023-0297

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
August 9, 2024	October 11, 2024	October 18, 2024	2023-0294

Summary of recommendations:

The Child Advocate recommends that the Legislature allocate dedicated funding for the Redetermined Adoption Assistance Program—established under MCL 400.115t—to ensure MDHHS has the resources and staffing needed to properly support adoptive families seeking care redeterminations. Once funding is secured, MDHHS should fully comply with all statutory requirements outlined in MCL 400.115t.Summary:

 This case came to the attention of the OCA after a complaint from an adoptive parent was received regarding a denied request for an adoption subsidy. The subsidy request is not allowed as it falls outside the 90-day timeframe specified by MDHHS policy and was received post adoption finalization. A full investigation was opened to determine if the Determination of Care (DOC) rates at the time of adoption were handled correctly, if an exception could be made in this case as the child’s circumstances have changed, and whether policy and/or law, allowed for an appeal later in a child’s life. A full OCA investigation was opened on May 22, 2023.

Case Objective: 

The objective of this review is to identify areas for improvement in the child welfare system by looking at how the case involving the child was handled by Kalamazoo County MDHHS and Bethany Christian Services. This report is not intended to place blame, but to highlight areas of concern regarding the case; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children. 

Family History and Background: 

Mother and Father are the adoptive parents of twins, The child, and Sibling. The child and Sibling were born premature and positive for amphetamine and methamphetamine on January 3, 2020. Their biological parents’ rights were terminated, and the adoption process began. Adoption consent was granted on November 9, 2020, with a subsidy contract signed and completed on January 13, 2021. The adoption was then finalized on January 27, 2021.

Information Discovered During the OCA Investigation:  

The assigned OCA investigator reviewed the DOCs from the foster care case that were completed for The child and Sibling prior to the adoption being finalized. In November 2020, at the age of ten months, the children were diagnosed with characteristics of Cerebral Palsy, (CP). 

Sibling was participating in Early On services and was receiving physical therapy at the Early Development Clinic. It was noted that his physical therapist anticipated that he would require physical therapy, occupational therapy, speech and language therapy, and behavior therapy as he grows and develops. It was further recommended that Sibling have various tests, including a brain MRI, EG, spine and hip x-rays, along with a neuropsychological test performed around his kindergarten year, middle school, and upon entering high school to assist with school planning needs. 

The child was receiving occupational therapy for feeding at the Early Development Clinic. He was exhibiting difficulty swallowing and had reflux. A Hammersmith Infant Neurological Exam (HINE) was completed on The child on November 25, 2020. The HINE is a “simple and scorable standardized neurological examination that can be used to help identify infants between 3 and 24 months of age who have a high probability of all types of CP.” The HINE assessment includes 26 items that assess “…cranial nerves, posture, movements, tone and reflexes.”¹ The child’s physical therapy progress notes state The child’s HINE assessment scored 72 out of 78 with 0 asymmetries. The notes further document that The child had lateral righting, trunk posture in sitting, suck/swallow issues, and reactions. A return visit was recommended in two to three months to determine what therapy was needed for The child. According to the American Academy for Cerebral Pasly and Developmental Medicine, at 9-12 months, scores of 73 or greater are regarded as optimal and those less than 73 as suboptimal.²

These progress reports for the children showed it was too early to determine a true diagnosis of Cerebral Palsy for either child.

The OCA investigator found that the DOCs completed prior to the adoption, were completed accurately based on the children’s needs at the time, a Level 1 DOC rate. The OCA investigator scored the Medically Fragile DOC to determine whether it would have made a difference for the DOC rate and found that the DOC would have remained the same, a Level 1 DOC rate. 

According to MDHHS Adoption policy AAM200, regarding support subsidy, a child must meet at least one of the following criteria:

• Be 3 years old or older.
• Being adopted by a relative within the 5th degree.
• Have a level 2 DOC (regular or medically fragile) or higher.
• Be adopted along with a sibling who meets one of the above criteria.

The child and Sibling were only a year old at the time of their adoption and were not adopted by a relative within the 5th degree. Because of this, and the DOC levels being a level 1, not a Level 2 or higher, the children did not meet the criteria for support subsidy at the time of the adoption. 

In this case, the family did not appeal the decision at the time the denial for subsidy was made but did attempt to appeal the decision in May 2021, approximately 180 days after the initial DOC. The appeal request was denied because it was made more than 90 days after the decision and post-adoption finalization. The family was informed the appeal request must be made within 90 days of the decision per MDHHS policy. 

The OCA investigator attempted to have an exception to the 90-day appeal made for this case with the Adoption and Guardianship Assistance Program Office within MDHHS. The OCA investigator was told an exception was not possible and an agreement is unable to be entered post adoption finalization. It was explained to the OCA that for a child to be eligible for adoption assistance, eligibility must be determined by MDHHS, and the Adoption Assistance Agreement must be negotiated and signed by the adoptive parent(s), and the MDHHS Adoption and Guardianship Assistance Program manager or designee, prior to the final order of adoption. Additionally, the OCA was informed the DOC rates are set prior to the final order of adoption and are not subject to increases after the adoption is finalized. The DOC rate is determined when a child is in foster care and are not within the scope of the Adoption and Guardianship Assistance Program Office. 

In reviewing federal and Michigan law, it is required the adoption assistance agreement is signed prior to the adoption being finalized. Federal regulations, 45 CFR 1356.40(b)(1) "require that the adoption assistance agreement be signed and in effect at the time of, or prior to, the final decree of adoption". 

MCL 400.115g (1) "The department may pay a support subsidy to an adoptive parent of an adoptee who is placed in the home of the adoptive parent under the adoption code or under the adoption laws of another state or a tribal government, if all of the following requirements are met: (c) Certification is made and the adoption assistance agreement is signed by the adoptive parent and the department before the adoption is finalized."

According to MDHHS Adoption Policy, AAM 700 which states in part “… an individual has a right to request a hearing within 90 calendar days from the date of the written notice by the Adoption and Guardianship Office.” The hearings would take place with The Michigan Administrative Hearing System (MAHS) which is the state’s central agency that provides impartial administrative law judges to conduct administrative hearings for MDHHS.

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_{[1] The Hammersmith Infant Neurological Examination (HINE). (n.d.). Holland Bloorview. https://hollandbloorview.ca/our-services/programs-services/neuromotor-services/hammersmith-infant-neurological-examination-hine} 

_{[2] Early detection of cerebral palsy: AACPDM. American Academy for Cerebral Palsy and Developmental Medicine. (n.d.). https://www.aacpdm.org/publications/care-pathways/early-detection-of-cerebral-palsy}

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Additional Research:

During the OCA’s investigation, additional research was conducted surrounding adoptions and risk factors for dissolved or discontinued adoptions post finalization. 

The OCA reviewed peer reviewed articles and journals surrounding Adoption and dissolved adoptions, including the Quality Improvement Center for Adoption and Guardianship Support and Preservation’s literature review titled ‘Risk and Protective Factors for Discontinuity in Public Adoption and Guardianship’³. Their literature review included trying to understand risk factors that lead to post-permanency instability, referring to this as discontinuity. Their review included compiling articles, books, and resources surrounding adoption risk factors and/or protective factors relating to discontinuity. The review examined the different child factors, family factors, agency factors, and other factors, that may play a role in discontinuity. 

The literature review states “…research has shown that the commitments made at the time an adoption or guardianship was finalized can become strained over time, resulting in instability, or discontinuity in care, for some children (Rolock, 2015; Rolock & White, 2016; Testa, Snyder, Wu, Rolock, & Liao, 2015). Although most children do not experience discontinuity (Child Welfare Information Gateway, 2012; Festinger, 2002; McDonald, Propp, & Murphy, 2001; Rolock, 2015), for those who do, discontinuity can have significant consequences for children who have already experienced the trauma of maltreatment and separation from primary caregivers.”

This research also uncovered agency factors have limited research available examining the effectiveness of post-adoptive services, while recognizing the need for post-adoptive services has only recently been observed. It is stated “…the trauma these children have experienced does not vanish once the child is adopted, many families are just starting to reach out more for help. Post-adoptive and guardianship services are meant to promote permanence and improve family functioning (Berry et al., 2007). What research has been conducted on post-permanency services indicates that most families did not even seek such services until 5 to 7 years post-adoption; and when families do seek services, they are seeking help because of child behavior problems or parent–child conflict (Avery, 2004).”

Inadequate subsidy, receiving inadequate information before placement, inadequate preparation, and training both before and after legal finalization of adoption or guardianship, and inadequate support in general are also identified as risk factors for discontinuity.

The OCA also reviewed ‘When Adoptions Fail’ written by Chuck Johnson, Kristen Hamilton, and Ryan Hanlon, of The National Council for Adoption (NCFA). The article discusses the differences between adoption disruption which occurs prior to finalization, and adoption dissolution which occurs after finalization. It is noted the precise numbers for adoption dissolutions “…are not readily tracked or reported by government agencies or private entities.”⁴  The NCFA further states they “…believe that the likelihood of dissolution can be reduced through better preparation of the prospective adoptive parents to the realities of adopting children exposed to trauma and loss, enhanced support services to families after adoption, particularly to those struggling, and better matching children’s needs with the ability of the prospective adoptive parents to parent them.” Additionally, “Over the last few decades, changes in adoption practice and public policy have contributed to the trend of a larger percentage of adoptive placements being older children, children with medical and cognitive special needs, sibling group placements, and children who have experienced trauma. Preparation and training of prospective adoptive parents is a key factor in ensuring they have realistic expectations and are equipped to meet the challenges that may arise when they become parents. Working to ensure parents and professionals have accurate information about the child’s social and medical history will allow for better matching, preparation, and meeting children’s needs. Ongoing post adoption support and education are also crucial ways of ensuring that the parents are informed as to how to meet the needs of their children as they develop. It is necessary that pre- and post-adoption training include an understanding of trauma-informed parenting, issues pertaining to grief and loss, and issues pertaining to attachment.”

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_{[3] Faulkner, M., Adkins, T., Fong, R., Rolock, N., University of Texas at Austin, School of Social Work, University of Wisconsin-Milwaukee, Helen Bader School of Social Welfare, Children’s Bureau, Spaulding for Children, University of North Carolina at Chapel Hill, Quality Improvement Center for Adoption & Guardianship Support and Preservation, & Department of Health and Human Services, Administration for Children and Families, Children’s Bureau. (2016). Risk & Protective factors for discontinuity in public adoption and guardianship. https://qic-ag.org/wp-content/uploads/2017/02/FinalLitReview_2-15-17.pdf} 

_{[4] National Council for Adoption. (2023, December 13). When adoptions fail - National Council for Adoption. https://adoptioncouncil.org/blog/when-adoptions-fail/} 

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Michigan Law:

The OCA also reviewed Michigan law surrounding adoption and adoption assistance, specifically MCL 400.115t. 

MCL 400.115t pertains to redetermined adoption assistance, requests, requirements, etc. concerning children adopted from foster care between the ages of 0 and 18 that were finalized after January 1, 2015. MCL 400.115t states:

(1) If sufficient funds are appropriated in the department's annual budget and subject to subsection (4), beginning January 1, 2015, the department shall pay redetermined adoption assistance to an adoptive parent of an adoptee who is placed in the adoptive parent's home under the adoption code or under the adoption laws of another state or a tribal government, if the adoptive parent requests redetermined adoption assistance and both of the following requirements are met:

(a) The department has certified that the adoptee requires extraordinary care or expense due to a condition the cause of which existed before the adoption was finalized.

(b) Certification is made before the adoptee's eighteenth birthday.

(2) If the department denies or the adoptive parent disagrees with the certification, the adoptive parent may request a hearing through an administrative law judge in a manner consistent with the rules promulgated under the administrative procedures act of 1969, 1969 PA 306, MCL 24.201 to 24.328.

(3) Redetermined adoption assistance does not affect or duplicate any original adoption assistance agreement that may be in place at the time that redetermined adoption assistance eligibility is requested. Redetermined adoption assistance shall be determined without regard to the income of the adoptive parent and shall be based on 1 or more of the following for which extraordinary care is required of the adoptive parent or an extraordinary expense exists in excess of a support subsidy:

(a) A physically disabled child for whom the adoptive parent must provide measurably greater supervision and care.

(b) A child with special psychological or psychiatric needs that require extra time and a measurably greater amount of care and attention by the adoptive parent.

(c) A child requiring a special diet that is more expensive than a normal diet and that requires extra time and effort by the adoptive parent to obtain and prepare.

(d) A child whose severe acting out or antisocial behavior requires a measurably greater amount of care and attention of the adoptive parent.

(e) Any other condition for which the department determines that extraordinary care is required of the adoptive parent or an extraordinary expense exists.

(4) An adoptive parent who has an adoption assistance agreement signed and in effect before January 1, 2015 may request redetermined adoption assistance under this section in the same manner as provided in this section beginning January 1, 2015 but not after March 31, 2015.

(5) An adoptive parent may only request 1 redetermined adoption assistance certification to be made under subsection (1) or (4) per adoptee placed in the adoptive parent's home.

(6) An adoptive parent of an adoptee who was adopted from foster care between the ages of 0 and 18 and whose adoption was finalized after January 1, 2015 may request redetermined adoption assistance under this section.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The Child Advocate finds MCL 400.115t allows adoptive families to make a one-time request for redetermined adoption assistance concerning children ages 0-18 adopted from foster care finalized after January 1, 2015, if sufficient funds are appropriated in the department's annual budget and the department has certified that the adoptee requires extraordinary care or expense due to a condition the cause of which existed before the adoption was finalized. The redetermined adoption assistance is based on one or more of the following for which extraordinary care is required of the adoptive parent or an extraordinary expense exists in excess of a support subsidy: A physically disabled child for whom the adoptive parent must provide measurably greater supervision and care. A child with special psychological or psychiatric needs that require extra time and a measurably greater amount of care and attention by the adoptive parent. A child requiring a special diet that is more expensive than a normal diet and that requires extra time and effort by the adoptive parent to obtain and prepare. A child whose severe acting out or antisocial behavior requires a measurably greater amount of care and attention of the adoptive parent. Any other condition for which the department determines that extraordinary care is required of the adoptive parent, or an extraordinary expense exists.	MDHHS Agrees.
The Child Advocate finds the Redetermined Adoption Assistance Program has not been historically funded in the state’s annual budget. The OCA learned this information from the Adoption and Guardianship Assistance Office and MDHHS policy. Thus, the Adoption and Guardianship Assistance Program Office has not accepted applications for redetermined adoption assistance as a result. MDHHS policy goes further and states: AAM 410: “The Redetermined Adoption Assistance Program was created by law that has not yet been funded by the state budge office. The Redetermined Adoption Assistance Program is subject to state legislative appropriations of sufficient funds. The amount of payment or continuation of payment is subject to adjustment by the Michigan Department of Health and Human Services (MDHHS) due to changes in the legislative appropriations of funds.”	MDHHS Agrees.
The Child Advocate finds the Redetermined Adoption Assistance Program is the only avenue for families to receive additional financial assistance in caring for children adopted from foster care after an adoption is finalized.	Families may apply for other public assistance programs such as Family Support Subsidy (MCL 330.1156), Medical Subsidy (MCL 400.115h), Serious Emotional Disturbance Waiver, and Children's Special Health Care Services.
The Child Advocate finds that children who are adopted from foster care can develop additional needs that are not known prior to the finalization of an adoption and the original DOC but are the result of trauma and/or instances that occurred prior to adoption.	MDHHS Agrees.

Recommendations:

Recommendation	MDHHS Response to Recommendation
The Child Advocate recommends the legislature provides additional funding to ensure that MDHHS receives capital for the Redetermined Adoption Assistance Program as outlined in MCL 400.115t. The funding allocation should consider the necessary services to assist Michigan's adoptive families requiring care redetermination, as well as sufficient staffing within MDHHS to effectively support these families. Additionally, it is advised that this program be designated as a specific line item in the MDHHS budget to secure funding, given that it has not received financial support since its establishment in 2015.	MDHHS agrees.
The Child Advocate recommends once funding is appropriated for the Redetermined Adoption Assistance Program, MDHHS comply with the requirements outlined in MCL 400.115t.	MDHHS agrees.

PDF Version of Report:  Case No. 2023-0294

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
January 26, 2024	April 2, 2024	May 16, 2024	2021-0895

Summary of recommendations:

The Child Advocate recommends strengthening MDHHS policy and practice for medically vulnerable children by requiring case managers to directly consult with the child’s treating medical professionals to assess whether medical needs are being met and to identify potential abuse or neglect. The Advocate also recommends revising the disposition of the November 2021 CPS investigation to include medical neglect, reflecting the parents’ failure to obtain necessary treatment for their child’s diabetic condition.

Case Background:

Date of Birth: February 10, 2010

Date of Death: November 22, 2021 (11 years)

Case Objective:

The objective of this review is to identify areas for improvement in the child welfare system by looking at how CPS investigations involving the child were handled by Berrien County MDHHS, and the involvement of MDHHS staff, physicians, and law enforcement. This review reinforces the idea that the safety and well-being of a child is a shared responsibility of the family, community, law enforcement, and medical professionals aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of the investigations; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children.

Family History: 

Mother and Father are the birth parents of the child and Sibling. As mentioned above the child was 11 at the time of his death and Sibling was 13. The main issue in this case was the child’s Type I diabetes which was diagnosed in 2018. The child was eight years old when he developed diabetes.

This OCA investigation concentrated on interactions with CPS and the child’s family from September 2020, and February 2021. Both investigations concerned the child’s diabetes and the care that his parents were providing. As The child’s death was directly related to his diabetes the OCA also reviewed the death investigation to determine if there was a correlation between past behaviors The child’s parents presented when caring for his diabetes and CPS’ interaction with the family concerning the child’s care.

Review of September 2020 CPS investigation:

Review of the February 2021 CPS Investigation

On February 10, 2021, five months after the child’s last hospitalization, Berrien County CPS was assigned an investigation concerning the child and Sibling. A mandated reporter from the children’s school made a call to MDHHS Centralized Intake with concerns The child was not getting the medical treatment he needed, advising his blood sugars were regularly over 200 and sometimes up to 400². The mandated reporter said Sibling and the child were home a lot due to Mother working, and Mother was not checking the child’s blood sugar levels as she should. The reporting source had additional concerns The child and Sibling had unaddressed mental health problems that included suicidal ideations. 

On February 11, 2021, CPS interviewed the reporting source and learned the child and Sibling had missed a “significant” amount of school. The reporting source also explained that the child and Sibling were living with their aunt in Indiana. The mandated reporter informed CPS that the child’s sugar levels were “sometimes at 400” and a staff member at the school tracked the child’s sugar levels. CPS was advised the child receives special education services for a learning disability and speech impairment.

On the same day, CPS made an unannounced visit to the family’s home. Case file records show Mother refused to allow CPS into the home, advising she had not had time to clean. Mother also told CPS the pipes were frozen, so the home had no water for about a week. CPS documented this as the reason why the child and Sibling were residing with their aunt, Aunt, in Indiana. Mother agreed CPS could come back to the home five days later, on February 16, 2020, to see the inside of the home. CPS informed Mother about the new complaint and the concerns. Mother confirmed the child was diabetic, but said he had everything he needed to take care of it. The OCA could not find documentation in CPS records indicating they confirmed or reviewed what the child used to care for his diabetes. The only documentation found by the OCA was the child took “medications.” Mother told CPS she is not regularly able to check the child’s blood sugar every day because of her work schedule, but her sister was checking it. Case file records show Mother told CPS that the child and Sibling only missed school when they were sick or when they were with their aunt. Mother also confirmed both boys had been depressed and expressed suicidal ideations. Records show Mother indicated she was taking the child and Sibling to their physician to address the suicidal comments. Mother admitted she had a domestic violence history with Father, advising CPS that Father was not living in the family home and that he had not seen the children since November 2020. 

Mother agreed to a safety plan of monitoring the children to avoid suicide attempts, giving the child his diabetes medication, and monitoring the child’s blood sugar level. The safety plan also indicated that the child and Sibling would continue to live with their aunt until the frozen pipes were repaired. Before CPS left the home, Mother’s sister, Aunt, arrived at the home without the child and Sibling. CPS spoke to Aunt who explained the child and Sibling were at her home in Indiana. Aunt agreed to the same safety plan as Mother. Following the home visit, the case manager requested Indiana CPS interview the child and Sibling at Aunt’s.  

As part of the CPS investigation, CPS contacted Southwestern Medical Clinic the following day, February 12, 2021. Clinic staff told CPS The child was last seen a year ago on February 28, 2020. The clinic staff also told CPS Sibling was last seen on April 3, 2020, for anxiety and he had been prescribed Zoloft. CPS was informed that both the child and Sibling had an upcoming appointment on February 15, 2021, to help the family find therapy for the boys. The clinic staff explained there were no documented concerns about abuse and/or neglect in their records. The CPS report does not document any mention of the child’s diabetes being discussed with the clinic staff. 

CPS interviewed Father via telephone on February 12, 2021. Father confirmed he did not live in Mother’s home. CPS case records show Father informed CPS that the child checks his blood sugar four times a day and that the child sometimes forgets. There is no documentation on how anyone else manages the child’s diabetes or what he does if his sugar levels are too high or too low. Case file records show CPS also safety planned with Father to “monitor the child’s blood sugar when he can” and to monitor the boys to “prevent suicide attempts.” 

Indiana CPS notified Michigan CPS that they (Indiana CPS) had interviewed Aunt (The child and Sibling’s aunt) and had verified the well-being of Sibling and the child on February 12, 2021. This was documented in an email. The email states Aunt told Indiana CPS she was diabetic and was teaching the child how to care for his diabetes and give himself his insulin shots. Aunt confirmed that both boys had an appointment with Southwestern Medical Clinic for their depression on February 15, 2021. Aunt told Indiana CPS that both the child and Sibling were doing online schooling. A safety plan was established with Aunt to “make sure” the children were in a “safe environment” and that she would “continue to meet their medical and mental needs.” It is documented in the CPS investigation report, that Indiana CPS briefly spoke with the child and Sibling when at Aunt’s home. The case file indicates the child and Sibling confirmed they don’t go to school or do their schoolwork as they should. Records show the child told Indiana CPS, that Aunt was “helping him learn how to manage his [d]iabetes.” 

On February 22, 2021, CPS spoke with both Sibling and the child over the telephone. CPS safety planned with both boys to “talk with someone if [they] feel the need to harm [themselves]” and to work on keeping their bedrooms clean.

CPS talked with Mother again about the child’s diabetes on March 10, 2021. Mother told CPS that the child knows how to take care of his diabetes, and he learned how to do so from Helen DeVos Children’s Hospital. She went over when the child tests his blood sugar during the day with CPS. There is no documentation by CPS of any further details or actions regarding how the child’s family provided care for the child’s diabetes.

On March 11, 2021, CPS obtained medical records from Lakeland Healthcare for the child and Sibling. Lakeland Healthcare records were requested as this health system provided some healthcare for the child and Sibling. Through these records, CPS confirmed that Sibling was taking medications for anxiety and the child had several different insulin medications to treat his diabetes. CPS also followed up with Mother via phone regarding the boys' mental health needs, as the child and Sibling were back in her care. Mother told CPS she would be taking the children to a “Riverwood counselor” to address those needs. CPS attempted to safety plan with Mother regarding the child’s diabetes, suggesting she have the child make a chart or enter it on a calendar when he tests his blood sugar. Mother responded to CPS that the child had a built-in alarm on his insulin pump to advise him when to check his blood sugar. She advised CPS that the pump was connected to her cell phone via Bluetooth and agreed to verify the child’s blood sugar results daily. 

On March 15, 2021, CPS concluded the investigation as a Category IV finding no preponderance of evidence existed that Mother medically or physically neglected Sibling or the child. The CPS investigation report did not document the reason behind this disposition. 

During the OCA’s investigation, the OCA discovered CPS did not find a preponderance of evidence supporting medical neglect regarding the child’s diabetes because the child knew how to treat his diabetes, had taken a class, and the medical records obtained did not document a concern for abuse or neglect. Both the child and Sibling were enrolled in counseling services addressing their mental health needs, leading CPS to not make a finding of medical neglect. CPS believed the child was mature enough and had the knowledge to care for his diabetes on his own. 

CPS contacted several individuals who had some knowledge of the child’s diabetic needs. However, CPS did not obtain definitive answers from any of the individuals on whether there was a concern for abuse or neglect relating to the child’s diabetic needs, whether his parents were able to meet his diabetic needs, or whether the child had any unmet needs related to his diabetes. Although CPS was aware that the child’s school paraprofessional maintained a log of the child’s glucose test results, CPS did not speak with the paraprofessional as this was overlooked.

The OCA investigator discovered CPS did not speak with any doctor treating the child regarding his medical needs. The medical records showing the child had diabetes were obtained by CPS which documented no concern for abuse or neglect. This was believed to be enough information along with what the family told CPS, to say the child’s diabetic needs were being met. The OCA received evidence that indicates CPS was unaware the child was being seen by an endocrinologist at Helen DeVos Children’s Hospital for his diabetes care. 

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Diabetes Type 1 Mellitus:

The following information is provided to give context to the amount of responsibility placed on 11-year-old The child.

According to the National Institutes of Health (NIH) National Center for Biotechnology Information (NCBI), “Type 1 diabetes mellitus (T1D) is an autoimmune disease that leads to the destruction of insulin-producing pancreatic beta cells. Individuals with T1D require life-long insulin replacement with multiple daily insulin injections daily [sic], insulin pump therapy, or the use of an automated insulin delivery system. Without insulin, diabetic ketoacidosis (DKA) develops and is life-threatening. In addition to insulin therapy, glucose monitoring with (preferably) a continuous glucose monitor (CGM) and a blood glucose monitor if CGM is unavailable is recommended. Self-management education and support should include training on monitoring, insulin administration, ketone testing when indicated, nutrition including carbohydrate estimates, physical activity, ways of avoiding and treating hypoglycemia, and use of sick day rules. Psychosocial issues also need to be recognized and addressed.”³

The NIH NCBI describes the care of T1D; “Self-management of T1D includes administering insulin multiple times daily with glucose monitoring and attention to food intake and physical activity every day, which is a considerable burden. Whereas newer technologies have helped people improve their glycemic control, they are costly, complex, and require education and training. Many people with diabetes fear hypoglycemia, hyperglycemia, and the development of complications, and depression, anxiety, and eating disorders can develop. The medical, education, training, psychological, and social challenges faced by people with T1D daily are best addressed by an interprofessional team that includes clinicians (MDs, DOs, NPs, and PAs), nurses (including diabetes nurse educators), pharmacists, dieticians, mental health professionals, social workers, podiatrists, and the use of community resources. Individualized treatment approaches, which can reduce the burden and further improve outcomes, are needed, and the interprofessional care model will yield the best possible patient outcomes.”⁴

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 _{[3] https://www.ncbi.nlm.nih.gov/books/NBK507713/ 
 [4] https://www.ncbi.nlm.nih.gov/books/NBK507713/} 

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Review of CPS Investigation Regarding The child’s Death, November 2021:

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CPS Policy Manual Research:

The OCA reviewed historical policy concerning children with medical conditions as part of this OCA investigation. In prior years, CPS policy referred to children with medical conditions as medically fragile children. Policy language shifted over the years, as detailed below, and now refers to children with medical conditions as vulnerable children. An overview of these changes is summarized below. 

CPS policy, PSM 713-04 Medical Examination and Assessment, dated May 1, 2016, identifies that medically fragile children "are particularly vulnerable to abuse and neglect; therefore, a worker’s observation of a medically fragile child is not sufficient to determine whether the child’s special needs are being met."
 
This 2016 CPS policy further explains that regardless of the allegations, "when investigating complaints which include a child who is physically or developmentally disabled or has a chronic medical and/or mental health condition, the worker is required to make collateral contacts with medical, school and other community resources who are knowledgeable about the child’s needs." The purpose of these contacts is to assist in evaluating potential safety and risk factors in the home. If these collateral contacts do not assist in determining if the child's needs are being met, then a "medical examination is required." Additionally, the policy states that "when an allegation is made that a medically fragile child’s needs are not being met by the caregiver, contact with the child’s primary doctor to evaluate the child’s care is required." The CPS investigation report must then document the assessment of the caregiver's ability to meet the needs both physical and medical of the child.
 
CPS policy PSM 713-04 Medical Examination and Assessment was changed on May 1, 2018. The medically fragile children section was updated. The policy continued to state that observation alone of a medically fragile child is insufficient when determining if the child's needs are being met. The policy states "A caseworker must contact the child's primary care physician when it is alleged that a medically fragile child has unmet medical, health or safety needs.” 

The 2018 policy stated that collateral contacts are required in investigations involving a medically fragile child if the child meets any of the following criteria: 

• Physically disabled
• Developmentally disabled
• Inability to verbally express themselves
• Has a chronic medical condition
• Has a diagnosed or reported mental health condition

Policy details that after case assignment, the caseworker must make collateral contacts as soon as possible to assess the child's needs. These collateral contacts include: 

• Medical professionals, such as primary care physicians
• A school or day care if enrolled
• Other community resources are knowledgeable of the child's needs.

PSM 713-04 continues to state that if the collateral contacts do not enable the caseworker to determine whether the child has been abused or neglected, "a medical examination is required."  The caseworker must document the caretaker's ability to meet the needs of the medically fragile child in social work contacts in MiSACWIS.

CPS policy PSM 713-04 Medical Examination and Assessment was again changed on August 1, 2019. This policy switched from medically fragile children to vulnerable children. The policy states that "children may be at a greater risk of abuse or neglect based on various factors including age, developmental ability, physical health or mental health considerations."

After August 1, 2019, CPS policy outlines that…"A child is considered a vulnerable child if they are: 

• Diagnosed with a physical or developmental disability 
• Have a chronic health condition such as asthma or diabetes
• Diagnosed or reported to have mental health concerns
• Under the age of two

When an allegation involves a vulnerable child, the caseworker must contact one or more individuals with knowledge of the child's needs. Caseworkers should also obtain and document the following information: 

• Concerns regarding potential child abuse or neglect
• The caregiver's ability to meet the needs of the child
• If the child has any unmet medical, mental health, or safety needs."

The August 1, 2019, policy change removed the requirement for a medical examination if the caseworker was unable to obtain an assessment of the caregiver's ability to meet the child's needs from collateral contacts made. The 2019 policy change also eliminated the need to contact medical professionals, changing the wording to, “contact one or more individuals with knowledge of the child’s needs”, as bolded above. 

Effective August 1, 2023, the policy surrounding vulnerable children was moved to PSM 713-01 CPS Investigation- General Instructions. This section of policy considers a child a vulnerable child if one of the following factors is true:

• “Age 0-5 years. Any child in the household five years of age or younger. Children in this age range are considered more vulnerable because they are less verbal and less able to protect themselves from harm...”
• “Significant diagnosed or suspected medical or mental health concern. Any child in the household has a diagnosed or suspected medical or mental health concern that significantly impairs the child’s ability to protect themselves from harm, or a diagnosis may not yet be confirmed, but preliminary indications are present, and testing/evaluation is in process OR the child is on a waitlist for evaluation. Examples include, but are not limited to, severe asthma, severe depression, and medically fragile (for example, requires assistive devices to sustain life).”
• “Not readily visible in the community. The child is isolated or less visible within the community (for example, the child may not have routine contact with people outside the household, and/or the child may not attend a public or private school and/or is not routinely involved in other activities within the community). Children who are less visible in their community are more likely to have signs of abuse/neglect go unnoticed or unreported, and they are less able to reach out to others for assistance.”
• “Diminished developmental/cognitive capacity. Any child in the household has diminished developmental/cognitive capacity that affects their ability to communicate verbally or to care for and protect themself from harm (for example, cannot communicate or defend themself, cannot get out of the house in an emergency if left unattended).”
• “Diminished physical capacity. Any child in the household has a physical condition/disability that affects their ability to protect themselves from harm (for example cannot run away or defend themself, cannot get out of the house in an emergency situation if left unattended.)”

This policy continues to state “When a child has been identified as vulnerable based on the above factors, the case manager must contact one or more individuals, excluding the perpetrator, with knowledge of the child’s needs. Case managers should also obtain and document the following in a social work contract: 

• Concerns regarding potential child abuse and/or neglect
• The caregiver’s ability to meet the needs of the child
• If the child has any unmet medical, mental health, or safety needs.”

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The child Advocate finds current policy surrounding Vulnerable Children is insufficient. In 2021 at the time of the child’s death, the policy surrounding vulnerable children was in PSM 713-04 Medical Examination and Assessment. In 2023, the policy concerning vulnerable children was changed and moved to PSM 713-01. Currently, and in the investigations leading up to the child’s death, CPS is only required to “contact one or more individuals” who are familiar with the child’s condition. Current policy eliminates the requirement to speak with a medical provider… (…is not sufficient enough to protect our most vulnerable children.; …does not provide adequate information to keep children safe.;) and may leave a “vulnerable” child without the protection sought by Children’s Protective Services.	Agree.
The child Advocate finds that Father and Mother are responsible for medically neglecting the child concerning his diabetic needs.	Agree. Based on the information obtained by the Office of Child Advocate, a finding of medical neglect is appropriate.

Recommendations:

Recommendation	MDHHS Response to Recommendation
The child Advocate recommends MDHHS amend PSM 713-01 surrounding vulnerable children, to state the case manager must contact and speak with the physician or medical personnel who are treating the vulnerable child’s medical condition (or, who are the most knowledgeable about the medical condition…). This policy change would allow the case manager to ask a treating physician questions about whether or not the child’s medical needs are being met, and if there are concerns for abuse and/or neglect.	The vulnerable child policy was modified in 2019 from requiring contact with a medical professional to complete the assessment to contacting one or more individuals, excluding the perpetrator, with knowledge of the child’s needs. This policy change was informed by feedback from medical providers and others, indicating the requirement was overwhelming and not achieving the intended outcome. While contacting a medical professional to complete the vulnerable child assessment is appropriate in the referenced case, there may be children considered vulnerable, who do not have a medical condition or require ongoing medical care outside of routine well-child visits. Contacting a medical professional in these cases may not provide the best insight into how well a parent or caregiver is meeting a child’s needs and may inadvertently inundate medical providers and their offices, and unintentionally compromise child safety. The Department recognizes there may be an opportunity to enhance this policy further for vulnerable children, specifically who have a significant or diagnosed medical condition, and will explore the requirement for CPS to make efforts to contact the treating provider for children who meet this criterion as part of the vulnerable child assessment. Any enhancements to this policy will be informed by medical professionals, child welfare staff and their supervisors, and other key stakeholders to help ensure the intended outcome is achieved.
The child Advocate recommends that MDHHS change the disposition of the November 2021 CPS investigation concerning the child’s death, to include medical neglect by his parents, because of failing to treat the child’s diabetic needs.	Agree. DHHS will amend the original investigation to reflect the new disposition.

PDF Version of Report:  Case No. 2021-0895

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
December 26, 2023	February 29, 2024	April 5, 2024	2022-0356

Summary of recommendations:

The Child Advocate recommends that Kalamazoo County MDHHS‑CPS comply with Michigan law by taking appropriate protective action whenever child abuse or neglect is present, and that MDHHS strengthen oversight by implementing a formal case‑management review process for severe abuse or neglect allegations. This process should include rapid managerial review, structured case conferencing, and documented decision‑making to ensure timely and appropriate interventions. The Advocate further recommends correcting the disposition of the October 2021 CPS investigation to reflect a preponderance of evidence for medical neglect, resulting in a Category II classification.

Case Background:

Date of Birth: March 19, 2010 

Date of Death: April 12, 2022 (12 years)

This OCA review included reading confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), service reports, medical records, social work contacts, and law enforcement reports. The OCA also interviewed MDHHS staff. Due to the confidentiality of OCA investigations, the OCA cannot disclose the identity of witnesses or complainants or sources of statements and evidence.  

Case Objective:

The objective of this review is to identify areas for improvement in the child welfare system by looking at how CPS investigations involving The child were handled by Kalamazoo County MDHHS, and the involvement of MDHHS staff, medical professionals, and law enforcement. This review reinforces the idea that the safety and well-being of a child is a shared responsibility of the family, community, law enforcement, and medical professionals aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of the investigations; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and advocate for changes within it on behalf of similarly situated children. 

Family History: 

Mother and Father are the birth parents of the child. Child was diagnosed with Type 1 diabetes in October 2020. 

This OCA investigation concentrated on interactions with CPS and Child’s family from October and November 2021 relating to medical neglect concerns surrounding Child’s diabetic needs. This investigation also reviewed Child’s death, which occurred in April 2022. 

Prior to 2021, Mother was the subject of several CPS investigations in Michigan. Three of these investigations resulted in substantiations for child abuse or neglect and were opened to provide ongoing services to the family. These cases were opened in 2001, 2017, and 2018. Mother’s parental rights were terminated to three other children in Colorado between 2003 and 2004 due to substance abuse and a lack of benefit from services provided to her. 

Review of October 2021 CPS investigation:

On October 19, 2021, Child was taken to Bronson Hospital for an altered mental state. Child has Type 1 diabetes and Mother appeared to struggle caring for Child and his diabetes. While at the hospital, Mother made statements to medical staff that she let Child crash to teach Child a lesson, that he is eleven years old and should be able to take care of his own “sugar” levels. A CPS complaint was made to MDHHS Centralized Intake for concerns of child abuse and neglect based on the statements and observed behavior of Mother and the hospitalization of Child due to potential neglect. The reporting source also expressed concern Child did not have the supplies needed to monitor his blood glucose¹ levels, including his blood glucose machine, needles, syringes, and insulin. The complaint was assigned to Kalamazoo County CPS for investigation. 

On October 19, 2021, CPS contacted Mother at Bronson Hospital. Mother was upset by CPS's involvement and would not cooperate. The CPS report documents Mother said she was tired of having to remind Child to take his diabetes medication and shots because he is eleven years old, and she (Mother) should not be responsible for constantly reminding Child. Mother advised CPS she needed to go back to work, that she was stressed, and she did not have time to be there every second to make sure Child took every single shot. Mother admitted to CPS she did not remind Child to do the “food shot” but usually made sure he took the “long-lasting shot at night.”² It is documented in the CPS report that Mother said, “I am not his slave, and I am not his servant.” Mother also told CPS it was not her fault Child left the supplies he needed to treat his diabetes at his grandmother’s home. Mother admitted to CPS that she had some supplies at her home but did not have Child “do the food one [shot] for a week to show him how shitty he would feel.” Mother refused to provide CPS with her current address and refused to sign a safety plan. 

CPS interviewed Child in his hospital room. Child told CPS he knew that he needed to take his shots but that he did not like to because they hurt. Child said the doctor told him he could take the shot in his leg, but he was scared those would hurt as well. Child told CPS they had been staying with someone in Vicksburg and that he left his glucose monitor at his grandmother’s house. 

The next day, October 20, 2021, contact between a hospital staff member and CPS occurred. The hospital staff member asked CPS if Child was going to be removed from Mother’s care. CPS informed the hospital staff member that Child was not going to be removed from his mother. During this conversation, CPS was advised Child would be released from the hospital in a couple of days.

On October 21, 2021, contact between a second hospital staff member and CPS occurred. The hospital staff member expressed that the nurses and physician “…are concerned about discharging him [Child] to his mother because she [Mother] will not cooperate and provide the hospital with her address.” CPS advised the hospital staff member that attempts to locate Mother and Child would continue to be made but “...that our goal is to help families remain intact...”. 

According to the CPS report, Child’s medical records documented Child was seen from October 19, 2021, to October 21, 2021, for hyperglycemia³.

There is a requirement in MDHHS policy to answer questions regarding children identified as “vulnerable”. Child’s type 1 diabetes makes him a vulnerable child. CPS requested the assistance of Bronson Hospital medical staff in answering those questions, however, it is unknown whether this occurred via written or verbal communication. The OCA found that CPS wrote the vulnerable child questions on a Word document and sent it to Bronson Hospital on November 3, 2021. The vulnerable child questions were completed by CPS in MiSACWIS on November 5, 2021. 

The first vulnerable child question answered was “Does Child have any unmet medical, health, or safety needs?” The documented answer stated, “The physicians and social workers are concerned that Child may not receive the care he needs from his mother after discharge from the hospital for his diabetes.”

The second vulnerable child question answered was “Can the caretaker adequately care for and meet the needs of Child?” The documented answer stated, “The physicians and social workers believe Mother has been neglectful of Child’s medical care.” 

The third and last vulnerable child question answered was “Can the caretaker adequately care for and meet the needs of Child?” The documented answer stated, “The physicians are concerned that Mother may not be able to adequately care for and meet the medical needs of Child.” 

CPS spoke with Father on November 9, 2021. Father informed CPS he had spoken with Mother the night prior (November 8, 2021) and Mother was having a difficult time getting Child to take his insulin. Father advised he was residing in Colorado but that he would gladly take custody of his son if needed.

On November 12, 2021, CPS received a voice message from a staff member at WMed Pediatrics after Mother signed a release allowing the office staff to speak with CPS. WMed’s message advised CPS Mother and Child had an appointment scheduled for November 11, 2021, and Child’s doctor had concerns Mother was not able to meet Child’s medical needs. CPS returned the phone call and spoke with this staff member on November 22, 2021. During this phone call, CPS was informed Mother still would not provide an address for where they are currently living as she did not want CPS to know. Mother told WMed staff Child is being home-schooled and he was provided with a new glucose monitor. CPS was advised medical staff did not believe Mother was hurting Child on purpose, but that Mother may not have the capability and medical knowledge to take care of Child and make sure Child takes his medication as prescribed. CPS was informed by the WMed staff that, “even though Mother knows how to monitor glucose levels, give shots, monitor diet, etc., she may not be able to retain the information to full capacity.” WMed staff added that if “...Child’s diabetes is not monitored closely, by the time Mother realizes Child is ill and needs medical attention, it could result in possible diabetic ketoacidosis⁴ with or without a coma.” 

The CPS report documented several efforts made by the case manager to try to locate an address for Mother and Child. The case manager made contact approximately ten times with family members and hospital staff, attempting to find Mother’s address. Mother informed the case manager via text message on November 16, 2021, that Child had a new monitor and was back on medication. Mother continued to refuse to provide an address. 

On November 24, 2021, a case conference between the case manager, supervisor, and program manager occurred. An additional narrative was entered in MiSACWIS showing it was decided no preponderance of evidence would be found at that time, however, the mother needs to understand the expectation is the child’s insulin/testing/dietary needs are her responsibility and she is expected to fulfill those needs as the adult caregiver. The additional narrative documented a letter would be mailed to the mother’s address with a duty to warn and the expectations mentioned above. Because CPS still did not know Mother and Child’s address the case manager was instructed to go to the “Drop-In Center” to try to gain more information about the family’s location. It is noted in the CPS report Mother and Child use the Drop-In Center as their address. 

The CPS case manager documented receiving a text message from Mother on November 29, 2021. Mother advised finding Child a new doctor who “don’t blame her”, and the doctor would be working toward getting Child a pump. Mother also advised she and Child would be attending diabetes education classes together. Mother again, would not provide an address. 

On November 30, 2021, the CPS case manager documented a “duty to warn” letter “will be sent” to Mother stating that the case would not be opened but if another incident should occur where Child is “medically neglected” further action could be taken by the department. 

The OCA found the CPS investigation closed on December 1, 2021, as a category IV disposition. A category IV is defined in part as, “…not a preponderance of evidence of child abuse or child neglect…”. The evidentiary requirement for ‘preponderance of evidence’ is 51% likely or greater. CPS believed they did not have enough evidence to substantiate Mother for abuse and/or neglect. Although the CPS disposition was a category IV finding of no child abuse or neglect, the CPS dispositional narrative currently states in part “...Category II, High-Risk Level, no overrides used”.

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_{[1] Blood glucose, or blood sugar, is the main sugar found in your blood. It is the body's primary source of energy. It comes from the food you eat. Your body breaks down most of that food into glucose and releases it into your bloodstream. When your blood glucose goes up, it signals your pancreas to release insulin.}

_{[2] To educate the reader, the difference between the “food” shot of insulin and the “long-action” shot of insulin can be explained by dividing insulin into groups depending on how it works in the body. Rapid- or short-acting insulin helps reduce blood glucose levels at mealtimes. Long-acting insulin helps with managing the body’s general needs. Both help manage blood glucose levels.}

_{[3] The American Diabetes Association (ADA) defines Hyperglycemia as the technical term for high blood glucose (blood sugar). Further describing that high blood glucose happens when the body has too little insulin or when the body can't use insulin properly.}

_{[4] Centers for Disease Control and Prevention: Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening. DKA develops when your body doesn’t have enough insulin to allow blood sugar into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body.} 

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Additional OCA Evidence Regarding October 2021 CPS investigation: 

During the OCA’s investigation, Child’s WMed Health medical records were reviewed. The WMed Health records document concerns for Mother’s ability to care for Child’s diabetic needs. On November 11, 2021, Mother obtained additional education on how to treat Child’s diabetes. Statements were found in the medical records indicating Mother stated she “let him crash and burn to teach him how serious this is.” The records document that Child is responsible for the majority of his care. Mother was advised to take Child to the hospital for further testing. Mother became irate and said she would take him to Helen DeVos Children’s Hospital instead. 

The medical records from Helen DeVos Children’s Hospital showed Child was treated for diabetic ketoacidosis on November 11, 2021. The medical records document Mother was having challenges in knowing what meals were appropriate. A home nurse was offered but Mother refused. The medical records also document Mother expressed concerns about the care provided to Child by WMed endocrinology. Mother asked for Child’s care to be transferred to Helen DeVos Children’s Hospital. It was noted that “…it is common for children this age to need very close supervision of their diabetes care from their parents. If expectations of diabetes self-care are not being met by the child, the parents should assume all responsibility of care.”  

During the OCA’s investigation, the OCA asked MDHHS staff about the statement in the CPS report alluding to a Category II disposition. The OCA investigator was informed a case could have been opened but since the mother was uncooperative and they did not know where she was living, the case was closed as a category IV instead. The OCA was informed this was the decision of management. The OCA confirmed CPS staff were and are aware policy states a petition should be filed asking for parents to participate when they are uncooperative. This did not occur as required. Through interviews, the OCA was provided with statements indicating the circumstances of Child’s case and the seriousness of his diabetes was not fully disclosed to the CPS program manager. The suggestion was made that this case was closed to comply with case count statistics and federal oversight of CPS investigations. The OCA also learned that the program manager relied on incomplete information upon making a disposition decision and the program manager did not review the case file or CPS investigative report. 

Review of CPS Investigation of Child’s Death, April 2022:

Reports reviewed indicate that On April 10, 2022, Child had an elevated blood glucose level and was non-verbal due to his condition. Reports reviewed by the OCA state Mother did not seek medical attention for Child on April 10, 2022. 

On April 11, 2022, Child was found unresponsive and blue, which caused Mother to drive Child to the hospital. Mother did not take Child to the emergency room (ER) but to the main entrance. Hospital staff observed Child’s condition and rushed him to the ER. Due to Mother not attending to Child’s medical needs, a CPS complaint was made to MDHHS Centralized Intake for concerns of abuse and neglect. This complaint was assigned to Kalamazoo County MDHHS for investigation. 

The CPS case manager contacted the assigned detective from the Calhoun County Sheriff's Office. The detective informed CPS Mother took off from the hospital when they attempted to speak with her. CPS was also told that law enforcement served a search warrant at Mother’s hotel room. A substance suspected to be methamphetamine was seized during the search. This substance was later confirmed to be methamphetamine. 

Child was observed by CPS at the hospital, unresponsive and hooked up to several medical devices. Child had circular red spots observed on his body. The CPS case manager was informed by hospital staff that Child may not live beyond several hours and that he was suffering from diabetic ketoacidosis and a respiratory illness. On April 12, 2022, the case manager was notified by hospital staff that Child had died. 

CPS worked with law enforcement and had a joint interview scheduled with Mother for April 13, 2022. Mother failed to show up for the interview. Mother advised the detective she would not be interviewed by anyone and that she was obtaining a lawyer. The detective was able to speak briefly to Mother and informed the CPS case manager that Mother said she was having difficulty caring for Child. Mother also told the detective Child would not do what he was supposed to do, and Mother did not know he was so sick. The detective advised CPS that Mother also expressed it was her fault. 

According to the CPS report, on October 6, 2022, the CPS case manager conducted a follow-up interview with Dr. Beck, Child's treating ER physician from Bronson Hospital. Dr. Beck informed CPS it was his opinion the action or inaction of Child’s mother, Mother, rose “…to the level of abuse or neglect.’, adding, “In his professional opinion, this was negligent homicide.” Dr. Beck advised CPS he was very familiar with the family and Child had been to the hospital on several occasions for poorly controlled diabetes. Dr. Beck advised CPS he could recall one occasion where Mother said she did not remind Child to check his blood glucose and take his insulin to “…teach him a lesson.” CPS documented informing the investigating detective about Dr. Beck’s statements. The OCA could not find evidence showing the detective subsequently spoke to Dr. Beck about these comments. 

The death investigation was closed as a category II substantiation for child abuse and/or neglect with an intensive risk level on October 12, 2022. The preponderance was for medical neglect of Child by his mother. A petition was not filed due to Mother having no surviving children in which she maintains parental rights.

The OCA investigator reviewed the autopsy report concerning Child. Child’s cause of death was documented as complications of diabetes mellitus, including diabetic ketoacidosis, and the manner of death was indeterminate. 

Diabetes Type 1 Mellitus:  

According to the National Institutes of Health (NIH) National Center for Biotechnology Information (NCBI), “Type 1 diabetes mellitus (T1D) is an autoimmune disease that leads to the destruction of insulin-producing pancreatic beta cells. Individuals with T1D require life-long insulin replacement with multiple daily insulin injections daily (sic), insulin pump therapy, or the use of an automated insulin delivery system. Without insulin, diabetic ketoacidosis (DKA) develops and is life-threatening. In addition to insulin therapy, glucose monitoring with (preferably) a continuous glucose monitor (CGM) and a blood glucose monitor if CGM is unavailable is recommended. Self-management education and support should include training on monitoring, insulin administration, ketone testing when indicated, nutrition including carbohydrate estimates, physical activity, ways of avoiding and treating hypoglycemia, and use of sick day rules. Psychosocial issues also need to be recognized and addressed.”⁵
 
The NIH NCBI describes the care of T1D; “Self-management of T1D includes administering insulin multiple times daily with glucose monitoring and attention to food intake and physical activity every day, which is a considerable burden. Whereas newer technologies have helped people improve their glycemic control, they are costly, complex, and require education and training. Many people with diabetes fear hypoglycemia, hyperglycemia, and the development of complications, and depression, anxiety, and eating disorders can develop. The medical, education, training, psychological, and social challenges faced by people with T1D daily are best addressed by an interprofessional team that includes clinicians (MDs, DOs, NPs, and PAs), nurses (including diabetes nurse educators), pharmacists, dieticians, mental health professionals, social workers, podiatrists, and the use of community resources. Individualized treatment approaches, which can reduce the burden and further improve outcomes, are needed, and the interprofessional care model will yield the best possible patient outcomes.”⁶

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_{[5] https://www.ncbi.nlm.nih.gov/books/NBK507713/} 

_{[6] https://www.ncbi.nlm.nih.gov/books/NBK507713/} 

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Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The Child Advocate finds the Michigan Child Protection Law, MCL 722.628d Categories any departmental response, section 8d (1), which identifies the Category levels for CPS investigations and what should occur in each Category. In part, Michigan law states if evidence of child abuse or neglect is confirmed, the case must be classified as a category I, II, or III. The child protection law further discusses when a case should be escalated and when a petition should be filed, listing “the child’s family does not voluntarily participate in services” as one reason to file a petition.	Agree. On January 9, 2024, Kalamazoo County Administration reviewed policy and the Child Protection Law in reference to MCL 722.628d with all CPS specialists and supervisors. Additionally, Kalamazoo administration has implemented random case reads to ensure ongoing compliance which is monitored closely by the Business Service Center (BSC).
The Child Advocate finds Kalamazoo County MDHHS did not make a finding for medical neglect of Child by Mother and classified the October 2021 investigation as a Category IV closure.	Agree
The Child Advocate finds, after reviewing all applicable evidence, that Mother placed Child at an unreasonable risk of harm due to Mother’s failure to take reasonable steps to intervene to eliminate that risk, and that Mother abused and/or otherwise neglected Child, causing a life-threatening injury that required immediate medical attention and hospitalization. Kalamazoo County did not follow guidelines in MCL 722.638 which states in part, “(1) The department shall submit a petition for authorization by the court… if 1 or more of the following apply:” “…a parent… … has abused the child… and the abuse included 1 or more of the following: (v)Life-Threatening Injury”. Additionally, Kalamazoo County MDHHS did not follow PSM 713-01, which states if evidence of child abuse or neglect is confirmed, the case must be classified as a category I, II, or III. Despite having a preponderance of evidence for the medical neglect of Child by Mother, the October 2021 case was closed as a category IV. The correct disposition, at the very least, should have been a Category II, an open services case. Given Mother’s refusal to cooperate with CPS, and her expressed intention to cause direct harm to Child, a petition for removal in a Category I case could have been justified.	Agree
The Child Advocate finds Kalamazoo County MDHHS did not intervene sufficiently to ensure Child’s safety as a result of the incorrect disposition being reached in the October 2021 CPS investigation. A petition should have been filed in accordance with MCL 722.638, and PSM 714-1. PSM-714-1 states in part: “A court petition is required if the department previously classified the case as Category II and the child(ren)'s family does not voluntarily participate in services.” Kalamazoo County MDHHS had evidence supporting medical neglect and concerns for Child’s safety, if he continued in Mother’s care, from medical professionals equipped to understand Child’s medical needs. Kalamazoo County MDHHS also had evidence Mother did not believe she should have to care for Child’s medical needs, it was his responsibility, and she withheld his diabetic supplies to teach him a lesson. Mother was also not cooperative with CPS and CPS was unaware of Mother and Child’s living arrangements, or if Mother was continuing to meet Child’s needs at the time of case closure.	Agree. On January 9, 2024, Kalamazoo County administration completed a review of PSM 714-1 with all CPS specialists and supervisors. Additionally, Kalamazoo administration has implemented random case reads to ensure ongoing compliance which is monitored closely by the BSC.
The Child Advocate finds that Kalamazoo County MDHHS-CPS mailed a duty to warn letter to Mother despite having no information about Mother’s primary residence. That same duty to warn letter states, “MDHHS is closing the investigation as a Category IV which indicates the Department found a no preponderance of the evidence to confirm the allegations. As this investigation is closing and an Ongoing Case is not being opened, you are not being placed on the Central Registry at this time. No perpetrator is being found in this investigation; however, should another incident occur in which your child is medically neglected, and something were to happen that places your child at an unreasonable risk of harm, and the department is notified, further action could be taken by the department. It is your duty as a parent to ensure the safety and well-being of your child is met at all times.”	Agree. On January 9, 2024, Kalamazoo County administration completed a review regarding interactions with parents including the validity of a “duty to warn” letter, mailing items without an available address, the vulnerable child policy, and correctly assigning Categories with all CPS specialists and supervisors. Additionally, Kalamazoo administration has implemented random case reads to ensure ongoing compliance which is monitored closely by the BSC.

Recommendations:

Recommendation	MDHHS Response to Recommendation
The Child Advocate recommends that when child abuse or neglect is present Kalamazoo County MDHHS-CPS comply with Michigan law and take the necessary actions to protect the child from their abuser or neglecter.	Agree
To assist Kalamazoo County CPS, and any other county agreeable to this solution, the Child Advocate recommends that MDHHS adopt a process of CPS case management review when there are allegations of severe abuse and/or neglect. This review can include the following process: The first line Children’s Protective Services Manager requests a Case Review Conference with the Children’s Protective Services Program Manager regarding the CPS Investigation/Ongoing Case. A meeting between the parties is scheduled and held within 24 hours of the initial request. The managers review the documents that memorialized the steps taken in the active investigation, service plan, or updated service plan, as well as the case history before the scheduled meeting. A case conference will be held with the Children’s Protective Services Program Manager regarding the active investigation/ongoing case via telephone, Microsoft TEAMS, or in person. The Children’s Protective Services Manager provides the Children’s Protective Services Program Manager with an overview of the case, as well as the protective interventions that have occurred and progress regarding the investigation/ongoing case to date. A consensus will be reached regarding necessary case actions after the following items are discussed: What are the allegations listed in the complaint? Who were the identified victims and perpetrators? How many children are in the home and what ages? What are the identified needs for the family and child based on the CANS/FANS, FTM/TDM, and interactions? What services have been provided to the family to date? Have there been any barriers to providing services? What safety plans are currently in place? Who are the identified supports for the family? What, if any, are the safety concerns? What are the service recommendations? The conference between the Children Protective Services Manager and Program Manager be documented in narrative format in the MiSACWIS case file in a social work contact.	Effective August 21, 2023, MDHHS implemented the Statewide Critical Case Review (CCR) process to better assess high risk investigations and provide critical support to staff. The protocol is intended to further support local office staff and supervisors with challenging and often complex safety decisions through a team-oriented approach to help ensure the safety and well-being of children and families. The process engages all levels of leadership within the local office throughout the investigation for required cases, up to and including the district manager and/or county director and requires robust discussion at designated points during the investigation. Discussion points include, but are not limited to prior child welfare history, child and family strengths, barriers, concerns, and safety planning. A final disposition conference must occur prior to case disposition. The current scope requires a CCR for the assigned referrals outlined below. CPS referrals involving an alleged child victim three years of age and under with the assigned maltreatment type of physical injury that include any of the following: Physical injury. Threatened harm of physical injury involving excessive physical discipline without a visible injury or unknown injury. Infants exposed to substances, except for those exposed only to THC. AND a family history that includes A prior confirmed case of physical abuse, physical injury, threatened harm of physical injury, or other related maltreatment type with a parent or living together partner (LTP) as the identified perpetrator. OR One or more denied investigations that involve allegations of physical abuse, threatened harm or failure to protect regardless of alleged perpetrator type, or physical injury, threatened harm of physical injury, or placing a child at an unreasonable risk. In cases where CCR criteria are not met upon initial review yet are determined to meet criteria throughout the course of the investigation, the CCR protocol must be followed. All items of the protocol should be reviewed, with the understanding that upper management should be involved at the first case conference (even if delayed) and prior to disposition. MDHHS will review the current scope to determine if enhancements should be made based on the OCA’s recommendations.
The Child Advocate recommends that MDHHS correct the disposition of the October 2021 CPS investigation to reflect a preponderance of evidence for the medical neglect of Child by Mother, changing the disposition into a Category II (a Category I with a mandated petition is not warranted as Mother has no surviving children in which she maintains parental rights).	Kalamazoo County DHHS corrected the disposition of the October 2021 investigation on January 8, 2024.

PDF Version of Report:  Case No. 2022-0356

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
October 17, 2023	December 20, 2023	January 10, 2024	2022-0581

Summary of recommendations:

The OCO recommends strengthening CPS investigative practice and accountability by requiring case managers to interview treating medical professionals during investigations involving physical or sexual abuse or severe injury; mandating that all case conferences between CPS case managers and supervisors be documented in narrative form within the case file; and correcting the Category II disposition in the investigation into the child’s death to a Category I to accurately reflect the severity of the findings.

Summary of case: 

Date of Birth: February 26, 2019

Date of Death: June 11, 2022 (3 years old)

The child was three years old when he died on June 11, 2022. Pursuant to MCL 722.627k, MDHHS notified the OCO of the child fatality. On July 18, 2022, the OCO opened an investigation into the administrative actions of CPS regarding Child’s death. The following report summarizes the information and evidence found during the OCO investigation.

Case Objective: 

The objective of this review is to identify areas for improvement in the child welfare system by looking at how CPS investigations involving the child were handled by Kent County CPS, and the involvement of MDHHS staff, physicians, and law enforcement. This review reinforces the safety and well-being of a child is the shared responsibility of the family, community, law enforcement, and medical professionals aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of the investigations; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and to advocate for changes within it on behalf of similarly situated children.

Background and History: 

Mother is the birth mother of Sibling One (DOB: 05/31/2016), The child (02/26/2019), and Sibling Two (02/26/2019). Sibling One’s father is Sibling’s Father and was not involved in Sibling One’s life during the scope of this investigation. Father is the father of Child and Sibling Two. Prior to Child’s death, Father and Mother, shared custody of Child and Sibling Two, following a week on week off schedule. During the investigations reviewed by the OCO, Mother’s boyfriend, Boyfriend, was residing in the home and assisted with the care of Mother’s children. Boyfriend has no children of his own. 

In July 2020 Mother was investigated by CPS for physical abuse of Child. The investigation resulted in a Category IV, which is a finding of no child abuse or neglect. Boyfriend was residing in the home during this investigation but was not identified as an alleged perpetrator.  

Review of 2020 CPS Investigation:

The focus of the OCO’s investigation starts in July 2020 when Child was observed with bruising and swelling to his face and nose area, suspected patterned bruising on his back, and concern for physical abuse. The CPS investigation was opened on July 23, 2020, and closed on September 15, 2020. The OCO review of this CPS investigation found several deficiencies and missed opportunities when MDHHS CPS attempted to determine what caused Child’s injuries. In summary the OCO discovered: 

• Mother was identified as the only suspected perpetrator of physical abuse, despite the children being in the care of her live-in boyfriend, Boyfriend.
• There was a breakdown in the coordination between CPS and law enforcement.
• The CPS case manager did not interview a potential witness.
• CPS did not interview the emergency room (ER) doctor who examined Child’s injuries.
• CPS did not follow up with the social worker from Helen DeVos regarding Child’s follow up examination.
• The CPS case manager and supervisor did not follow up with the Center for Child Protection. 

On July 23, 2020, Father (Child’s father) brought him to the ER at Spectrum Health after picking him up from Mother’s home. Child had bruising and swelling to his face and nose, and a mark that appeared to be a pattern bruise on his back. According to CPS and medical documentation, these injuries were not consistent with the explanation provided by Mother, therefore a complaint was made to CPS Centralized Intake (CI).

The complaint was opened for an investigation and assigned to Kent County CPS. CPS began their investigation on July 24, 2020, by contacting the ER social worker from Spectrum Health. CPS was informed Child was brought into the hospital for a medical examination by his father due to bruising to his face and back. The ER social worker advised CPS the story provided for the cause of the bruises was possible but suspicious. The ER social worker told CPS photos had been taken of the injuries and the child was with his father for the night.

The same day CPS sent the Kent County Sheriff’s Department a law enforcement notification (LEN). Due to Child and Sibling Two being with their father, CPS also completed a home visit to Father’s home. Child and Sibling Two were observed but could not be interviewed due to their age and developmental abilities. The children were one year old at the time of this CPS investigation. Child was documented by CPS to have a small, curved cut on the front of his left eyebrow, a few centimeters in length, a reddish bruise to the bridge of his nose, a brownish bruise in the middle of his upper forehead, two curved red bruises that looked like a bite mark from a child between his upper shoulder blades, a small green/brownish bruise on his right shoulder blade, a light bruise on the left side of his ribs near his armpit, four red marks on the inside of his right bicep, and a linear bruise on the top of his right forearm.

Father told CPS, Mother informed him that Sibling One (age 4 during the 2020 CPS investigation) hit Child with a large metal rod which caused the marks and bruises. Father said he did not believe this explanation could cause so many injuries and that is why he had Child medically examined. 

On July 27, 2020, CPS and law enforcement conducted a joint home visit with Mother, her son Sibling One, and Mother’s boyfriend, Boyfriend. The CPS report documents CPS interviewed Sibling One while the detective interviewed Mother and Boyfriend. CPS documented Sibling One immediately began telling CPS about a net falling apart that scratched Child’s forehead and he got in trouble. Sibling One was unable to provide CPS with any details on what the net looked like or describe how the scratch occurred. Without prompting, Sibling One told CPS Child had bug bites on his back. When asked about the injuries on Child’s back, Sibling One denied biting Child and said the dog bit Child’s arm and left bruises. Sibling One denied any kids get hit and asked if he could be done talking.

The CPS report documents law enforcement’s summary of contact with Mother and Boyfriend. Mother informed law enforcement she left Boyfriend in charge of Sibling One and Child while she went to the store. Mother advised she had been gone for about ten minutes when Boyfriend called her, and stated Child got hurt. Mother told the detective Child had a circular mark near the side of his nose, and a mark on his back when she returned home. Mother said she believed Sibling One accidentally hit Child with a butterfly net that broke. She told law enforcement the net was thrown out. Mother also explained she cleaned Child up, took pictures, and sent those photos to Father informing him of what happened. Mother thought everything was fine, but then Father refused to bring Child home. 

Boyfriend informed law enforcement he was home with his roommate, as well as Child, and Sibling One when Mother went to the store. He advised he was using the restroom when he heard Child scream, so he ran out to see what happened. Boyfriend told law enforcement he ran into the roommate who was in her bedroom located next to the bathroom. When he got to the living room, he saw Sibling One rocking in a chair holding a broken butterfly net. Child was “sprawled out like a drunk person” on the entertainment center. There is no documented interview or attempt to interview the roommate, to corroborate the explanation of events. The roommate was a potential witness to the incident that caused Child’s injuries, CPS did not document interviewing or attempting to interview her. This interview could have provided additional information which would either corroborate or refute Boyfriend’s explanation of events.

On July 30, 2020, a social worker from Helen DeVos Children’s Hospital Academic General Pediatric Clinic emailed CPS to inform the case manager that Child was seen for a follow-up visit for suspected non-accidental trauma. The social worker advised the CPS case manager she had a release signed by Father to speak freely with the case manager about the case and asked that the case manager email or call her directly. There is no response or conversation documented between the social worker and CPS case manager in the CPS report. The OCO was unable to interview the case manager assigned to this CPS investigation as the person is no longer employed with the State of Michigan. Of note, there is a documented case conference between the CPS case manager and that individual’s supervisor on August 13, 2020, however the OCO is not able to determine details of this case conference.

The next documented effort in MiSACIWS shows CPS requested the ER medical records for Child on August 18, 2020. It does not appear the medical records were received from the hospital prior to CPS closing this case. Additionally, there is no indication that the medical records were reviewed by the CPS case manager.

On August 22, 2020, the CPS case manager sent a text message to the assigned detective requesting confirmation no criminal charges were issued. There is no documented response in the CPS case file. The OCO could not verify if this request received a response.

The CPS case manager spoke with Mother by phone on September 10, 2020. It is documented she was questioned further regarding Child’s injuries. Documentation shows Mother believed the two injuries on the top of Child’s mid back were from falling onto the entertainment center and did not believe it was a bite mark because Child is the only child that bites others. Mother denied knowing about red marks or bruises on Child’s arms as she did not see them when Child was with her. Mother agreed to forward photos of Child that she took directly after the incident, as well as screenshots of her text messages informing Father. Mother also advised having Child’s medical records concerning the injuries and agreed to send CPS photos of the records. Mother told CPS Father would not allow her to see the children if Boyfriend was visiting her home, so she no longer is allowing Boyfriend to visit. Mother informed the case manager she did not know where Boyfriend was. Mother told CPS, the roommate was only a friend and denied she lived in the home.

CPS documented reviewing the screenshots and pictures. A summary of the text messages shows Mother informed Father about Child’s injuries. Mother explained in texts to Father that Sibling One was not listening after he was told to stop swinging a butterfly net around, and Sibling One hit Child so hard it knocked Child off his feet causing Child to hit the entertainment center with his back. She also sent photos of the butterfly net to Father, which was described in the CPS case file as "…a long metal rod with a red handle. The tip of the rod is also metal and has a circular opening at the end, like a straw."

CPS received screen shot photos of the medical records from Mother for Child's ER visit on July 23, 2020. According to the CPS investigative report, Child’s medical records state the physical exam found bruising and swelling to the bridge of his nose. The medical records also indicate photographs were taken, however there are no photographs from the hospital in the CPS case record. The medical report documented "a parental concern about possible child physical abuse." According to CPS documentation, medical records state Father told staff that he picked Child up and noticed the injuries and immediately contacted Mother who said an older sibling hit him with a telescope.

The CPS investigative report documents a case summary and photographs were sent to the Helen DeVos Children’s Hospital Center for Child Protection  (CCP) on September 12, 2020. There is no documented follow up or response from the CCP. The case manager also attempted to reach Boyfriend, at a phone number previously provided, leaving a voice message. There is no documentation to show if a return phone call was received from Boyfriend.

CPS concluded their investigation as a Category IV, stating there was no preponderance of evidence of physical abuse by Mother towards Child. CPS documented that the statements given by Father at the hospital were clearly false given the evidence of text messages provided by Mother. The investigation was closed with a moderate risk level on September 15, 2020.

The OCO investigator interviewed CCP staff about the requests submitted to them by CPS during the CPS investigation. A staff member informed the OCO investigator that the CPS case manager wanted to “run the case by them” for their (CCP’s) opinion.

The CCP made it clear they are unable to diagnose a child they have not seen. CCP staff explained when the concerns are regarding physical abuse, it is time sensitive in terms of labs, but also visualizing injuries. One exception would be if CPS obtained evidentiary photographs with a scale, and proper lighting. There were no photographs of evidentiary value in this CPS case. CCP staff explained that they would not be able to evaluate the bruising the case manager was referencing, two months after the injuries occurred.

The OCO investigator asked how often a second opinion request this late into a case occurs. CCP staff advised they view these requests as more of a “curbside consult,” adding that CPS running a case by them to get their “blessing” is not, in any way, a second opinion. CCP staff indicated they do get these requests often, despite reminding case managers to contact them immediately after their investigation starts.

Death of the child:

As previously mentioned, the death of the child is what brought these cases to the attention of the OCO. On June 9, 2022, Child was found unresponsive in the family home while being cared for by Boyfriend. According to documentation reviewed by the OCO, Child presented to the ER with numerous injuries, including a significant massive acute hemorrhage on his brain, cerebral edema, subdural hemorrhages, diffuse subarachnoid hemorrhage, multiple abrasions to his trunk, one abrasion to his forehead, soft tissue hemorrhaging in his pelvis around the urinary bladder, and a proximal left humerus fracture. Child was also found to have retinal hemorrhages and retinoschisis with no natural disease. Child passed away from his injuries on June 11, 2022. Child’s cause of death was determined to be craniocerebral trauma. Due to some injuries being consistent with non-accidental trauma and other injuries being consistent with an accidental fall, the manner of death was indeterminate. CPS’ investigation found a preponderance of evidence of physical abuse of Child by Boyfriend, and the investigation was placed in a Category II. 

OCO Investigations with Similar Circumstances:

OCO case 2022-0263

Concerning the death of Child Two had a similar case issue. The medical provider who examined Child Two was not directly contacted or interviewed by the assigned case manager. This caused the incorrect disposition to be reached. In Child Two’s case, had the assigned case manager spoken directly to the medical provider, they would have been informed that Child Two's injuries were highly indicative of physical abuse, and were not accidental. The case manager did not do this, and relied on another case manager, in another county, who incorrectly documented their conversation with the doctor. The injuries were then mistaken for accidental trauma by CPS. Child Two died a few months later at the hands of his abuser.

OCO case 2020-0440

Concerning the death of Child Three also has a similar circumstance, as the medical provider was not contacted prior to the child being medically assessed. If CPS had contacted the medical provider prior to the child's examination, more specific details of the case manager's concerns could have been relayed to the provider and may have changed the way the provider handled the examination. The case manager investigating the abuse of Child Three prior to her death, did not seek a second medical opinion.

OCO case 2021-0974

Concerning the death of Child Four, is an example of a case manager speaking with medical professionals to gain information regarding a child’s injuries. The case manager had a sit-down interview with the doctor who examined Child Four. This interview provided the case manager with insight into Child Four's injuries, and helped CPS understand those injuries were not all caused on the day of her death. This conversation provided the case manager with sufficient evidence to support filing a petition for termination regarding Child Four’s surviving sibling. When interviewed by the OCO the case manager said speaking with the examining physician was very helpful in determining the outcome of the case.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The children’s ombudsman finds the 2020 CPS investigation concerning physical abuse of Child was inadequate.	MDHHS agrees and on November 7, 2023, the assigned supervisor, section manager, district manager, and county director met to discuss the findings of this report related to the 2020 investigation. Additionally, during an All-Staff meeting held on November 15,2023, county administration shared policy requirements and expectations related to medical follow up with all first-line staff.
The children’s ombudsman finds CPS failed to contact and interview appropriate medical professionals during the 2020 CPS investigation concerning physical abuse of Child.	MDHHS agrees and on November 7, 2023, the assigned supervisor, section manager, district manager, and county director met to discuss the findings of this report related to the 2020 investigation. Additionally, on November 9, 2023, section managers followed up with all CPS supervisors regarding the policy expectations related to medical exams on November 12, 2023, county administrators shared the information with all first
The children’s ombudsman finds a recommendation from the Michigan Child Death State Advisory Team’s 2015-2020 report states, "In CPS cases where a child is referred for a medical evaluation, require that direct communication occur between the CPS worker and the medical staff completing the evaluation to ensure that workers obtain a full understanding of the findings of that evaluation.”	MDHHS recognizes for any case where CPS requests a medical exam, speaking directly with the examining practitioner is ideal; however, medical professionals are not always immediately available to respond to a CPS case manager. Avoiding delays is important for the department to take quick actions to protect the safety and well-being of children. Policy allows case managers to speak to other professionals at the medical facility to gather and relay information to avoid potentially critical delays in examination, treatment of children, and any necessary safety planning to ensure child safety.
The children’s ombudsman finds the assigned case manager from the 2020 CPS investigation into Child’s injuries, is no longer employed with the State of Michigan, and the assigned supervisor from the 2020 CPS investigation was not able to fully recall details of the case given the amount of time passed. As a result, it is unclear what direction was provided to the case manager concerning any requests for follow up with medical professionals concerning Child’s injuries.	Agree
The children’s ombudsman finds a prior ombudsman recommendation to MDHHS from March 2023 suggests PSM 713-01 be amended to require case conferences between CPS case managers and their supervisors be documented in a narrative format in the case’s social work contacts. The OCO received the following response to this recommendation from MDHHS: “MDHHS is working with appropriate experts to assess this recommendation. The department will thoughtfully research potential revisions to policy to provide additional guidance around documentation of case conferences between specialists and supervisors to avoid any unintended consequences that would negatively affect children.”	MDHHS agrees, has prepared draft policy language, and is soliciting final feedback prior to implementation.
The children’s ombudsman finds that MDHHS should correct the investigation disposition into the child’s death to a category I case.	MDHHS agrees and has updated the June 10, 2022, investigation in SACWIS to reflect a Category I disposition.

Recommendations:

Recommendation	MDHHS Response to Recommendation
The OCO recommends MDHHS amend ‘PSM 713-04 Medical Examination and Assessment’, to require the assigned case manager conduct interviews with treating medical professional(s) as part of an investigation into physical abuse, sexual abuse, and/or severe physical injury.	MDHHS agrees that a policy change requiring the assigned case manager to pursue interviews with the treating medical professionals would be beneficial. Current policy allows case managers to speak to other professionals at the medical facility to gather and relay information to avoid potentially critical delays in examination and an update to require staff to pursue interviews with the treating physician will be explored.
The OCO recommends MDHHS amend PSM 713-01 to require that case conferences between CPS case managers and their supervisors be documented in narrative format in the case file’s social work contacts.	MDHHS agrees, has prepared draft policy language, and is soliciting final feedback prior to implementation.
The OCO recommends MDHHS correct the category II disposition of the investigation into the child’s death to a category I.	MDHHS agrees and has updated the June 10, 2022 investigation in SACWIS to reflect a Category I disposition.

PDF Version of Report:  Case No. 2022-0581

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
October 12, 2023	December 13, 2023	January 10, 2024	2022-0076

Summary of recommendations:

The Children’s Ombudsman recommends strengthening CPS policy and practice related to parental mental health by requiring caseworkers to contact mental health professionals when there is evidence of psychosis, defining psychosis within CPS policy, and expanding the definition of threatened harm to explicitly include parental mental health concerns. The Ombudsman further recommends amending threatened‑harm assessment requirements to ensure caseworkers evaluate the severity and history of mental‑health‑related risks, service engagement, and child vulnerability, and adding a specific safety‑assessment question addressing parental mental health. These changes would provide clearer guidance and more consistent decision‑making in cases where caregiver mental health may impact child safety.

Summary:

Date of Birth: 03/05/2020

Date of Death: 05/03/2022

Objective:

The objective of this review is to identify areas for improvement in the child welfare system by looking at how CPS investigations involving the child were handled by Wayne County CPS, and the involvement of staff, physicians, and law enforcement. This review reinforces that the safety and wellbeing of a child is the shared responsibility of the family, community, law enforcement, and medical personnel aiding children and families. This report is not intended to place blame, but to highlight the areas of concern regarding the handling of the investigations; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and to advocate for changes within it on hehalf of similarly situated children.

Background and History:

Mother and Father are the birth parents of Sibling and the child.
 
On January 1, 2022, Mother was arrested for the attempted murder of her children, Sibling, and the child, after she was found by the Inkster Police Department in the family’s bathtub with the children. The children’s throats had been cut and the child was unresponsive. This led to both children being hospitalized and CPS became involved. CPS filed a termination of parental rights for both parents concerning the children. Sibling and the child became temporary court wards on January 7, 2022 Child succumbed to his injuries on May 3, 2022.

The day after police found Mother and her children, January 2, 2022, statements were made to the media, by law enforcement, that CPS failed this family. The Inkster Police Department publicly stated Mother had a history of mental health problems, CPS had been involved with the family previously, and that CPS did not do enough to protect these children. A public complainant brought this case to the attention of the OCO asking if more could have been done on a systemic level in relation to law enforcement and mental health professionals’ involvement. 

The OCO investigation included reviews of the prior CPS history for the family, which included an investigation in 2018 and 2020. Both investigations surrounded concerns for Mother’s mental health. 

Review of 2018 CPS Investigation:

December 12, 2018, was the first time CPS encountered the family. A complaint was made to MDHHS centralized intake concerning improper supervision of Sibling by Mother. Sibling was six months old at the time of this complaint. Law Enforcement officers found Mother running down the street holding knives. During this incident, Sibling was discovered in her car seat inside the family home and was taken to the police department. Mother became aggressive towards law enforcement and was petitioned to Garden City Hospital where she was sedated due to her aggressive behavior. CPS responded to the police station and assisted with making a safety plan for Sibling to go home with maternal grandparents.

CPS conducted an interview with Sibling’s father who is Mother’s husband, Father, at the police station. During this interview Father informed CPS Mother was previously diagnosed with Bipolar, Post Traumatic Stress Disorder (PTSD), and Manic Depression. He informed CPS that Mother was not taking medications because she was breastfeeding Sibling. Father advised CPS Mother had been hospitalized in the past and was not involved in any counseling services. During this interview, Father also informed CPS he was diagnosed with PTSD and depression. He advised receiving services at Psygenics Inc. and signed a release of information for CPS to speak with his counselor and psychiatrist. Father agreed to allow Sibling to stay with her maternal grandparents under a safety plan. 

On December 13, 2018, CPS discovered that Mother was being transferred from Garden City Hospital to Behavioral Center of Michigan. The safety plan was also lifted on the 13th, and Father was able to pick up Sibling from the grandparents on December 14, 2018.

CPS’ next contact was a home visit on December 21, 2018, where Mother, Father and Sibling were present. Mother told CPS she was a good mother and denied that she would harm her child. Mother confirmed she was diagnosed with bipolar disorder with manic episodes, stating she has them once per year. Mother advised she stopped taking her medications due to adverse side effects that they could have on Sibling during breastfeeding. CPS asked her to schedule a counseling appointment and to inform her therapist and doctor of her concerns for side effects. Mother advised CPS she had been admitted to Stonecrest Behavioral Hospital for about four to five days after leaving Garden City Hospital. CPS did not develop a safety plan with the parents during this home visit. 

On January 2, 2019, CPS spoke with Father and again asked that Mother schedule an intake appointment to treat her mental health. On January 9, 2019, Father informed CPS Mother scheduled an intake appointment with Psygenics Inc., and she can attend sessions with him to work on their communication skills. CPS called and spoke with Father’s counselor, Counselor. Counselor was asked if Mother would be able to attend counseling sessions with Father and Counselor advised CPS that this was allowed. No further questions were inquired of Counselor regarding Father, his treatment, or his compliance with his appointments.

CPS completed a Family Team Meeting (FTM) by phone with the parents. During this meeting a safety plan, in which Mother would attend the Psygenics Inc. intake appointment and take medications as prescribed, was agreed upon. CPS informed Mother that this was a serious matter and she needed to continue to address her mental health to avoid any future issues regarding child safety. The case was then concluded as a Category III Open/Close for a preponderance of evidence supporting improper supervision of Sibling by Mother. CPS noted Mother had an upcoming counseling appointment for intake on February 11, 2019, and they provided the family with a community service pamphlet. The investigation was approved and closed on February 4, 2019.

During the OCO’s review, the safety assessment for this CPS investigation noted that Sibling was safe with no immediate harm factors identified. Based on the definitions, the OCO identified two immediate harm factors that could have been identified and explained. Number seven of the safety assessment, states “caretaker did not provide supervision necessary to protect the child from potentially serious harm.” CPS’ investigation found that Mother had left Sibling alone in the home at six-months old, which is not providing the supervision necessary to protect her from potential serious harm. Number 14 of the safety assessment states “caretaker’s emotional stability seriously affects their current ability to supervise, protect or care for the child.” Mother had a mental health episode that left her unable to care for the child, resulting in her six-month old infant being left home alone. 

The OCO’s review of the risk assessment for the CPS investigation showed it was incorrectly scored, resulting in a low risk level. Question N1 of the risk assessment states: “current complaint and/or finding includes neglect” was marked ‘no’ and should have been marked ‘yes’ as improper supervision is neglect. In addition, CPS substantiated Mother for improper supervision, which is neglect. Question N6 states: “provides inadequate supervision of the child” was also scored ‘no’ and should have been marked yes. CPS found improper supervision as a six-month old child was left in the home alone, which is not appropriate for their safety, and could have resulted in harm to the child. Had these questions been answered appropriately, the risk level would have increased from low to moderate.

The risk assessment being scored low or moderate does not have an impact on this CPS investigation.  The outcome would not have changed had the assessments been scored correctly. The inaccurate risk assessment score becomes important in future investigations as the accuracy of this assessment is relied upon to make future decisions. It is important that risk assessments are scored accurately as each investigation has the potential to impact future investigations. 

Review of 2020 CPS Investigation:

The next time CPS became involved with the family, was on May 17, 2020. Mother and Father now had a second child, Child (the child). Sibling, the couples first child was now two years old, and Child was approximately two months old at the onset of this CPS case. The CPS investigation began due to concerns of improper supervision and physical neglect of Sibling and Child by their parents. The concerns surrounded Mother’s mental health, noting she had schizophrenia and bipolar disorder, and had not been taking her medications. The complaint to MDHHS centralized intake stated two to three days prior to May 17, 2020, Mother had taken a pot of boiling hot water and poured it on her head. The complaint also stated Mother took a razor blade and used it to cut the back of her head. The same complaint stated Father did not call 911 when the incident occurred. Mother’s mother contacted 911 on May 17, 2020, after learning of the incident. EMS and law enforcement responded to the home, finding Mother in a catatonic state. She was transported to Garden City Hospital. Father refused to allow law enforcement officers to verify the safety of the children. 

Due to the COVID-19 pandemic CPS spoke with Father via video chat on May 17, 2020. Father confirmed Mother had a mental health episode and was transported to the hospital. He confirmed having the children in his care and allowed CPS to make face to face contact via video chat. CPS documented both children had no visible signs of abuse or neglect. Father advised he was not opposed to having CPS come to the home but due to COVID-19, he was not allowing anyone to enter. CPS made a safety plan surrounding safe sleep practices as Child during the video call. There is no documentation of a safety plan surrounding Mother’s mental health. It was noted in the CPS case file there was no safety plan needed due to Mother being admitted to the hospital. 

From May 18, 2020, to May 27, 2020, CPS attempted contact with Father and Mother, but were unsuccessful. CPS then contacted the Inkster Police Department to determine if any additional contact with the family had occurred and to inquire if Inkster police could complete a well-being check on the family. CPS did not document if law enforcement agreed to conduct a well-being check on the family or if one was completed. CPS continued attempting to contact the family via phone and in person from May 28, 2020, to May 30, 2020. These attempts were not successful.

During this timeframe CPS spoke with staff at Henry Ford Medical Center Pediatrics in Livonia. It was discovered there were no upcoming appointments for the family. CPS also learned the family was a no-show for their last scheduled appointment. Henry Ford Medical Center Pediatric staff informed CPS Child had never been seen at their facility and Sibling had not been seen since October 11, 2019.

On May 31, 2020, CPS received a voice message from Mother. The CPS investigation report documents Mother stated she was still in the hospital; the children are being cared for by their father and are safe. Mother did not feel that “CPS was needed and does not understand why her [sic] child’s father was being harassed while keeping the children safe.” On the same day CPS conducted a home visit with a police officer from the Inkster Police Department. Father answered the door while holding his son (Child) and allowed Sibling to come to the door to be seen by CPS. Father could not explain why he had not responded to CPS phone calls.

CPS attempted to obtain more information from Mother’s mother during the investigation, however, Mother’s mother refused to provide information, stating Mother was blaming her for CPS involvement. Mother’s mother advised she and Mother were not currently speaking.

CPS obtained medical records from Garden City Hospital for Mother. The medical records are documented to indicate Mother had risk factors of depression, psychosis, and schizophrenia; she was disheveled, had poor hygiene and was mumbling to herself. She was transferred to the burn unit at Detroit Medical Center due to second degree burns on her face, ear, and upper back. CPS made a collateral contact on June 10, 2020, with the inpatient social worker at Detroit Medical Center. The inpatient social worker advised CPS that Mother needed counseling and was referred to Hegira Health for outpatient services. The inpatient social worker did not believe Mother would harm her children and told CPS Mother promised to stop self-harming. CPS documented the social worker explained she did not have immediate concerns for the children but that the situation with Mother was “not perfect.” CPS documented the social worker would not elaborate on what she meant by this statement but that the social worker emphasized Mother needed to get help. 

CPS attempted contact with the family again on June 11, 2020. The family did not answer the door and law enforcement was requested to assist. Once law enforcement arrived, a white female, later identified as Mother, opened the door, looked out and closed it. As CPS and police were about to leave the home, Father came to the window and said his children were fine. CPS asked for a good working phone number, to create a safety plan, and explained they wanted to verify the children were safe. Father brought Sibling to the window, and she waved to CPS. Mother then began yelling at CPS that the baby was asleep, and they were not going to wake him up. The baby (Child) was not seen by CPS on this date. CPS documented they advised Father not to leave the children alone with Mother and that she needed to follow up with her mental health concerns. Father is documented telling CPS “Mother did not have mental health concerns”, and he wanted CPS to leave. CPS again advised Father of his responsibility to make sure his children were safe, and he said he knew. 

The investigation has no documented discussion with Mother about her follow up treatment to address her mental health. It is documented CPS sent a letter to Mother and Father on June 25, 2020, advising them the importance of providing safety and stability to the children and calling for assistance during a mental health episode. The report documents a community resource guide was included with each letter. The investigation was closed as a Category IV with no preponderance of evidence supporting physical neglect or improper supervision. The disposition documents the parents’ refusal and lack of cooperation throughout the CPS investigation but that the children remained in the care of their father during the mental health episode. It was documented Mother was encouraged to follow through with mental health treatment. 

During the OCO’s review, the safety assessment was noted to mark number 15, “other” as yes with the explanation “based on past CPS and police intervention, the mother reportedly has a history of mental health concerns that may impact her ability to care for the children if she is the sole caregiver. The father has expressed to CPS that he is aware of the mother’s needs, and he is present in the home and capable of providing daily care to his children. The family indicated they did not have a desire to cooperate with CPS or participate with any recommended services.” To address this safety factor, CPS documented the use of “family resources, neighbors, and other individuals in the community as safety resources.” CPS noted Mother’s mother was identified in medical records as a support for Mother. 

The contrary is documented when CPS answered the risk assessment question, N4 “Primary caretaker’s social support, b. Limited or negative social support from relatives/friends/neighbors.” CPS provided an explanation that Mother had limited social support as hospital records noted Mother’s support was her mother, however Mother’s mother informed CPS Mother had ended communication with her due to her hospitalization and CPS involvement.

In the safety assessment CPS could have marked question N14: “Caretaker(s) emotional stability seriously affects current ability to supervise, protect, or care for the child.” Mother was diagnosed with psychosis, depression, anxiety, and schizophrenia. She had a mental health episode that involved pouring hot water on herself and cutting the back of her head with a razor blade. Her mental health status caused her to be hospitalized for inpatient treatment, leaving her unable to care, supervise or protect her children. 

In review of the risk assessment, the OCO noted that CPS properly scored N7 pertaining to the primary caretaker currently having a mental health problem. CPS wrote “Mother has been diagnosed with psychosis, depression, anxiety, and schizophrenia. Due to the severe mental health [sic], Mother was referred to an outpatient program for continued care.” 

CPS scored "A10: All caretakers are motivated to improve parenting skills; b. Yes, caretakers are willing to participate in parenting skills program or other services to improve parenting or initiate appropriate services for parenting without referral by the department."

A10 should have been scored: "C. No, one or both caretakers need to improve parenting skills but refuse services." The parents were uncooperative with CPS and refused to participate in any services referred by the department. During CPS' last contact with Father and Mother, Father stated "that Mother does not have mental health concerns." There is also no documented conversation with Mother regarding her mental health treatment or her willingness to participate in the outpatient services referred to her by the hospital. Both parents were uncooperative and told CPS to leave them alone.

CPS could have also then scored "A11 Primary caretaker views incident less seriously than the department." Mother was not taking responsibility for the incident, was refusing to speak to CPS about what happened, and Father stated Mother did not have any mental health concerns.

The OCO notes that this investigation was completed during the onset of the COVID-19 Pandemic. The OCO recognizes the barriers this created for CPS when working with families and addressing concerns of child abuse and neglect.

Additional Information:

Interview efforts were difficult for the OCO investigator due to the amount of time that expired between the 2018 CPS investigation and the OCO investigation. Additionally, some case managers are no longer employed with MDHHS and were unable to be located. Supervisors from both cases do not recall many details due to the long period of time since last interacting with these cases. MiSACWIS documentation is often the only evidence the OCO can rely on to draw conclusions about what actions were taken. The OCO found MiSACWIS documentation was lacking in several areas of the CPS investigations reviewed from 2018 and 2020. 

Between June 2020 and January 2022 CPS did not have contact with the family. During this 18-month period the Inkster Police Department responded to a call about domestic violence between Mother and Father where a child was involved. This occurred on March 13, 2019. The Inkster Police Department did not refer this incident to MDHHS Centralized Intake. Therefore, CPS was not involved.

Review of 2022 CPS investigation and the child’s death:

On January 1, 2022, and after 18 months of no interaction with the family, CPS again became involved with the family. On January 1, 2022, law enforcement responded to the home to find Mother had stabbed and cut the throats of Sibling and Child. Both children were taken to Children’s Hospital due to stab wounds and other injuries. Child had also been strangled and had to be intubated.

CPS spoke with medical staff and law enforcement during their investigation. CPS was informed Child was stabbed multiple times by his mother. Child had to have surgery to repair his carotid arteries and was listed in critical condition as his injuries were life threatening. He also had multiple bruises to his neck, legs, face, arm, and hand. Sibling had knife wounds to her neck and her face and was covered in bruises. Sibling was released from the hospital and placed in the care of her maternal aunt, via a safety plan.

On the same day Father was involved in an unrelated car accident after he left the house on December 31, 2021, due to Mother’s erratic behavior. While being treated at the hospital Father was in a state of psychosis and was admitted to Pontiac General Hospital for mental health treatment. CPS interviewed Father in coordination with the Inkster Police Department. This is the first time Father was advised Mother harmed their children. Father told the interviewers Mother thought someone was coming through the windows or was watching the family. He left the home that evening at approximately 6 pm (December 31, 2021) to drive around and clear his head. Father explained Mother was “acting crazy and it threw him off his wagon.”

CPS spoke with Mother at the jail after submitting a petition to the courts for removal of the children. Mother denied recalling what she did and told CPS, Father thought people were trying to kill him, and that he also had a nervous breakdown. 

A preliminary hearing was held on February 8, 2022, regarding removal of the children from the home, suspending parenting time for both parents, and to order trauma assessments of the children. The petition also included a request for termination of parental rights for both children, listing both parents as respondents. This investigation was concluded as a Category I with a preponderance of evidence supporting threatened harm, physical abuse, and failure to protect. The CPS case manager documented no historical threatened harm was found; therefore, a threatened harm assessment was not completed. The safety and risk assessments appeared to be scored appropriately.

During the foster care case, Child’s condition continued to worsen. He was not able to breathe or eat without medical assistance and was experiencing seizures and brain hemorrhages. It was the opinion of medical providers that the child would not recover from his injuries and would remain in a vegetative state. Father did not wish to give up on his son and continued life saving measures. Child was kept under life saving measures until his father made the decision to stop life support. The child succumbed to his injuries on May 3, 2022.

Additional Research:

During the OCO’s investigation, additional research was made surrounding psychosis, assessing parental mental health, parental mental health’s impact on children, and any additional steps that could be taken by CPS professionals when addressing these concerns. 

Prior to researching the assessment of parental mental health and its impact on children, the OCO reviewed the definition of psychosis. The National Institute of Mental Health describes psychosis as a word used to "describe conditions that affect the mind, where there has been some loss of contact with reality. When someone becomes ill in this way it is called a psychotic episode. During a period of psychosis, a person’s thoughts and perceptions are disturbed and the individual may have difficulty understanding what is real and what is not.  Symptoms of psychosis include delusions (false beliefs) and hallucinations (seeing or hearing things that others do not see or hear).” Other symptoms include incoherent or nonsense speech, and behavior that is inappropriate for the situation. A person in a psychotic episode may also experience depression, anxiety, sleep problems, social withdrawal, lack of motivation, and difficulty functioning overall. A person in a psychotic episode may also “behave in confusing and unpredictable ways and may harm themselves or become threatening or violent towards others.”  

The OCO reviewed multiple studies and peer reviewed published journals including an abstract published in the National Institute of Health’s National Library of Medicine titled ‘Maternal mental illness and the safety and stability of maltreated children’. The abstract cites ‘Child Abuse; The International Journal’, which is the official publication of the International Society for Prevention of Child Abuse and Neglect . The international journal describes how mental illness often negatively influences parenting behavior placing child safety at risk due to many different factors. As an example, depression elevates the risk of coercive or hostile parenting and corporal punishment. Additionally, the journal explains that mothers with schizophrenia are less responsive and emotionally involved with their children compared to depressed mothers and mothers without mental illness stating further, “Mental illness is associated with heightened risk of child maltreatment. Analysis of the National Institute for Mental Health's Epidemiologic Catchment Area survey demonstrated that maternal depression places children at risk for abuse (Chaffin, Kelleher, & Hollenberg, 1996). Others have found a similar association between maternal depression and maltreatment (Kotch et al., 1999, Sheppard, 1997, Windham et al., 2004). Children of parents with depression or schizophrenia are 2 times more likely to experience abuse than children of parents without mental illness; children of parents with antisocial behavior are 6 times more likely to experience abuse (Walsh, MacMillan, & Jamieson, 2002). Parents with undifferentiated mental illness are also 2 times more likely to abuse and neglect their children (Brown, Cohen, Johnson, & Salzinger, 1998). This maltreatment risk suggests that a high proportion of mothers entering the child welfare system have a mental disorder.” . The journal continues to describe various types of parental mental health issues and the negative impacts on child safety and wellbeing, stating clearly that “Mental illness is associated with heightened risk of child maltreatment”, and an “increased likelihood of foster care placement”. 

The peer reviewed journal, "Parental mental health: disruptions to parenting and outcomes for children” , was also reviewed and speaks to the connection between parental mental health, maternal depression and how this affects children’s mental health during their development. It also speaks to the impacts on children by disruptions in parenting relating to mental illness as "parental mental illness will in most cases impair parenting ability." It was found that the "age of the child will largely determine their vulnerability or resilience to different disruptions in parenting behavior, or in their relationships with their parents." The journal explains mental health problems are "frequently associated with other family or environmental factors, such as marital disharmony, conflict and domestic violence, separation or divorce, other stressful life events, poverty, severe economic deprivation, and social isolation." These associated factors are often by themselves correlated with negative impacts on children without an association with parental mental health, suggesting that "they should be viewed somewhat differently from other disruptions to parenting."

This journal explored modifying interventions to reduce or minimize the disruptions to parenting resulting from mental health problems in one or both parents. The journal suggests that parenting supports should be aimed at minimizing disruptions to parenting should be "initiated preventatively, when the mental health problems become apparent in the parent, and before they become apparent in the child."

The journal also explored injuries to children when parental mental health is present in mothers. It found that children were "significantly more likely to have sustained more serious injuries if their mothers were depressed or had a history of depression or treatment of a psychiatric disorder."

Additionally, during the OCO’s research, the OCO found other states include specific questions on their safety assessments when discussing a parent’s mental health. New York CPS policy  safety assessment asks: 

“5. Parent(s)’/Caretaker(s)’ apparent or diagnosed medical or mental health status or developmental disability negatively impacts his/her ability to supervise, protect, and/ or care for the child(ren). 

• Parent(s)/Caretaker(s) exhibits behavior that seems out of touch with reality, fanatical, bizarre, and/or extremely irrational.
• Parent(s)/Caretaker(s) diagnosed mental illness does not appear to be controlled by prescribed medication or they have discontinued prescribed medication without medical oversight and the parent/caretaker’s reasoning, ability to supervise and protect the child appear to be seriously impaired.
• The parent(s)/caretaker(s) lacks or fails to utilize the necessary supports related to his/her developmental disability, which has resulted in serious harm to the child or is likely to seriously harm the child in the very near future.”

Ohio CPS has similar wording within their CPS safety assessment. Ohio’s safety assessment asks:

“7. Behavior(s) of any member of the family or any person having access to the child is symptomatic of mental or physical illness or disability that suggests the child is in immediate danger of serious harm. "

The guidance for this question continues stating "This safety factor evaluates if behaviors of any member of the family or any person having access to the child(ren) are symptomatic of a mental or physical illness or disability to the extent that the child(ren) is in immediate danger of serious harm. The evaluation includes whether a caretaker acts out or exhibits distorted perception which seriously impedes his/her ability to parent the child(ren). This safety factor takes into account whether a physical or psychological illness or impairment is present and profoundly impacts the caretaker's ability to meet the basic needs of the child(ren). Also included is an evaluation of whether an intellectually impaired adult places the child(ren) in physical danger and/or is able to recognize and provide for the child(ren)'s basic needs."

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_{[1] U.S. Department of Health and Human Services. (n.d.). Understanding psychosis. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/understanding-psychosis}

_{[2] Science Direct Journal, 2023, Child Abuse & Neglect. https://www.sciencedirect.com/journal/child-abuse-and-neglect}

_{[3] Child Abuse & Neglect Volume 35, Issue 5, May 2011, Pages 309-318. https://www.sciencedirect.com/science/article/abs/pii/S0145213411000706?via%3Dihub}

_{[4] Smith, M. (2004), Parental mental health: disruptions to parenting and outcomes for children. Child & Family Social Work, 9: 3-11. https://doi.org/10.1111/j.1365-2206.2004.00312.x} 

_{[5] New York State Child Protective Services Manual Chapter 6; https://ocfs.ny.gov/programs/cps/manual/2020/2020-CPS-Manual-Ch06-2020Mar.pdf}

_{[6] Ohio Children’s Protective Services Worker Manual, Assessing Safety; https://emanuals.jfs.ohio.gov/FamChild/CPSWM/Policy/Assessing-Safety.stm} 

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Criminal Case Disposition:

According to the records of the Third Judicial Circuit Court of Michigan, on October 6, 2023, Mother was found not guilty of Homicide – Felony murder, Assault with intent to murder, and two counts of Child abuse – 1st Degree by reason of insanity. 

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The children’s ombudsman finds the MDHHS CPS manual does not provide specific enough guidance to case managers regarding caretakers’ and parents’ mental health and its potential maltreatment of children in their care.	MDHHS agrees and will work with medical and mental health experts, other key stakeholders, and child welfare case managers and their supervisors to determine how to enhance CPS policy to offer more guidance to staff around assessing and responding to parents’ and caregivers’ mental health needs to help ensure child safety.
The children’s ombudsman finds that the reviewed 2018 CPS investigation left questions unanswered surrounding Mother and Father’s mental health. Additional contacts could have been made to determine if further services, support, or safety measures were needed. CPS did not put a safety plan into place when returning Sibling to her father’s custody. The children’s ombudsman believes there could have been a safety plan put in place for father and Sibling to help the father in the event Mother returns to the home and has another mental health experience that jeopardizes the health and safety of Sibling. CPS did not attempt any collateral contacts to determine if Mother completed her intake assessment and was treating her mental health appropriately. The children’s ombudsman found Mother was a no show to two scheduled appointments at All Wellbeing Services in 2019 but was never actually seen by their agency. CPS did not obtain or review any mental health records or police reports. CPS did not obtain more information surrounding Father’s mental health treatment, if he was compliant with services, or if there were any concerns for his parenting, when speaking with his counselor. During the OCO’s investigation, it was discovered through requests for mental health records, that no records were able to be located for either Mother or Father at Psygenics Inc. from 2018 to 2022. The children’s ombudsman found that Father was treated from April 4, 2018, to October 5, 2018, at the Team Wellness Center, for schizoaffective disorder, symptoms of depression and psychosis. CPS did not properly score the safety and risk assessments.	Wayne County agrees with OCO findings 2 a-e. Wayne County acknowledges the importance of collateral contacts with mental health professionals in situations like the 2018 case. In 2023, in accordance with the MDHHS Keep Kids Safe Action Agenda, MDHHS implemented a critical case review process for cases with younger youth involved. In that process, upper management ensures collateral contacts are being made and risk is appropriately assessed.
The children’s ombudsman finds CPS did not appropriately assess parental mental health during the 2020 CPS investigation. CPS did not interview Mother as Mother refused to cooperate with CPS. There is no evidence, written or verbal, that CPS asked questions of Father regarding his ability to care for the children, or why he did not call for treatment of Mother when her episode of psychosis occurred. There is no evidence an adequate assessment of Father’s ability to protect the children had taken place. There is no evidence of any attempted contact or documentation of attempted contact by CPS with outpatient services Mother was referred to upon her release from the hospital. Follow up with these service providers would have shed light on whether Mother had been attending follow up appointments and addressing her mental health needs. There is no evidence documenting communication between CPS and law enforcement occurred outside CPS requesting law enforcement assistance on home visits. If CPS had received the police reports and/or spoken with law enforcement about the family, or recent involvement with the family, perhaps CPS would have been informed of the domestic violence between Mother and Father in 2019. CPS did not properly score the safety and risk assessments as the assessments contradicted one another. When documenting broad trends/patterns of any alleged or confirmed maltreatments, CPS stated “There is not a trend for the family, however there is a trend of improper supervision and threatened harm as it relates to Ms. Bole’s mental health.” A threatened harm assessment did not occur surrounding Mother’s mental health as policy does not require one to occur. Through obtaining mental health and medical records, the OCO found that Mother was admitted voluntarily in April 2019 for her mental health. Records indicate she was treated for unspecified psychosis, rule or schizophrenia, and severe anxiety and depression. Mother did participate in tele-health mental health treatment and medication reviews through Heigra Outpatient Services from June 15, 2020, to November 23, 2020.	Agree
The children’s ombudsman finds staff within MDHHS do not believe CPS policy currently provides enough guidance and assistance on assessing parental mental health and its effects on child safety.	MDHHS agrees and will work with medical and mental health experts, other key stakeholders, and child welfare case managers and their supervisors to determine how to enhance CPS policy to offer more guidance to staff around assessing and responding to parents’ and caregivers’ mental health needs to help ensure child safety.
The children’s ombudsman finds the COVID-19 pandemic further complicated matters in May 2020 due to delays with services being provided across the state and a lack of providers willing to accept new patients. Additionally, the OCO investigation found the amount of service providers who are available and willing to work with a family on an ongoing basis is lacking.	While MDHHS acknowledges the COVID-19 pandemic impacted most aspects of child welfare, including service provision, the department provided detailed practice guidance to staff at the very onset to help ensure child safety and meet the needs of children and families despite health concerns for staff, children, families, and service providers. MDHHS consistently seeks to expand mental health services and access for children and families and offer other prevention services and support. MDHHS reviewed and offered flexibilities post pandemic to decrease administrative burdens and increase behavioral health workforce. In March 2022, MDHHS created the Bureau of Children’s Coordinated Health, Policy, and Supports, dedicated to addressing behavioral health needs of Michigan’s children, youth, and their families. The Bureau is structured to support work related to children’s behavioral health policy analysis and modification, expansion of access to services, data collection and continuous quality improvement, provision of evidence-based practices, partnership expansion with other child serving agencies and organizations, and implementation of technical assistance and consultation for youth and families experiencing complex behavioral health challenges in the public mental health system. The Bureau of Children’s Coordinated Health, Policy, and Supports also serves as the primary entity for development and management of Medicaid-funded home and community-based services for children, youth, and their families; implementation of a standard assessment process to determine eligibility and obtain access to behavioral health services; establishment of a public-facing dashboard to support transparency and decision making pertaining to specialty behavioral health services; and expansion of training and initiatives focused on growing the behavioral health workforce. Additional information regarding the bureau can be found at: Bureau of Children's Coordinated Health Policy & Supports (michigan.gov).

Recommendations:

Recommendation	MDHHS Response to Recommendation
The children’s ombudsman recommends MDHHS amend CPS policy 713-01, requiring caseworkers to make a collateral contact with mental health professionals when there is evidence of psychosis in a parent during a CPS investigation. This required contact would aid CPS in determining if mental health professionals believe the parent is compliant with treatment, services and if there is any concern for harm to the children.	Current CPS policy does recommend case managers make collateral contacts to thoroughly assess child safety during an investigation, including contact with mental health providers. However, MDHHS will work with medical and mental health experts and other key stakeholders to determine when specific collateral contacts should be required based on the unique circumstances of a case to better assess a parents’ and caregivers’ mental health and the potential impact on safety. MDHHS is proactively working to identify behavioral health services across the state to better connect families to services.
The children’s ombudsman recommends CPS policy manual define psychosis.	MDHHS agrees and will work with mental health experts to define psychosis in CPS policy.
The children’s ombudsman recommends MDHHS amend CPS policy 711-2 relating to threatened harm, expanding the definition of this to include the mental health of a parent. This can require a threatened harm assessment when the parent has history of mental health diagnosis in previous CPS investigations and the current case involves concerns relating to the parents' mental health and ability to meet the child's needs.	MDHHS agrees and will review the current threatened harm assessment with medical and mental health experts, other key stakeholders, and child welfare case managers and their supervisors to determine how best to utilize the assessment in cases involving a parent or caregiver’s mental health to ensure the safety and well-being of children. Policy will be updated to reflect any recommendations.
The children’s ombudsman recommends CPS amend policy 713-11 pertaining to the threatened harm assessment. An amendment to require an assessment by the case manager when mental health is present in one or both caregivers and the prior history relates to concerns surrounding mental health. The threatened harm assessment would then require the worker to evaluate and assess the "severity of past behavior, length of time since past incident, evaluation of services, benefit from services (including if conditions have been rectified) and vulnerability of child(ren)." This information can aid CPS in comprehensively determining if threatened harm remains a factor for maltreatment and/or if CPS should request court involvement.	MDHHS agrees and will review the current threatened harm assessment with medical and mental health experts, other key stakeholders, and child welfare case managers and their supervisors to determine how best to utilize the assessment in cases involving a parent or caregiver’s mental health to ensure the safety and well-being of children. Policy will be updated to reflect any recommendations.
The OCO recommends CPS amend policy 713-11 to add a question to the safety assessment specifically surrounding parental mental health similar to those found in New York and Ohio CPS safety assessments.	MDHHS is actively revising the department’s safety assessment in partnership with Evident Change and will consider this recommendation during development. CPS policy will be amended to reflect the questions and other assessment items within the revised safety assessment upon completion.

PDF Version of Report:  Case No. 2022-0076

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
August 6, 2019	November 28, 2023	December 15, 2023	CAS-02825-V7H4W6 (2018)

Summary of recommendations:

The OCO recommends that MDHHS establish specialized units within the Children’s Services Agency to manage foster care cases involving highly vulnerable children. These units should be staffed by caseworkers with defined minimum experience, enhanced training, and reduced caseloads to ensure thorough assessment, documentation, and response to each child’s needs and safety risks. Staff assigned to these units should possess the expertise necessary to address the complex needs of children who face heightened risk of abuse or neglect.

Advocate's Note:

June 5th, 2023

Office of children's ombudsman (OCO) case number C AS-02825-V7H4 W 6 (2018).

The attached report of findings and recommendations is being made public pursuant to the children's ombudsman act.
The ombudsman shall not disclose information about an ongoing law enforcement or children's protective services investigation. The ombudsman may release the results of its investigation to a complainant or an individual not meeting the definition of the complainant if the ombudsman receives notification that releasing the results of its investigation is not related to and will not interfere with an ongoing law enforcement investigation or ongoing child protective services investigation. 

In September 2019, the OCO was notified by the Ingham County Prosecutor’s office that the results of the OCO investigation may interfere with the criminal case against Jessica Bice. On June 27, 2023, the Ingham County Prosecutor’s office provided written notification that releasing the OCO report would not interfere with the criminal case. 

A previous ombudsman authored the report of findings and recommendations. The report was not provided to MDHHS until a release was received and is now being made public as required under Michigan law. 

As the children’s ombudsman, I support the findings and recommendations made in this document.

Ryan Speidel

Children's Ombudsman

Case Background:

The child died on August 17, 2018. Pursuant to MCLA 722.627k, the Michigan Department of Health and Human Services (MDHHS) notified the Office of the Children’s Ombudsman (OCO) of the child fatality. On August 20, 2018, the OCO opened an investigation into the handling of Ingham County Children’s Protective Services (CPS) and foster care (FC) cases pursuant to our statutory responsibilities. 

The OCO reviewed confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), including but not limited to service reports, medical records, scene reenactment, and social work contacts. The OCO also spoke with MDHHS Staff, the child’s Lawyer-Guardian ad Litem, the Prosecuting Attorney, the law enforcement officer responsible for investigating the death, the Medical Examiner (ME), and medical personnel in the child’s doctor’s office. 

Case Objective:

The objective of this review was to identify areas for improvement in the child welfare system by looking at Ingham County’s handling of this family’s case and the involvement of staff, physicians, and law enforcement. This review reinforces the safety and well-being of a child is the shared responsibility of the family, community, and both law enforcement and medical personnel aiding children and families. It is not intended to place blame but to highlight areas of concern regarding the handling of this case and advocate for changes in the child welfare system on behalf of similarly situated children. 

Family History: 

The child was born on August 28, 2011, and lived with his mother and father. According to the child’s medical records, he was diagnosed in June 2012 with multiple medical conditions, including infantilism, pediatric failure to thrive (FTT), and a myoneural disorder. In July of 2013, he was diagnosed with a congenital chromosomal disorder; in 2014 he was diagnosed with atopic dermatitis and allergic rhinitis. The child’s mother committed suicide in June 2017. After multiple unsuccessful threats and suicide attempts, the father became the sole caregiver for the child. 

In August 2017, the father physically abused the child and subsequently threatened suicide when faced with the child’s removal. On August 8, 2017, the child was removed from the father’s care after a medical examination determined the father physically abused the child. The child was placed with his paternal aunt, and her six-year-old son where he remained until August 17, 2018, when he died. 

CPS Involvement

February 1, 2018, CPS Investigation:

A neglect complaint was made with allegations that the maternal aunt was physically neglecting the child who was nonverbal with multiple impairments by not properly cleaning and grooming him and not cleaning his wheelchair, which was covered in dried feces. It was also alleged that the child had discharge from his ear and had an untreated rash on his face and buttocks. The child was treated at urgent care for wax build-up in his left ear canal and a rash. The investigation allegations were unfounded, and he was released to his maternal aunt where he remained. 

May 23, 2018, CPS Investigation:

A physical abuse complaint was made with allegations that the maternal aunt was physically abusive to the child who reportedly had bruises on his back that appeared to resemble finger marks. He was medically examined at the hospital on May 24, 2018, by a doctor. The doctor could not determine if the marks on the child were from physical abuse. During this encounter, the child weighed 47 pounds. Seven days later during a follow-up appointment with his primary care doctor, the child weighed 40 pounds. The doctor did not report any concerns that the maternal aunt was abusive or neglectful. The investigation was concluded with no findings of abuse and noted there were significant concerns about the maternal aunt’s mental health that were to be addressed through foster care case management. 

CPS Investigations concerning the death of the child:

August 17, 2018, CPS Investigation: 

On August 17, 2018, a CPS complaint was made that the child was found not breathing and after CPR was unsuccessful the child was transported to the hospital where he was pronounced deceased. An autopsy was completed by Pathologist Patrick Hansma, DO. At the time of his death, the child weighed 29 pounds. Dr. Hansma determined that the child’s death was a result of blunt force trauma to the head and neck, adding a contributing factor of caregiver neglect. The child was emaciated consistent with ongoing undernutrition, and his manner of death was classified as a homicide. 

According to Dr. Hansma, it would have taken a period of two to three months for the child’s weight to decline from 47 lbs. to 29 lbs., and had medical care been sought for him on or about July 26, 2018, the malnutrition could have been treated. The August 17, 2018, investigation was concluded as a category I with a preponderance of evidence being found for failure to protect, improper supervision, medical neglect, physical abuse, and threatened harm. The maternal aunt’s son was initially placed in a licensed foster home and subsequently transitioned to the home of his father. Her son’s foster care case was closed after his father was granted full custody. A petition was filed on May 16, 2019, requesting termination of the maternal aunt’s parental rights to her son. 

On July 12, 2019, the maternal aunt was criminally charged with first degree child abuse and open murder for the child’s death. She was convicted of child abuse first degree and homicide second degree on June 20, 2023. 

Foster care involvement prior to the child’s death:

When the child entered foster care in August 2017, he had already been diagnosed with a medical condition that considered him a medically fragile child¹. Due to this, the OCO report concentrates on the foster care case in the months leading up to the child’s death. 

The child’s foster care case was assigned to four foster care workers over the 12-month period he was in care. The first foster care worker (FCW) was assigned from August 11, 2017, through February 27, 2018. The child’s case was reassigned to a second FCW from February 27, 2018, to March 6, 2018, and then reassigned back to the first FCW from March 6, 2018, through April 6, 2018. The third FCW was assigned to the child’s case from April 6, 2018, through April 17, 2018, a total of eleven days. The child’s case was assigned to the fourth and final FCW on April 17, 2018. The child’s case remained with the fourth FCW until he died. 

When the child’s most recent FCW was assigned case responsibility, the FCW had recently begun employment with the State of Michigan, finished the minimum amount of general case management training with the Child Welfare Training Institute (CWTI), and was assigned a position with Ingham County MDHHS. 

On June 6, 2018, a Family Team Meeting (FTM) was convened at the agency to discuss whether the maternal aunt would be medically cleared by her doctor to become licensed, obtaining an educational planner for the child to address issues between the school and the aunt, and respite care for the summer through Community Mental Health. During this FTM, the aunt was documented to be emotional and defensive, raising concerns for her metal stability. According to interviews conducted by the OCO, the team decided to request a voluntary psychological evaluation and drug screens or request they be court ordered if the aunt did not agree to the evaluation and testing. 

On June 15, 2018, the child’s final foster care worker, the foster care supervisor, and the licensing worker were notified that the aunt’s doctor expressed specific and direct concerns about her mental instability, possible drug use, that she should not have a special needs child in her care, and they could not recommend her for foster home licensure. Specifically, the doctor did not believe the aunt should have another child in her care, besides her own, especially a special needs child, that he feared neglect, and had concerns for mental instability. These concerns were indicators of substantial risk of harm to a vulnerable child. Despite having reasonable knowledge that continued placement in the aunt’s home presented a substantial risk to the child’s safety and well-being, at the permanency planning hearing (PPH) on June 21, 2018, the FCW testified, given the child’s special needs, it would be unlikely another foster home would be located for placement. This hearing continued placement with the aunt. The plan for permanency remained reunification with his father, his placement was maintained, and the request for a court order forcing the aunt’s participation in services was denied.

In 2018, foster care policy FOM 722-03 stated that a placement change is required if the current placement is considered harmful or is no longer in the child’s best interest. When presented with information that the child was a medically fragile child, was at substantial risk based on mental instability, possible drug use, and a medical opinion, the aunt should not have a child with special needs in her care, no definitive action for replacement was implemented. The child remained with the aunt until he was found deceased. 

On July 26, 2018, the FCW documented an unannounced home visit with the aunt, and the child was visually observed in a diaper while sitting in his stroller. The FCW did not document any concerns or indicators of child abuse or neglect and instructed the aunt to seek medical attention for the child if she thought it was necessary since she reported back that the child was depressed and not eating. 

The child died on August 17, 2018, and at the time of his death, he weighed 29 pounds. According to the ME, if medical attention had been sought for the child on or after July 26, 2018, the child could have been treated for starvation. The child’s foster care case was closed in September 2018 due to his death. 

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_{[1] June 2018: Medically Fragile Children, per MDHHS protective services manual, are considered children with chronic health conditions. The 2018 MDHHS foster care manual refers to these children as children with chronic health conditions. Current manuals refer to medically fragile children as “vulnerable children”. The term medically fragile was removed from policy after 2018.}

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Relevant Policy Violations:

• FOM 722-03, Placement Selection and Standards, Reasons for Placement Change was not initiated on or after the doctor reported that the aunt should not have a special needs child in her care. 
• FOM 722-06H, Case Contacts, conference with supervision missed in September of 2017, all social work contacts not entered timely, and no monthly contact with the licensing worker. 
• FOM 801, Health Services for Children in Foster Care, Chronic health Concerns policy not documented as required. There was no contact by the case workers with the child’s doctors regarding information in his medical reports. 

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The OCO finds when the child entered foster care in August 2017, he had already been diagnosed with infantilism, pediatric FTT, myoneural disorder, congenital chromosomal disease, atopic dermatitis, and allergic rhinitis. These conditions made him a medically fragile/vulnerable child with multiple chronic conditions.	Agree
The OCO finds from August 2017 through August 2018, the child had four foster care workers assigned to his case during five separate occasions. The length of time the foster care workers assigned to the child’s case was six months, seven days, thirty days, eleven days, and four-and-one-half months respectively.	Agree
The OCO finds that when the child’s most recent FCW was assigned case responsibility, he had recently begun employment with the State of Michigan, finished the minimum amount of general case management training with CWTI and was assigned a position with Ingham County MDHHS.	Agree
The OCO finds between May 24, 2018, and his death on August 17, 2018, the child had lost 38% of his body weight. One healthcare provider and the last foster care caseworker assigned to manage the child’s case did not notice or express concern regarding the continued and extreme weight loss the child at 6 years old, experienced before he died.	Agree
The OCO finds that Ingham County failed to comply with FOM 722-03. According to the May 2018 Maltreatment in Care (MIC) investigation report, the FCW, foster care supervisor, and licensing worker were notified on June 15, 2018, that the aunt’s doctor expressed specific concerns about her mental instability, possible drug use, and that she should not have a special needs child in her care. Despite having reasonable knowledge that continued placement in the aunt’s home presented a substantial risk to the child’s safety and well-being, the FCW testified at the permanency planning hearing on June 21, 2018, it would be unlikely to find another foster home placement given the child’s special needs. The child remained in the aunt’s custody, where he died without MDHHS initiating a change in placement.	Agree

Recommendations:

Recommendation

MDHHS Response to Recommendation

The OCO recommends MDHHS implement units within the Children’s Services Agency that specialize in the handling of foster care cases involving vulnerable children. The OCO recommends that caseworkers assigned to vulnerable children’s cases have a pre-determined minimum amount of case management experience, more specialized training, and a reduced number of cases. This may allow a case manager to service a vulnerable child more appropriately; document and ensure all their needs are being met; make the required contacts with medical professionals; identify and address all needs of the child and caregiver; document and accurately report all concerns of a child’s placement to the court; and act upon information received which indicates a child’s safety and wellbeing is at substantial risk in their current placement. Furthermore, the OCO recommends that employees who staff the specialized unit have the proper experience and training to address the specific needs of children who are more vulnerable to child abuse and neglect.

Agree, improvements are needed related to vulnerable children’s cases, and this is currently being assessed, enhanced, and redesigned pertaining to how child welfare professionals, including supervisors and specialists, are trained initially upon hiring into child welfare and continuously throughout their careers to improve interactions with children and families and strengthen teaming and engagement approaches.

PDF Version of Report:  Case No. 2018-0285

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
August 23, 2023	November 2, 2023	December 15, 2023	2022-0263

Summary of recommendations:

The OCO recommends strengthening multidisciplinary team (MDT) functioning by having county prosecutors or their designees lead regular MDT meetings that include law enforcement, medical and mental health professionals, and Child Advocacy Centers. The OCO further urges the Legislature to amend MCL 722.628 to formally require law enforcement participation on MDTs and to fund dedicated MDT liaisons in each county. The OCO also recommends that county DHHS offices develop detailed processes with their MDTs for obtaining medical assessments, second opinions, and direct communication with medical providers, and ensure all involved counties participate when cases cross jurisdictions. Additionally, the OCO recommends amending MCL 722.628 to require in‑person or phone contact with law enforcement within 24 hours of submitting a Law Enforcement Notification and amending MCL 722.638 to require petitions for termination of parental rights when individuals responsible for severe abuse or serious harm have rights to other children.

Case Background:

Child was four years old when died on March 10, 2022. Pursuant to MCL 722.627k, MDHHS notified the OCO of the child fatality. On March 15, 2022, the OCO opened an investigation into the administrative actions of CPS regarding Child’s death. The following report summarizes the information and evidence found during the OCO investigation.

The OCO review included reading confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), service reports, medical records, social work contacts, court documents, and law enforcement reports. The OCO also interviewed MDHHS staff, medical professionals, hospital staff, and law enforcement personnel. Due to the confidentiality of OCO investigations, the OCO cannot disclose the identity of witnesses or complainants, or sources of statements and evidence.
Case Objective:
The objective of this review is to identify areas for improvement in the child welfare system by looking at how child protective services (CPS) investigations involving Child were handled by Oakland and Wayne County CPS, and the involvement of MDHHS staff, court personnel, physicians, and law enforcement. This review reinforces that the safety and well-being of a child is the shared responsibility of the family, community, law enforcement and medical personnel aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of the investigations; inform policy, procedure, and practice of MDHHS and partners within the child welfare system; and to advocate for changes within it on behalf of similarly situated children.

Family History: 

Mother is the birth mother of Child (DOB: 09/09/2017) and Sibling (DOB: 06/18/2021). Child's father passed away in 2018. Sibling’s father is Sibling’s Father. Mother, Sibling’s Father, Child, and Sibling lived together during the timeframe of the CPS cases the OCO reviewed. After Child’s death Sibling’s Father’s parental rights to Sibling were terminated.

Relevant to the OCO’s findings and recommendations it is important to note that Sibling’s Father has two additional biological children with a woman named Partner. Those children are Child Two (DOB: 08/21/2012) and Child Three (DOB: 08/18/2017). Child Two and Child Three both reside with their mother. As of the writing of this report, Sibling’s Father maintains his parental rights to both biological children he shares with Partner.

In October of 2021 Mother (Child’s mother) was investigated by CPS for physical abuse of Child. That investigation resulted in a Category IV, which is a finding of no child abuse or neglect. Sibling’s Father was residing in the home during this investigation but was not identified as an alleged perpetrator.

Review of CPS Investigation Prior to Child's Death:

The central part of the OCO’s investigation starts in October 2021 when Child suffered a near fatal injury requiring emergency surgery. This CPS investigation opened on October 2, 2021, and closed on December 8, 2021. This investigation occurred just five months before Child died. The OCO review of this investigation found several deficiencies and missed opportunities when MDHHS CPS attempted to determine what caused Child’s severe injuries. The facts presented to the OCO during its investigation of the October 2021 investigation are complex in nature. In summary the OCO found:

• Mother’s live-in boyfriend (Sibling’s Father) was not identified properly by CPS and thus was not considered relevant to the CPS investigation.
• CPS did not complete a CPS or criminal background on Sibling’s Father.
• Had CPS properly identified Sibling’s Father and conducted a background review they would have found that Sibling’s Father has:
  • A criminal history involving serious violence.
  • Prior history with CPS in which he was substantiated for medical neglect of his biological child.
• The required law enforcement notification (LEN) was not submitted to a law enforcement agency for 10 days, well outside of the legally mandated 24 hours when severe child abuse is being investigated.
• Two law enforcement agencies were sent a LEN, the Detroit Police Department (DPD) and the Wixom Police Department (PD).
  It is unknown if DPD received the LEN.
• The delay in the LEN sent to Wixom PD caused a 27-day delay in having the Wixom police department open a child abuse investigation.
• There was little communication and no joint investigation completed by the parties who should be participating as a multidisciplinary team, if best practices are used.
• Wixom police investigators assigned to this case were unaware of Michigan’s model child abuse protocol.
• A significant statement made by Child during his hospital stay, in which Child asked if Sibling’s Father was going to hit him, was not included in the CPS investigation.
• A physician, Dr. Norat, specializing in non-accidental trauma and child abuse injuries was consulted, however his statements were not used correctly.
• The assigned CPS investigator in Oakland County did not speak directly with Dr. Norat.
• The CPS investigator appears to have disregarded statements from the medical practitioners who agreed that Child’s injuries were inconsistent with the explanation of those injuries given by Child’s mother.
• Dr. Norat attempted to explain the force necessary to cause Child’s injury as a hypothetical cause.
• The CPS investigator used the hypothetical example provided by Dr. Norat as the actual cause of Child’s injuries.
• These examples were not provided as a cause for Child’s injuries by his caregivers.
• CPS was aware that Child had a broken arm during his forensic interview but did not document the injury. Sibling’s Father was the only adult with Child when Child sustained his broken arm.
• The OCO investigation shows that Child’s severe injuries sustained in October of 2021 were the direct result of physical child abuse.
  CPS closed the October 2021 child abuse investigation by finding no child abuse occurred.

 

Summary of Investigations:

On October 1, 2021, Child’s mother brought him to the emergency room (ER) at Children’s Hospital at Detroit Medical Center due to abdominal pain. It was discovered Child needed emergency surgery as he had two holes in his small bowel. Child did not have any bruising or visual injuries to his abdominal area.

Evidence shows Mother told hospital staff Child had been at his grandmother’s home the entire week prior to being taken to the hospital. Mother denied any knowledge of trauma to Child’s abdomen or any abuse. Mother also explained that when Child returned home, he slept a lot and complained of pain. The day before Mother brought Child to the hospital, Child’s symptoms and pain worsened and his abdomen became distended. Mother also described Child as lethargic with a poor appetite. According to statements provided to hospital staff, Mother said the morning of October 1, 2021, she felt Child’s abdomen which was firm and looked concerning, that is why Mother brought Child to the hospital. Mother provided a possible explanation to hospital staff for Child’s injuries. Mother described another four-year-old child at her mother’s home who is very rough, and that Child informed her this child punched him in the stomach. Due to the severity of Child’s injuries and the explanation given, the hospital staff had concerns for physical abuse and contacted MDHHS Centralized Intake on October 2, 2021.

Because the hospital is located in Wayne County, the CPS complaint was initially assigned to the Wayne County South Central MDHHS office. An on-call CPS specialist for Wayne County South Central responded to the hospital on October 2, 2021, and verified the well-being of Child. Due to Child being asleep, no interview was attempted at that time. CPS spoke with Mother who explained not knowing what happened to her son. Evidence indicates that Mother told the CPS specialist Child had been with her mother, Maternal Grandmother, for a week. Mother further described picking Child up on Wednesday (September 29, 2021) and Child was complaining his stomach hurt. She thought he was constipated as he did not complain about it again and seemed normal. On Friday (October 1, 2021), Mother noticed Child would not stand up and his stomach was hard. She decided to bring Child to the hospital. Once at the hospital it was discovered Child had a fever and two holes in his small bowel. Mother informed the CPS on call specialist that she (Mother) was told by “doctors” that Child’s injuries were caused from blunt force trauma to the abdomen or something Child ate. Mother explained that she was informed Child had been hit by another four-year-old child while at her mother’s house. No safety plans were made during this visit regarding Child or his sibling, Sibling.

The next social work contact entered into MiSACWIS is dated October 6, 2021. This contact was with hospital staff to inform CPS that Child would be released from the hospital. After contact with the hospital, Wayne County CPS asked Oakland County CPS for what is known as a courtesy request. This particular courtesy request was made because Child lived in Oakland County and the intent was to transfer the investigation to Oakland County.

After receiving the courtesy request Oakland County CPS spoke with Child’s maternal grandmother, Maternal Grandmother, via phone. Maternal Grandmother informed CPS she cares for Child four days to a week at a time, due to Mother working. Maternal Grandmother confirmed she had Child for the entire week prior to his hospitalization and denied knowing what caused Child's stomach pain. Maternal Grandmother informed CPS that she has custody of her four-year-old nephew, who often plays rough with Child, and she constantly must separate them.

An Oakland County CPS supervisor responded to the courtesy request with some follow up questions for Wayne County CPS. The supervisor asked Wayne County CPS if a LEN had been sent and if a criminal history request had been completed. The OCO could not determine who the criminal history request was for as this is not documented. The Oakland County supervisor also asked the Wayne County specialist to follow up with medical professionals regarding their opinion of Child's injury and to conduct a home visit to Maternal Grandmother’s home which is in Wayne County. The same Wayne County CPS specialist was asked to interview all household members at Maternal Grandmother’s home.

At the direction of the Oakland County CPS supervisor, the Wayne County CPS specialist contacted Children's Hospital and spoke with the hospital’s social worker. According to CPS records the Children's Hospital social worker informed Wayne County CPS that Child had two perforations in his intestine which had to be corrected through emergency surgery. The Children's Hospital social worker also explained that the only way Child could have sustained this injury was through trauma to the abdomen. In addition to the injury to his intestines, the Children's Hospital social worker also explained Child had a bruised liver.

The Wayne County CPS specialist visited Child at the hospital on October 8, 2021, and documented doing what the specialist referred to as a forensic interview. During this interview the TV in Child’s hospital room was turned on, and the CPS specialist documented Child not understanding some of the questions he was asked. Child said Cousin One hit him and Cousin One is a kid. Child said this happened when he was at his grandmother's home.

It is documented the CPS specialist then spoke with Dr. Norat, one of Child’s treating physicians. Dr. Norat explained that Child had two small holes in his bowel and a bruise on his liver resulting from “nonspecific trauma.” In his attempt to explain to the case worker the force necessary to cause such an injury, Dr. Norat provided an example of a child riding a bike down a hill and hitting the handlebars of the bike, or from a child who was involved in a car accident. Dr. Norat told the Wayne County CPS specialist that Child’s intestine needed surgical intervention and the injury could have been caused by non-accidental trauma.

The courtesy request for a home visit was conducted by Oakland County on October 8, 2021. Mother provided the same version of events to the CPS specialist that she had relayed to hospital staff and the Wayne County Specialist. According to Mother, while at the hospital Child was examined by “a doctor” who informed Mother that Child’s injury could have been a result of being hit, riding a bike, jumping off of bunk beds onto an object, or rough playing. This is the first time the OCO noticed a conflict in Mother’s statements about the possible cause of Child’s injuries.

Previous statements made by Mother to CPS indicated the doctor explained blunt force trauma or something Child ate.

Mother told the CPS specialist she asked Child “what happened”. According to Mother’s statement, Child told his mother that his cousin hit him. Mother stated that Child’s cousin has hit her, adding the cousin has “a heavy hand”, and does hit hard. Mother informed CPS that her mother and her boyfriend, Sibling’s Father, watch the children while she works. The CPS specialist documented Sibling’s Father’s name wrong spelling it two ways. The OCO could not find evidence to show CPS conducted any type of background check on Sibling’s Father. Sibling’s Father’s background was not reviewed until Child’s death investigation.

Michigan law requires that MDHHS submit a report to the local law enforcement agency and the prosecuting attorney within 24 hours of becoming aware that a child sustained a severe injury from suspected child abuse or neglect1. This report is referred to as the law enforcement notification, or LEN. Evidence obtained by the OCO shows that MDHHS CPS waited ten days, until October 12, 2021, to submit a LEN. At this time Mother, Child, and Sibling lived in the City of Wixom in Oakland County, so a LEN was sent to the Wixom Police Department. Additional LENs were sent to the Detroit Police Department and the Wayne County Prosecutor's office as information provided by Mother stated that the injuries possibly occurred at Maternal Grandmother’s house in the City of Detroit.

In reviewing evidence and conducting interviews the OCO found that CPS was not sure where the incident causing Child’s intestine and liver injuries occurred.

CPS created a safety plan on October 12, 2021, 11 days into the investigation. Mother agreed to have her sister, Maternal Aunt, stay at Mother’s home and care for Child until CPS completed their investigation. The OCO discovered that the only criminal history obtained for this investigation was on Maternal Aunt. No other criminal histories were reviewed.

The Wayne County CPS specialist spoke with Dr. Norat again on October 12, 2021. It is documented Dr. Norat stated the injury could be non-accidental or accidental. Dr. Norat expressed concern because he had no history or explanation of what caused the injuries to Child. Dr. Norat told the CPS specialist the type of injury Child sustained would have been caused by a large amount of force applied to Child’s abdomen. Records show Dr. Norat again explained that because he (Dr. Norat) did not have a plausible explanation for Child’s injuries he was concerned the injuries were the result of child abuse. Dr. Norat had been provided with an explanation of another four-year-old hitting Child which possibly caused the injury. Dr. Norat refuted that explanation and informed the CPS specialist "the only way a four-year-old could have hurt another four-year-old is if he [the four-year-old] pushed him [Child] out of a window and he [Child] fell on a tree." Dr. Norat stated this injury would be feasible if the four-year-old hit Child in the stomach with a bat.

Dr. Norat informed CPS he spoke with Child’s surgeon. The medical background Dr. Norat received from Child’s surgeon indicated that Child’s injury did not appear to have occurred the day Child was brought into the ER, that it had happened “days ago”. Dr. Norat further explained to CPS that Child had a “liver injury due to a forceable injury to the stomach and a perforated intestine. It would have to be a force great enough to push the intestine to the spine, that type of force does not happen every day." Treating physicians at the hospital also noted Child had scratches on his shoulder and scalp.

Child’s scalp was also bruised. Dr. Norat added there are no hard surfaces on the belly, and just because Child did not have bruising on his belly does not mean “nothing [sic]” happened to him.

On or about October 20, 2021, Wayne County CPS called DPD to inquire about the LENs. DPD informed CPS that the case had not yet been assigned. On October 28, 2021, Oakland County CPS contacted Wixom PD who informed CPS they did not receive the LEN. A second LEN was submitted to Wixom PD. Wixom PD sent an email explaining that an officer will take an initial report then a detective will be assigned for further investigation.

On October 21, 2021, Wayne County transferred the CPS investigation to Oakland County. At this point, Wayne County CPS involvement with the case ended.

A forensic interview of Child was scheduled at Care House, Oakland County’s Children’s Advocacy Center (CAC), for November 9, 2021, but had to be rescheduled to November 17, 2021. During the interview Child provided no information to the forensic interviewer identifying who caused his injury.

During the OCO’s investigation, it was discovered that Child had a broken arm when he arrived at the CAC to be forensically interviewed. There is no record or documentation of Child’s broken arm in the CPS investigation. Through interviews, the OCO learned the explanation for Child’s broken arm was he fell down the apartment complex stairs, while in the care of Sibling’s Father. All the evidence combined showed that when Child sustained the fractured arm, the safety plan agreed to by Mother was still in place, and Child was only to be cared for by Mother’s sister. The safety plan did not include Sibling’s Father as the caretaker for Child. Mother was not in compliance with the agreed-upon safety plan. CPS did not follow up on the noncompliance with the safety plan.

On December 2, 2021, with knowledge of Child’s broken arm, CPS conducted a home visit at Mother’s residence. Sibling’s Father, Mother’s boyfriend, was present and agreed to be interviewed. Sibling’s Father was asked by CPS and denied using physical discipline with Child. Sibling’s Father told CPS he has watched Child’s cousin playing rough with Child on multiple occasions. Sibling’s Father informed CPS that Child has told Sibling’s Father that his (Child’s) cousin has hit him and is strong for his age. The OCO determined the ‘cousin’ Sibling’s Father was referring to, was the four-year-old child who lived with Maternal Grandmother.

Throughout the CPS investigation CPS did not identify the four-year-old child who Mother, Maternal Grandmother and Sibling’s Father accused of causing Child’s injury. CPS records refer to this child as Cousin One, or one of 3 other names. 

Oakland County CPS completed a safety assessment, and one immediate harm factor was identified. This immediate harm factor was “Caretaker(s) explanation of any injury to a child is unconvincing and the nature of the injury suggests that the child's safety may be of immediate concern”. The immediate harm factor identified by CPS aligns with Dr. Norat’s statement of non-accidental trauma but does not align with the disposition of this investigation as a category IV.

CPS concluded this investigation finding no child abuse had occurred. In the case closure disposition CPS partially summarized Dr. Norat’s statements. CPS used the injury being sustained by a bike handlebar or from a car accident as the reason for the injury. None of Dr. Norat’s other statements were cited in the disposition as supporting evidence. CPS also noted that due to no disclosures being made at the Care House interview, there was no preponderance of evidence found supporting improper supervision or physical abuse by Mother. The risk level was low, and the case was closed.

The OCO reviewed medical records from Child’s hospital stay at Children’s Hospital from October 1, 2021, to October 12, 2021. The records confirmed Child had two areas of perforation in his bowel, one posteriorly about 1.5cm and one smaller anterior perforation about a half a centimeter. Records show Child also had a contusion, about 1 centimeter by 3 centimeters on his liver. Due to these injuries’ surgery had to be performed to repair the perforations. It is documented that in the professional opinion of nurse practitioner the injuries were concerning for non-accidental trauma as no significant abdominal trauma for Child had been provided. Dr. Norat, Medical Director of the Child at Risk Evaluation (CARE) Team, agreed with the finding of non-accidental trauma.

The OCO also discovered a note was entered into Child’s hospital records on October 10, 2021, nine days post-surgery. The note states that a hospital social worker overheard a conversation between Child and Sibling’s Father. The conversation was about Child accidentally urinating in the hospital bed overnight. In this conversation Child was heard by the hospital social worker asking Sibling’s Father, “does this mean you’re going to hit me?”. Hospital staff attempted to contact the assigned CPS specialist to provide this information, however the specialist was unavailable. The medical chart indicates a voicemail was left for the CPS specialist however the OCO could not determine if this information was ever provided by hospital staff to CPS. It is unknown if the CPS specialist was ever made aware of Child’s comments to Sibling’s Father.

The OCO interviewed a hospital staff member who was involved with Child and familiar with the circumstances of his surgery and hospital stay at Children’s Hospital. The hospital staff member confirmed they had concerns for non-accidental trauma when Child presented with the intestinal and liver injury. The hospital staff member explained during the interview that the type of injury Child sustained is not something typically seen in children and that it was from “forceful trauma to the abdomen.”

During the OCO’s interview with the hospital staff member the OCO learned that the hospital staff member believed Sibling’s Father was the individual who caused the injuries to Child. This staff member had the impression Sibling’s Father was safety planned out of the home after Child sustained the intestine and liver injuries. The hospital staff member confirmed Sibling’s Father was the individual in Child’s hospital room when Child was overheard saying “does this mean you’re going to hit me?”. The hospital staff member provided insight into Child’s broken arm, stating the type of fracture Child sustained was common in children and would not be concerning on its own, however given the suspicious nature of Child’s abdominal injuries the broken arm was highly concerning for abuse. The hospital staff member informed the OCO that prior to Child’s death, no law enforcement agency contacted hospital staff regarding Child’s abdominal injuries from October of 2021. The hospital staff member interviewed by the OCO believed that no law enforcement agency was not involved. The OCO determined that there were no multi-disciplinary team meetings held where medical staff were invited to participate.

The OCO gathered evidence confirming Dr. Norat had concern for non-accidental trauma causing Child’s injuries. The evidence also confirmed that Dr. Norat’s medical opinion was a four-year old could not have caused the injuries Child sustained by merely punching Child. The OCO did not find any version of events where anyone with knowledge of Child’s injuries explained that his injuries were caused by the handlebar of a bike. No one provided CPS or Dr. Norat with this explanation. The OCO confirmed with Dr. Norat that a bike accident did not cause Child’s injuries.

The OCO obtained evidence supporting a breakdown of the multidisciplinary team in this case. Evidence obtained shows a LEN was not sent to any law enforcement agency until after 10 days following the start of the CPS investigation. When the LEN was sent, it was submitted by facsimile. Weeks went by before Wixom PD became involved which occurred after Child had been discharged from the hospital. Wixom PD, once involved, requested a forensic interview of Child at Care House. Due to the delayed LEN submission, Child was not interviewed at the Care House until 48 days after the start of the CPS investigation. Documentation shows law enforcement did not have any contact with medical staff and concerns relayed from the medical staff to CPS, were never relayed to law enforcement. Law enforcement was also unaware of Sibling’s Father’s involvement with the family or that he was a household member.

Interviews conducted with mandated reporters from both law enforcement and medical professionals, showed there was very little communication between all parties regarding this case. The State of Michigan’s Model Child Abuse Protocol, which instructs Multi-Disciplinary Teams on how to cooperate and conduct joint investigations, was not utilized.

Interviews with law enforcement investigators revealed they did not know about the state’s model child abuse protocol. The interviews confirmed that law enforcement investigators had very limited communication with CPS concerning Child and his injuries. Interviews revealed the investigating law enforcement agency was unaware of Dr. Norat’s concerns for non-accidental trauma causing Child’s injuries. They were also unaware Child had a broken arm during the investigation. The investigating law enforcement agency closed their case citing a lack of disclosure indicating child abuse during Child’s forensic interview and there was an impression that DPD was investigating the incident that caused Child’s injuries. The OCO investigation shows that DPD was not involved in Child’s case.

The OCO was informed that had law enforcement been aware of Sibling’s Father’s involvement in the home, a criminal background check would have been completed. The criminal background check would have shown Sibling’s Father’s extensive violent history, and likely would have led to more questioning surrounding this incident. Sibling’s Father’s public criminal history included Felony Assault with a Dangerous Weapon (2019), Felony Criminal Sexual Conduct (2019) Felony Unlawful Imprisonment (2019), Felony Assault with Intent to do Great Bodily Harm Less than Murder by Strangulation (2019), Misdemeanor Domestic Violence and/or Knowingly Assaulting a Pregnant Individual (2019) and Felony Torture (2019).

During this investigation professionals from both law enforcement and CPS informed the OCO the process for notifying law enforcement through a LEN is ineffective. Currently, a LEN is sent via email or fax to the law enforcement agency with perceived jurisdiction. When the jurisdiction is unknown, the LEN is sent to multiple agencies, which is what occurred in this case. A LEN was sent to both Wixom PD and DPD. It is documented in MiSACWIS that a LEN was faxed to DPD, however there is no physical evidence DPD received the LEN for this case. It was determined through the OCO’s investigation that MDHHS employees are unaware that a LEN can be sent to the Michigan State Police (MSP) when the jurisdiction is unknown. In addition, mandated reporters from all teams, stated direct contact with the law enforcement agency receiving the LEN would assist with more appropriate response times. The OCO found that in many cases the faxed LEN is lost, and emailed LENs are overlooked. The result is a delayed response from a law enforcement agency.
In addition to the lack of communication between the multi-disciplinary team, there was also a lack of communication between Wayne County CPS and Oakland County CPS. No one from Oakland County CPS spoke with Dr. Norat to gain clarity regarding his medical assessment. The result was an inaccurate representation of Dr. Norat’s comments to the Wayne County CPS specialist being found in the Oakland County investigation.

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_{[1] MCL 722.628(1)}

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Death of Child - CPS Case Summary:

Child died in March 2022 as the result of child abuse. Sibling’s Father was found to be the abuser who caused Child’s death. Below is a summary of the death investigation and evidence found by the OCO during its review.

In reviewing the initial complaint dated March 5, 2022, called into MDHHS centralized intake from Providence Park Hospital, the complaint indicates Child was found unresponsive by Sibling’s Father. The complaint also reported Child had a rectal temperature of 85 degrees, roughly 13 degrees lower than the average normal temperature of a human being and was in cardiac arrest. Due to Child’s injuries and critical condition, Child was transferred to Mott Children’s Hospital in Ann Arbor.

At Mott Children’s Hospital several other injuries were observed which created suspicion of child abuse, so another complaint was made to MDHHS centralized intake detailing the injuries. The reported injuries were both new and old. New injuries noted were a “posterior skull fracture (acute), and a 4-millimeter subdural hematoma (brain bleed)”. The old injuries identified were a “humeral fracture”, and “4-5 old rib fractures”. The rib fractures were documented as “healing” and did not appear to be due to chest compressions. The complaint stated Child’s prognosis was unknown. An additional skeletal examination would be done to check for further injuries. Child was intubated and unresponsive. The complaint to MDHHS centralized intake stated non-accidental trauma and child abuse was the suspected cause of Child’s condition. The complaint stated the individual who caused Child’s injuries was an “unknown boyfriend”, and Mother was not at the home when Child was found.

Mott Children’s Hospital is located in Ann Arbor. Consequently, Washtenaw County CPS was assigned this investigation. Interviews that CPS conducted with hospital staff indicate Child's injuries appeared to be the result of blunt force trauma to the head. Hospital staff relayed to the CPS specialist statements that Sibling’s Father gave to them when describing events at the home he shared with Mother. Sibling’s Father told hospital staff Child was brushing his teeth and he (Sibling’s Father) heard a thud, found Child unresponsive and attempted to wake him up by placing him into cold water and tapping him on the face. Sibling’s Father also relayed Child urinated and defecated on himself. Hospital staff also shared statements made by responding law enforcement officers that Sibling’s Father waited an hour to contact law enforcement after he found Child.

When interviewed Mother provided the following information to CPS. Mother stated that she was at work at the time of the incident and told CPS her children were left with Sibling’s Father. Mother explained that she started having Sibling’s Father watch the children more after Child's bowel injury (October 2021 CPS investigation) as she believed those injuries happened at her mother's home. Mother denied knowing Child had a broken arm or broken ribs and stated he never complained of pain near his ribs.

Due to the suspicion of child abuse being involved, CPS spoke to Mott Children’s Hospital Child Protection Team (CPT) nurse practitioner Andrea Duncan and CPT physician, Dr. Bethany Mohr. According to Dr. Mohr’s statement, Mother gave her a version of events that conflicted from the version of events she had previously provided to CPS. Dr. Mohr stated Child's injury could not have occurred simply by falling on the tub, but the injuries were possible if Child’s head was slammed on the side of the tub. Dr. Mohr expressed heightened concern due to Child’s other injuries. The CPT believed that it was highly unlikely Child would survive his injuries and added that he was hypothermic when he arrived at the hospital.

Child died from his injuries on March 10, 2022.

Following his death, the CPS investigation transferred to Oakland County CPS as this is where Child’s injuries occurred and where the family resided. A new CPS complaint was also made to centralized intake regarding Sibling’s Father’s other biological children with Partner. Partner and her children with Sibling’s Father reside in Macomb County. Due to this complaint Macomb County CPS interviewed Partner. During this investigation Oakland County CPS was made aware that Partner was previously in a relationship with Sibling’s Father for twelve years, Sibling’s Father was extremely violent during their relationship, and she was the victim in a criminal case of domestic violence and sexual assault in Wayne County. Partner identified Sibling’s Father as the individual charged with these crimes. There was a no contact order in place, and Sibling’s Father had not physically seen the children in several years, however she allowed phone contact at her discretion.

It is important to note that Sibling’s Father was arrested on December 4, 2019, and incarcerated in the Wayne County Jail due to the domestic and sexual assault of Partner. At the time of his arrest in December of 2019, he was on circuit court probation after pleading guilty to feloniously assaulting Partner in June of 2019. Due to the COVID-19 pandemic, Sibling’s Father was released from jail in June of 2020 on a $5,000 personal bond with a GPS tether. The Wayne County Prosecutor argued against Sibling’s Father’s release which was denied by the court2. After his release Sibling’s Father became involved with Mother and Child, and fathered Sibling.

A home visit was conducted at Mother's residence following Child's death. During this home visit CPS and Mother discussed the intestine injury from October 2021. Mother explained that she believed it came from her three-year-old cousin who was extremely rough. Mother was asked if a medical professional confirmed this narrative as a plausible explanation and she said no. She explained that a safety plan was in place during that investigation, and Child had an interview at the Care House, where he denied physical abuse. She denied being aware of the outcome of this investigation. Mother and CPS also spoke about Child’s broken arm in November of 2021. Mother explained that she was at work when Child sustained his broken arm, adding that Child was in the care of Sibling’s Father.

Sibling’s Father was interviewed by CPS in jail. Sibling’s Father and CPS discussed the October 2021 investigation. Sibling’s Father informed CPS he and Mother noticed Child’s stomach was swollen during a bath which led Mother to take Child to the hospital “a few days later”. During this interview Sibling’s Father told CPS he took Child to the Care House interview with Maternal Aunt. This is the first time it was made known that Sibling’s Father accompanied Child, a child abuse victim, to the forensic interview at Care House. Sibling’s Father and CPS also discussed Sibling’s Father’s explanation for the cause of Child’s broken arm in November 2021. Sibling’s Father admitted to being the cause of Child falling down the stairs (which caused Child’s broken arm) but explained it was accidental. He denied intentionally pushing Child. Sibling’s Father believed that the other child’s (Mother’s cousin) “continuous aggressive treatment of Child" led to Child's equilibrium being off and that this led to him constantly falling and hitting his head since September of 2021. Sibling’s Father gave a version of events to describe how Child sustained the injuries in March 2022 which eventually caused Child's death, explaining Child fell and hit his head on the tub. He believed his fall was a result of Child being in constant confusion due to “continuous beatings" by the other child at the grandmother’s home. Sibling’s Father did admit Mother only took Child to his grandmother’s house for care one more time after October 2021 and because of this Sibling’s Father became the sole caretaker of Child and Sibling (Child’s sister), while Mother was at work.

Due to the results of the child abuse investigation CPS filed a petition for the removal and termination of parental rights of Sibling from both Mother and Sibling’s Father.

CPS appropriately concluded Child’s death investigation as a Category I. A preponderance of evidence was found supporting physical abuse of Child by Sibling’s Father, failure to protect and improper supervision of Child by Mother, and improper supervision and threatened harm of Sibling by Mother and Sibling’s Father. Court records show Sibling’s Father was arrested for homicide-felony murder and one count of felony child abuse in the 1st degree.

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_{[2] “Releasing dangerous convicts due to COVID backlogs; new case getting new scrutiny” WXYZ Detroit News, March 14, 2022, https://www.wxyz.com/news/releasing-dangerous-convicts-due-to-covid-backlogs-new-case-getting-new-scrutiny}

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Law and Policy Research:

Research was conducted into states outside of Michigan and how the respective child welfare entities and law enforcement interact. The OCO located foundationally sound policies in Tennessee and New York.

The State of New York CPS manual3 requires CPS to “immediately give telephone notice and forward a copy of the report to the appropriate local law enforcement agency when CPS receives a report that contains any of the following:

• Allegations of suspected physical injury by other than accidental means which causes or creates a substantial risk of death, serious or protracted disfigurement, protracted impairment of physical or emotional health, or protracted loss or impairment of the function of any bodily organ;
• Allegations of sexual abuse of a child; or
• Allegations of the death of a child”.

This requirement is also codified in New York law; “If the local child protective services determines that local law enforcement shall be given notice, they shall give telephone notice and immediately forward a copy of the reports to local law enforcement”4.

The State of Tennessee Department of Children’s Services (DCS) administrative policies and procedures manual 14.65 states:

“The Child Protective Investigation Team (CPIT) serves as the statutorily mandated Multi-Disciplinary Team (MDT) in Tennessee. DCS uses the MDT approach during investigations of severe child abuse to ensure completion of a strategic and thorough investigation, as well as providing child victims with the needed supports to ensure their safety.”

The Tennessee DCS manual further states that each CPIT be composed of one staff member from DCS CPS, one representative from the Office of the District Attorney General, one juvenile court officer or investigator from a court of competent jurisdiction, one law enforcement officer with countywide jurisdiction, and the director of the children’s advocacy center or designee. The CPIT is required to immediately convene per local protocols to discuss and develop a case strategy. The CPIT also determines investigative tasks and assigns responsibility to team members. Tennessee also provides the CPIT a form (cs-05616) to aid in the coordination of the child abuse investigation.

In both the State of New York and the State of Tennessee the child abuse investigator with the state’s respective CPS agency is required to physically speak with members of the MDT. In both states this requirement is specifically to speak with and develop investigative strategies with the investigating law enforcement agency.

MCL 722.628(3) requires MDHHS to seek the assistance of and cooperate with law enforcement officials within 24 hours after becoming aware of the following:

• Child abuse or child neglect is the suspected cause of a child's death.
• The child is the victim of suspected sexual abuse or sexual exploitation.
• Child abuse or child neglect resulting in serious physical harm to the child.
• Law enforcement intervention is necessary for the protection of the child, a department employee, or another person involved in the investigation.
• The alleged perpetrator of the child's injury is not a person responsible for the child's health or welfare.
• The child has been exposed to or had contact with methamphetamine production.

MCL 722.628(4) requires law enforcement officials to cooperate with the department when conducting these types of investigations. This subsection also states, “The department and law enforcement officials must conduct investigations in compliance with the protocols adopted and implemented as required by subsection (6).”. MCL 722.628(6) requires the department and each county prosecutor to develop a protocol for involving law enforcement officials and CACs, as appropriate, in the above listed child welfare investigations.

MDHHS CPS policy manual, PSM 712-3 only requires the department to notify law enforcement officials. Additionally, the CPS policy manual states:

“In addition to the situations requiring a referral to law enforcement and the prosecuting attorney in this policy item, the case manager must also seek assistance from law enforcement for any referral in which it is necessary for the protection of the child(ren), a department employee, or another person involved in the investigation; MCL 722.628(3). Case managers must make efforts to coordinate and communicate with law enforcement in mutually conducted investigations.”

Although Michigan law requires the department and the county prosecutor to develop protocols for a coordinated investigation, the MDHHS CPS manual does not appear to require a coordinated investigation. The manual guides case managers to “…make efforts to coordinate and communicate…” with law enforcement officials.

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_{[3] New York State Child Protective Services Manual: Chapter 6
[4] NY Soc Serv L § 424
[5] State of Tennessee DCS Policy and Procedure Manual 14.6
[6] Tennessee DCS cs-0561 form}

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Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The OCO finds Child’s perforated bowel and bruised liver, were the result of non-accidental trauma in October 2021.	Agree
The OCO finds MCL 722.628 requires the department to “…seek the assistance of and cooperate with law enforcement officials…” and must conduct investigations in coordination with law enforcement officials, as directed by the county child abuse and neglect protocol.	Agree
The OCO finds PSM 712-3, Coordination with prosecuting attorney and law Enforcement requires MDHHS CPS to notify law enforcement within 24 hours regarding complaints involving acts that constitute 1st, 2nd, 3rd, or 4th degree child abuse, severe physical injury, and allegations including sex crimes, methamphetamine production and abuse/neglect alleged by someone not responsible.	Agree
MDHHS Publication 794, A Model Child Abuse Protocol Utilizing a Multidisciplinary Team Approach, states CPS must coordinate investigative efforts with law enforcement and other MDT members by using a coordinated investigative team.	Michigan Department of Health and Human Services (MDHHS) agrees that coordination with law enforcement is best practice, though MDHHS Publication 794, A Model Child Abuse Protocol Utilizing a Multidisciplinary Team Approach, Section VI-C, utilizing a Multidisciplinary Team Approach does not mandate it.
The OCO finds there was an overall breakdown of the multi-disciplinary team during the October 2021 CPS physical abuse investigation into Child’s intestine and liver injuries. The OCO finds there has been a significant breakdown in the use of the multi-disciplinary teams across the State of Michigan. As a result, teams are not working together properly, and child abuse is being missed. Child’s death is an example of a worst-case scenario when the required agencies do not work as a multi-disciplinary team.	Agree, the local multidisciplinary team has recently reviewed and updated the Oakland County Child Abuse and Neglect Protocol and provides ongoing training to each of the multidisciplinary agency groups.
The OCO found the CPS investigation into the cause of Child’s October 2021 injuries was insufficient.	Agree, although CPS missed or delayed in certain investigative steps, the department followed through on critical actions November 2, 2023 Page 3 to ensure child safety. CPS made contact with the local child abuse expert at Children’s Hospital to determine his assessment of the child’s injuries, requested a second opinion, and coordinated with law enforcement to complete a forensic interview of the child at the local Child Advocacy Center. Doctors completed a thorough examination of the other child including a skeletal exam. Additionally, to maintain the safety of the sibling, CPS implemented a safety plan during the investigation by having a relative move into the mother’s home to provide additional oversight and supervision. Since this investigation, DHHS has implemented a statewide Critical Case Review Process.
The OCO finds law and/or policy in other states requires CPS to inform law enforcement officials through verbal communication in cases involving severe physical injury, child death, physical abuse, and sexual abuse related complaints. MCL 722.628, PSM 712-3, and the State of Michigan’s Model Child Abuse Protocol does not mandate law enforcement as a member of the Multi-Disciplinary Team. MCL 722.628, PSM 712-3, and the State of Michigan’s Model Child Abuse Protocol does not mandate verbal communication between CPS and the investigating law enforcement entity or individuals.	Agree
The OCO finds that in cases where it is unknown what jurisdiction the incident occurred in, PSM 712-3 provides no guidance to case specialists on what agency or agencies should receive the LEN.	Agree, MDHHS will update policy to provide guidance to case managers when it is unknown what jurisdiction an incident occurred in, and what agency/agencies should receive the LEN.
The OCO finds Sibling’s Father’s parental rights of his biological children remain intact because those children are not related to Child. Sibling’s Father’s parental rights remain intact despite his involvement in Child’s abuse and subsequent death. MCL 722.638, mandates a petition for termination of parental rights (TPR) in cases of severe physical abuse, murder, abandonment, torture, and sexual abuse, of the abused child or siblings of the abused child, however the law does not contemplate biological children of the abuser when those children are not related to the child victim.	Agree

Recommendations:

Recommendation	MDHHS Response to Recommendation
The OCO recommends county prosecuting attorneys, or their designee, conduct regular MDT meetings to increase communication among members. The OCO has seen positive outcomes when the MDT is actively involved in case-by-case decision-making to facilitate and support the work of its members. The MDT should include members of law enforcement, medical personnel, mental health personnel, and Child Advocacy Centers. The OCO recommends the Michigan Legislature amend Child Protection Law, MCL 722.628(6), to require that, as the lead criminal investigators, law enforcement be added to the MDT, along with the prosecuting attorney and the department. The OCO recommends the Michigan Legislature provide funding for MDHHS to hire individuals who serve as liaisons to the MDT for each county MDHHS office. Liaison duties could include but are not limited to, serving as a bridge between MDT members, assisting the MDT leader in facilitating monthly MDT case review meetings, collaboration with MDHHS central office on policy changes, and actively participate in the investigation as an advisor to the MDT when the child presents with abnormal or suspicious bruising or injury, severe injury, sexual assault, or death.	MDHHS agrees and will always work with its law enforcement and legislative partners on any funding or policy that will improve child protection.
The OCO recommends MDHHS require local county directors develop processes in coordination with the local MDT. This process could include detailed direction for case specialists on medical assessments, local child abuse medical experts, when to access a second medical opinion, and to obtain firsthand information from the medical provider directly involved in the examination of a child. MDHHS could encourage the assigned county completing the disposition of the case, to have direct contact with the medical professionals and/or review the medical records to confirm accuracy of any prior information gathered from other specialists. Invite medical practitioners involved in child abuse and neglect cases to MDT meetings and case reviews. When multiple counties are involved in a case, both counties should be present at MDT meetings to ensure all information discovered is shared between all MDT members.	MDHHS actively works with local offices across the state to continue enhancing their MDT processes and partnerships. MDHHS has required local offices to review their county protocol in collaboration with their MDT, ensure they consider the OCO recommendations included in this Report of Findings and Recommendations, and make any enhancements by July 2024.
The Children’s Ombudsman recommends the Legislature amend MCL 722.628 to require, in addition to sending a LEN, in person or phone contact with law enforcement officials within the same 24 hours currently required for LEN submission. The purpose of the in person or phone contact will be to discuss the circumstances that required the LEN.	PSM 712-3, Coordination with Prosecuting Attorney and Law Enforcement, outlines required collaboration between CPS and law enforcement, including efforts to coordinate and communicate with law enforcement in mutually conducted investigations, how November 2, 2023, Page 6 to handle delays in starting an investigation, and when to request law enforcement reports. Collaboration between CPS and law enforcement is clearly outlined in department policy and is sufficient for investigative purposes
The Children’s Ombudsman recommends MDHHS amend PSM 712-3 and the Michigan Model Child Abuse Protocol to require in person or phone contact with law enforcement when MDHHS is required to submit a LEN.
The Children’s Ombudsman recommends the legislature amend MCL 722.638 to require a petition for termination of parental rights when an individual is found responsible for, abandonment of a young child, criminal sexual conduct involving penetration, attempted penetration, or assault with intent to penetrate, battering, torture, or other serious physical harm, loss or serious impairment of an organ or limb, life threatening injury, and/or murder or attempted murder when the person responsible has rights to other children who are not the victim child or a sibling of the victim child.	MDHHS will work with our legislative partners to ensure a legislative change of this nature falls under the purview of CPS and has no unintended consequences.

PDF Version of Report:  Case No. 2022-0263

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
March 27, 2023	May 26, 2023	June 7, 2023	2020-0440

Summary of recommendations: 

The OCO recommends strengthening Michigan’s CPS investigative practices by amending PSM 713‑04 to ensure that medical practitioners receive case information directly from CPS caseworkers, and by amending PSM 713‑01 to require thorough narrative documentation of all case conferences. The lack of documented supervisory discussions—where critical thinking, professional judgment, and knowledge transfer occur—proved material in the OCO’s review of the actions preceding Trinity’s death. To address this, the OCO further recommends clarifying the importance of timely initial case conferences, outlining required discussion topics, and mandating detailed narratives in all investigative reports. Together, these changes will improve accountability, reduce reliance on recollection, and better safeguard Michigan’s children.

The OCO also recommends a series of improvements to strengthen medical decision‑making, multidisciplinary coordination, and family support during CPS investigations. These include requiring county directors to develop clear processes and training for obtaining timely second medical opinions; expanding continuing education for healthcare professionals on detecting child abuse injuries; and enhancing annual training for CPS and law enforcement on identifying abuse in young children. Additional recommendations call for DHHS to support families when safety plans disrupt existing support systems, maintain and train staff on updated lists of qualified child abuse medical experts, and ensure MDTs meet regularly under prosecutorial leadership with dedicated DHHS liaisons. Finally, the OCO recommends that CPS caseworkers directly contact all individuals with firsthand knowledge of allegations reported to Centralized Intake to ensure complete and timely information gathering.

Advocate's Note:

June 7, 2023

Office of Children’s Ombudsman (OCO) Case Not. 2020-0440

The attached report of findings and recommendations is being made public pursuant to the Children’s Ombudsman Act. The report has been redacted as required by Michigan law. 

The Michigan Department of Health and Human Services (MDHHS) previously released several child protective services report regarding the death of Trinity Chandler. The released MDHHS reports made some information, that would have otherwise been redacted from an ombudsman report, available to the public. The same publicly released information is not redacted in the ombudsman’s report. 

The OCO investigation was conducted during my tenure as the OCO deputy director. The report of findings and recommendations was authored by a multidisciplinary team as the OCO. As the children’s ombudsman, I support the findings and recommendations made in this document. 

Ryan Speidel
Children’s Ombudsman

Case Background:

Trinity Chandler died on December 19, 2020. Pursuant to the Child Protection Law, MCL 722.627k, the DHHS notified the OCO of the child fatality. On January 6, 2021, the OCO opened an investigation into the administrative actions of CPS regarding Trinity Chandler’s death. The following report summarizes the information and evidence found during the OCO investigation. 

The OCO review included reading confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), an autopsy report, service reports, medical records, social work contacts, court documents, photographs, text messages, drug screens, and law enforcement reports including search warrants. The OCO also interviewed DHHS staff, medical professionals, and law enforcement personnel. Due to the confidentiality of OCO investigations, the OCO cannot disclose the identity or sources of statements and evidence. 

Case Objective:

The objective of this review is to identify areas for improvement in the child welfare system by looking at how child protective services investigations involving Trinity Chandler were handled by Oakland County CPS (CPS), and the involvement of staff, court personnel, physicians, and law enforcement. This review reinforces that the safety and well-being of a child is the shared responsibility of the family, community, and both law enforcement and medical personnel aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of the investigations; inform policy, procedure, and practice of DHHS and partners within the child welfare system; and to advocate for changes within it on behalf of similarly situated children.  

Family History: 

Justine Comstock and Father Sr. are the birth parents of Trinity Chandler (DOB: 8/18/2017) and Sibling One (DOB: 6/14/2011). Samual Smart is the living-together-partner (LTP) of Trinity’s mother, Justine. Justine has two additional children, Sibling Two (DOB: 11/6/2009) and Sibling Three (DOB: 07/15/2008), who reside with their father, Sibling’s Father. According to case file documentation, Justine communicates with Sibling Two and Sibling Three but has not seen them since some time in 2018. Samual is the father of LTP’s daughter, who resides with her Justine. Prior to Child’s death, Justine had been substantiated in two Category II cases and one Category I case with trends of improper supervision, physical abuse, and failure to protect. Prior to Trinity’s death, Samual had been substantiated in one Category III case with a trend of improper supervision.

In 2012, a Category II case was opened on Father and Justine due to failure to protect and physical neglect of Sibling One. The case subsequently ended in 2013 when Father and Justine voluntarily released their parental rights to Sibling One. Details in this case are limited because the event predates the implementation of MiSACWIS, meaning full case details are not available in the system.   

In October of 2016, Justine was substantiated for physical abuse due to concerns she was hitting Sibling Three and Sibling Two with a bungy cord. At the end of the investigation, the case was closed as a Category II. MiSACWIS records document that the Friend of the Court (FOC) awarded full custody of Sibling Three and Sibling Two to their father, Sibling’s Father, with no visitation for Justine.   
In February 2020, allegations of improper supervision and physical neglect were reported to Centralized Intake by Trinity’s father, Father. During this time, Trinity was living in her father’s house. Also living in the home were Father’s LTP and her daughter, Justine, and Samual.
Evidence shows Father reported to Centralized Intake that Justine and Samual were asked to leave his home due to nonpayment of rent. Father explained to Centralized Intake that Samual became violent and attacked Father with a hockey stick with Trinity present in the room where the altercation was taking place. Father also told Centralized Intake that he believed Samual had an unknown mental health concern that made him violent. 
 
The CPS investigation determined that a physical altercation took place between Samual and Father over rent payment. The CPS investigation was closed on March 16, 2020, as a Category IV with a moderate risk level.

Summary of OCO Investigations into CPS Actions:

On October 7, 2020, Michigan State Police (MSP) received a complaint regarding possible child abuse of a three-year-old Trinity, who resided in Groveland Township, Oakland County. The 911 call was made by Trinity’s babysitters, Babysitter One and Babysitter Two. They noticed unexplained markings on Trinity’s face and wanted to make law enforcement aware because they were concerned for Trinity’s safety. They believed the injuries were caused by Samual.  

On that same day, an MSP trooper arrived at the babysitter’s home in response to the 911 call and initiated his investigation. The trooper documented the injuries on Trinity’s face. 

The trooper reported the complaint to Centralized Intake within the 24 hours required by the Child Protection Law, MCL 722.628. The allegations were received and assigned for CPS investigation. 

Evidence shows that on the day before the MSP investigation began, October 6, 2020, Babysitter Two was babysitting Trinity at Babysitter Two’s home, and Trinity bumped into a counter causing a bruise. At this time, Babysitter Two said Trinity had no other markings on her forehead. Trinity was nearsighted and because of her poor vision, Trinity frequently bumped into things like walls and corners. On October 7, 2020, when Trinity came over, Babysitter Two observed several new markings, bruises, and abrasions on Trinity’s face. There was a notably large bruise on Trinity’s left cheek. According to reports reviewed, the trooper was concerned about the extent of Trinity’s injuries, calling them “disturbing.” When interviewed by the trooper, the babysitter said Trinity told her that “Moo Moo (Samual) hurt me because he was grumpy” and “Moo Moo said I hit the wall.” The babysitter photographed the injuries and shared them with Trinity’s mother. Trinity’s mother indicated that she did not know how Trinity received the bruises. Trinity was checked by EMS on the scene. 

During the OCO investigation, the trooper acknowledged his lawful ability to remove Trinity pursuant to Juvenile Code, MCL 712A.14a however he did not believe the circumstances rose to the statutory threshold for protective custody. The trooper decided not to remove Trinity from her home and continued his investigation.  

On October 8, 2020, the first day of the CPS investigation, the CPS caseworker met with Justine, Samual, and Trinity. During the visit, Trinity was observed to be clean and appropriately dressed. Trinity was observed with a minor scratch above her right eye near the eyebrow, a bruise approximately the size of a penny on her forehead, several small scratches on and around her nose, a very dark bruise about the size of a quarter on her left cheek, several small bruises and a small scratch on her right cheek, a dark bruise-like mark on her right eyelid, and a purple mark on the top of her left ear that appeared to be a scratch. The CPS caseworker documented that Trinity said she needed her glasses and repeated the statement continually. Trinity’s mother claimed that she didn’t know where the bruises on Trinity's face came from, and that Trinity is usually with Justine’s LTP or the babysitter, Babysitter Two, while Justine is at work. Samual denied using any physical discipline and said he believed that the bruises occurred at the babysitter’s house. 

The CPS caseworker established a safety plan with Justine and Samual. They agreed to use alternatives to physical discipline, such as timeouts, while the investigation was ongoing. If Trinity sustained more injuries, Justine agreed to take Trinity to a doctor.  Justine voluntarily added that she would not allow Samual, Babysitter Two, or Babysitter One to be alone with Trinity until the cause of her injuries was determined. 

In addition to the statements by Justine and Samual indicating a lack of knowledge for a source of the injuries, evidence showed that a satisfactory home assessment was completed during the home visit. Trinity’s bedroom was appropriate, there was an adequate amount of food in the home and there were no visible health or safety hazards. No medication, alcohol, or drug paraphernalia was observed during the home assessment.  

The CPS caseworker requested Justine take Trinity in for a medical exam. The CPS caseworker arranged for the exam to occur at Ascension Genesys Hospital, but Justine did not take Trinity. The CPS caseworker made a second request for Justine to take Trinity and again contacted the hospital to make arrangements. Justine called the CPS caseworker to request moving the exam to an urgent care due to an anticipated lengthy wait at the emergency room. 

On October 9, 2020, Trinity was seen by a physician’s assistant (PA) to provide a medical examination of her injuries. Before Trinity arrived at urgent care, the CPS caseworker contacted the urgent care office to inform them Trinity would be arriving for a medical exam. PSM 713-04. Trinity was seen by a PA at Springfield Urgent Care. Following the exam, the CPS caseworker documented that the PA explained that Trinity’s bruising was “a little larger” than what could be caused by a fist, that “clearly she ran into something.” The examination determined the injuries were consistent with Trinity’s mother’s explanation, that Trinity runs into walls and corners, and that her “clumsiness” was likely attributed to Trinity not wearing her glasses. During an interview with the OCO, the examining PA explained he had ten years of experience treating patients in an emergency room where he also conducted child abuse exams.  

On October 12, 2020, the CPS caseworker discussed the medical examination with her supervisor. By policy, there is no narrative detailing what occurred in this supervision conversation. PSM 713-01.

On October 16, 2020, the CPS caseworker contacted the trooper and informed him that Trinity had been examined at an urgent care on October 9. The medical examination determined that Trinity's injuries were consistent with the explanation provided by Trinity’s mother. The trooper told the CPS caseworker that he doubted the explanation provided by Trinity’s mother. His investigation determined that Trinity sustained the injuries while in Samual’s care. Given his investigation, the trooper did not believe the injuries were caused by Trinity’s clumsiness. 

A forensic interview for Trinity was conducted on October 22, 2020 at CARE House Oakland County. Trinity arrived at CARE House appropriately dressed and free from visible marks or bruises. Present at the forensic interview was the forensic interviewer, Trinity, the CPS caseworker and an MSP detective. According to case documentation, there is no indication that there was a representative present from the Oakland County Prosecutor’s Office to observe Trinity’s interview. The CPS caseworker stated that prior to her interview, Trinity successfully answered the CARE House forensic interviewer’s questions establishing competency. During the interview, Trinity identified Samual as “Moo Moo.”  Trinity was shown pictures of her injuries. Once shown the photos, Trinity wanted to show the pictures to her Justine. Trinity said she did not run into any walls. Toward the end of the interview, Trinity was asked for a final time about where her “boo boos” came from, Trinity said, “I opened my mouth and Moo Moo told me to shut my mouth.” At the end of the interview, there was a determination that Trinity’s statements did not amount to a clear disclosure of abuse. The CPS caseworker told Trinity’s mother that if any new marks or bruises were noticed on Trinity, that she contact the CPS caseworker and the trooper, and that she take Trinity in for a medical examination. The CPS caseworker reminded Trinity’s mother that her responsibility is to protect Trinity from harm. The safety plan was lifted by the CPS caseworker. 

On November 4, 2020, the CPS caseworker followed up with the babysitter to see if she witnessed any signs of abuse or neglect on Trinity while under her care. The babysitter repeated to the CPS caseworker what she had previously told the trooper. The babysitter also told the CPS caseworker she has personally seen Justine’s LTP, Samual kick cats and dogs and heard that he has a history of aggression. The babysitter also told the CPS caseworker about previous marks and bruises she observed on Trinity. However, the OCO confirmed the babysitter did not report those previous marks and bruises either to law enforcement or to Centralized Intake. 

On November 5, 2020, the trooper called the CPS caseworker to tell her he was seeking a search warrant for Justine’s and Samual’s cell phones. The search warrant intended to secure possible conversations regarding the source of Trinity’s injuries and any evidence about Trinity being coached for her CARE House forensic interview. Based on this information, the CPS caseworker requested an extension of the CPS investigation which was approved by her supervisor on November 6, 2020.  

On November 5, 2020, CPS obtained Trinity’s medical records from her three-year well child examination at Fenton Family Medicine which occurred on October 22, 2020. The medical records stated there were no concerns regarding Trinity’s health and recommended she return next year for her four-year checkup.   

The CPS caseworker met with Trinity on November 5, 2020, and observed a “very small, thin, faint scratch” on the side of Trinity’s face. Trinity’s mother told the caseworker that the scratch was from a cat. Trinity was observed to be very happy and energetic throughout the visit. She was running around on the home’s porch and in the front yard. Trinity’s mother also reported to the CPS caseworker that Trinity attended an eye doctor appointment, and a new pair of glasses would be arriving in two weeks.  
 
On December 1, 2020, the trooper updated the CPS caseworker about the status of his request for a search warrant. The trooper was unable to obtain an authorized search warrant from the court, due to a determination by the court that the search warrant lacked probable cause. After the search warrant was denied, the trooper sought assistance from an MSP detective and resubmitted the search warrant. Again, the search warrant was denied by the court. After the second denial, the trooper requested help from an assistant prosecutor from the Oakland County Prosecutor’s Office. After consulting with the Oakland County Prosecutor’s Office, the trooper submitted a third request for a search warrant, which was also denied. Journal entries contained in the MSP report show that the trooper’s actions to obtain an authorized search warrant in this case occurred between November 20, 2020 to December 9, 2020. 

The OCO reviewed documentation from December 7, 2020, which showed that Trinity received her new glasses from the eye doctor. Trinity’s mother informed the CPS caseworker that Trinity was still a little clumsy while wearing her glasses, but stated she believed it was because Trinity was getting used to having bifocals. On December 11, 2020, Trinity’s mother sent a text message to the CPS caseworker with photos of Trinity wearing her new glasses. The first photo received by the CPS caseworker depicted a shadow on part of Trinity’s face. The CPS caseworker requested a different photo with better lighting. Trinity’s mother sent an additional photo of Trinity in her new glasses. In that photo, a small mark, possibly a bruise, was visible on Trinity’s left shoulder. In the second photo, Trinity is wearing a different shirt and her hair is in a different style. 

On December 11, 2020, the CPS caseworker called the optometrist to understand the severity of Trinity’s eyesight. The optometrist said although Trinity’s prescription worsened over time, Trinity’s mother was not neglectful in her delay to obtain Trinity’s new glasses. 

As part of the CPS investigation, the CPS caseworker contacted Samual’s Training and Treatment Innovations (TTI) case manager on December 14, 2020. Samual was voluntarily receiving services at TTI.  The TTI links individuals and their families with available services needed to maintain good mental and physical health and stability. The case manager reported that Samual was receiving services for mental health and sobriety treatment through TTI. The case manager said she had not been in contact with Samual recently because he obtained a new cell phone. She told the CPS caseworker that as far as she was aware, Samual was complying with his medication and treatment plan. The TTI case manager denied Samual had issues following his treatment plans or engaging in services in the past. The case manager said she has ‘no concerns at all’ regarding Samual being around children or his capability to care for children. The TTI case manager told the CPS caseworker she would visit Samual at home during the upcoming week. 

CPS determined that the evidence collected during the investigation did not rise to the level of a preponderance of the evidence for child abuse or neglect because:

• The medical examination determined the injuries were consistent with Trinity’s mother’s explanation, that Trinity runs into walls and corners, and that her “clumsiness” was likely attributed to Trinity not wearing her glasses.
• The determination that the forensic interview did not result in Trinity making a clear disclosure of abuse.
• The optometrist reported no concerns of medical neglect.
• Samual’s TTI case manager reported no known issues regarding Samual being around children.

The OCO learned during the investigation that the CPS caseworker remained uncomfortable because of Trinity’s injuries and statements made by the babysitter.  

On Friday, December 18, 2020, the CPS caseworker met with Trinity’s mother and Trinity at 3:50 P.M. Another more experienced CPS caseworker was in the car while Trinity’s caseworker was talking to the family. In light of the CPS determination of a lack of preponderance of the evidence, the case was to be closed on Monday, December 21, 2020. The CPS caseworker made contact on this day to ensure that the family was engaged in services prior to case closure. After arriving at Trinity’s home, the CPS caseworker knocked on the door several times because she could hear people inside the house. Trinity’s mother came outside, followed shortly by Trinity, who was wearing a one-piece pajama set and tennis shoes. While Trinity walked around outside looking at the snow, the CPS caseworker observed new injuries on Trinity’s head. Specifically, the CPS caseworker observed a yellowish-brown bruise on Trinity’s right cheek, a small scratch near her lip, and a small, light scratch near her left ear. Trinity also appeared to have a broken blood vessel in the lower portion of her left eye. When asked about the bruising on Trinity's face, her Justine said Trinity had misplaced her glasses “for a minute” and had fallen while playing in her room because it was a “mess.” The CPS caseworker photographed the newly observed injuries on Trinity’s head. Trinity appeared excited to have her photo taken. Trinity did not appear fearful of her Justine. 

The OCO investigation determined that after observing Trinity’s face, the CPS caseworker believed the new injuries provided sufficient evidence to establish a preponderance of evidence to substantiate Trinity’s mother and Samual on child abuse. Given her inexperience as a new caseworker, she was unsure how to proceed after seeing Trinity’s new injuries. The CPS caseworker called the on-call supervisor because her direct supervisor was on leave. There is evidence to show that the on-call supervisor advised the CPS caseworker that she did not need to report Trinity’s new injuries into Centralized Intake because they would discuss the case on Monday. Trinity’s CPS caseworker was not comfortable with waiting until Monday, so she went back to the car to seek advice from her colleague. They decided to call and leave a voicemail for the Oakland County CPS program manager. The CPS program manager did not return the CPS caseworker’s phone call that evening. Instead of returning the CPS caseworker’s call, the program manager called the on-call supervisor, and it was determined that they would wait until Monday to discuss the new injuries. The OCO interviewed the parties involved and there are discrepancies on the interaction between the caseworkers, supervisor, and program manager that cannot be clarified. The record shows that a supervision contact took place between Trinity’s caseworker and the on-call supervisor, but no details were entered per DHHS policy. PSM 713-01.
 
During the evening of December 18, 2020, Samual and Trinity were at his brother's home until approximately 12:00 A.M. After they returned home Trinity stated she had a bellyache. Samual said she vomited and went to bed. According to Samual, when he tried to wake Trinity up around 6:00 A.M. on December 19, 2020, she was acting sluggish and moving slow. Samual said he and Trinity went to their van to pick Trinity’s mother up from work and said he tried to keep Trinity awake but she kept "nodding off." Samual called his father and after speaking with him, Samual took Trinity to the fire station. CPR was started and Trinity was transported to the hospital. Trinity was pronounced dead at Ascension Genesys Hospital on December 19, 2020, at 7:25 A.M. The cause of death was unknown, but there were concerns regarding abuse. Findings included bruises and a left subconjunctival hemorrhage. When interviewed by MSP after Trinity’s death, Trinity’s mother admitted that she felt Samual was capable of killing Trinity and had been assaultive toward Trinity’s mother in the past. These statements from Trinity’s mother were inconsistent with previous statements she had made to the CPS caseworker and the trooper earlier in the investigation.  

On December 19, 2020, the trooper obtained an authorized search warrant for Samual’s phone. The search of the phone led to MSP restoring a deleted video recorded on December 14, 2020. According to the autopsy report, the video revealed a person “strike the decedent’s nose and she started crying, then the person placed a pillow on her chest while she was laying supine on the floor and external force from the person (possibly kneeling) was applied against the pillow with her chest under it for approximately 17 seconds. She became unresponsive, the pillow was removed and the person stopped exerting force on her. She regained consciousness. Approximately 30 seconds later, the person placed a pillow on her chest again while she was laying supine on the floor and external force from the person (possibly kneeling) was placed against the pillow with her chest under it for approximately 20 seconds. The person stopped applying force to the pillow and the decedent was told to go sit down. She was subsequently kicked to the floor while walking to a chair. She got up from the floor and sat on the chair.”

On June 24, 2021, a phone call was documented between the CPS caseworker and the Genesee County Assistant Medical Examiner, Dr. One, who verified that the cause of death for Trinity was “complication of blunt force trauma to the chest” and the manner of death was ruled homicide. Dr. One advised that, “the injury to Trinity’s heart are [sic] consistent with being caused by the actions depicted in the video from December 14, 2020 found on Samual’s phone, which showed him kneeling on Trinity’s chest.” It was also documented that, “Dr. One advised Trinity’s heart was examined by Dr. Two in Kent County and it is Dr. Two’s opinion the injury was sustained several days prior to Trinity’s death. Dr. One stated any time an injury to the tissues around the heart are visible when viewed under a microscope, as Trinity’s was, the injury is severe enough to cause death. He stated the injury to Trinity’s heart was not caused the morning she died, as an acute (recent) injury would have shown acute inflammation around the heart, which was not observed. Dr. One advised he does not know if it would be reasonable for Trinity to be exhibiting any symptoms or signs of injury or distress between when she sustained the injury and when she died, but he did state he ‘finds it interesting’ she was reportedly experiencing nausea and vomiting the night prior to her death because those are common symptoms of a heart attack, which is a similar injury to Trinity’s.”   

The CPS investigation into the death of Trinity was opened on December 19, 2020 and was submitted for disposition on July 14, 2021. The case was substantiated as a Category II with an intensive risk level that Trinity was physically abused by Samual and this abuse ultimately led to her death on December 19, 2020. Additionally, Trinity’s mother was substantiated on failure to protect Trinity from this abuse.  
 
On November 21, 2021, in accordance with the Children’s Ombudsman Act, MCL 722.929(5), the OCO sent a letter to the Oakland County Prosecutor. The letter informed the Oakland County Prosecutor that the OCO investigation was complete and inquired about the status of the ongoing law enforcement investigation and whether the release of the OCO report would interfere with the criminal investigation. On June 2, 2022, the Oakland County Prosecutor’s Office, responded to the November 21, 2021 OCO letter and stated there was an ongoing investigation in the matter and a release of the OCO report may interfere with the criminal investigation. The Oakland County Prosecutor’s Office asked the OCO not to release its report until the criminal investigation was completed. 

On January 26, 2023, the OCO contacted the Oakland County Prosecutor’s Office to see if there was an ongoing criminal investigation in this case. The Oakland County Prosecutor’s office then notified the OCO that there was no longer an ongoing criminal investigation, as the defendant in this matter, Samual pled no contest to the Second Degree Murder of Trinity and awaited sentencing before the Oakland County Circuit Court. 

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The OCO finds, pursuant to the medical examination of Trinity, the injuries that caused her death were sustained several days prior to the day she died.
The OCO finds the injuries that caused Trinity’s death are consistent with the actions depicted in a video on Samual’s phone of a person kneeling on Trinity’s chest. The video was dated December 14, 2020.
The OCO finds that PSM 713-04 creates gaps in communication between the examining practitioner and a CPS caseworker regarding allegations of child abuse. The policy allows the CPS caseworker to talk to a professional at the medical facility when the medical practitioner is not available. The OCO finds that in accordance with this policy, the CPS caseworker spoke to the receptionist of the medical facility. The OCO finds that allowing the CPS caseworker to talk to a professional at the medical facility in lieu of directly speaking to the medical practitioner is inadequate to help inform the practitioner about the possibility of abuse as a potential cause of injuries.
The OCO finds that PSM 713-01 prohibits narratives about supervisory case conference discussions from being memorialized in MiSACWIS. This issue of not documenting narratives in case conferences has proven to be material in the OCO investigation of DHHS administrative acts prior to Trinity’s death. During this investigation the OCO received conflicting statements. Because this policy prohibits narratives, the OCO investigation could not distinctly determine whether supervision: Reviewed photographs of Trinity’s injuries from October 8, 2020, prior to her death. Discussed the adequacy of the safety plan. Provided clear guidance to the CPS caseworker on how to further investigate injuries observed the day before Trinity’s death. Provided the CPS caseworker with adequate support needed relative to the CPS caseworker’s experience.
The OCO finds PSM 713-04 provides guidance to CPS caseworkers about seeking second medical opinions. Based on facts presented in the investigation, a second medical opinion could have been, but was not sought in this case.
The OCO finds SRM-103 does not currently mandate annual in-service training for CPS case workers regarding objectives on detecting injuries attributable to child abuse.
The OCO finds that the safety plan developed by the CPS caseworker and Trinity’s mother removed Trinity’s childcare providers. Trinity’s mother rejected alternative childcare providers suggested by the CPS caseworker and allowed Samual to continue to care for Trinity while she was at work, contrary to the safety plan.
The OCO finds that Trinity’s mother did not share crucial information about LTP’s violent tendencies during the joint CPS and law enforcement investigation. Throughout the investigation, Trinity’s mother continually reinforced that LTP had a healthy and loving relationship with Trinity. Only after Trinity’s death, did Trinity’s mother inform CPS that she believed Samual killed Trinity and disclosed a history of violent behavior exhibited by him.
The OCO finds that Samual was initially criminally charged by the Oakland County Prosecutor’s Office with First Degree Felony Murder, MCL 750.316. The Oakland County Prosecutor’s Office offered, and Samual accepted, a reduced charge of Second Degree Murder MCL 750.317. Samual tendered a no contest plea and entered into a sentencing agreement with the Oakland County Prosecutor’s Office to a minimum of 40 years in prison. On February 22, 2023, pursuant to the sentencing agreement, Samual was sentenced in the Oakland County Circuit Court to 40 years to 99 years in prison for the murder of Trinity.

Recommendations:

Recommendation	MDHHS Response to Recommendation
The OCO recommends PSM 713-04 be amended to: Remove the provision that allows the CPS caseworker to provide information to a professional at the medical facility when the medical practitioner is not available. It is critical that the examining practitioner be provided with case details directly from the CPS caseworker before the exam is conducted.	MDHHS recognizes for any case where CPS requests a medical exam, speaking directly with the examining practitioner is ideal; however, medical professionals are not always immediately available to respond to a CPS specialist. Avoiding delays is important for the department to take quick actions to protect the safety and well-being of children. Policy allows specialists to speak to other professionals at the medical facility to gather and relay information to avoid potentially critical delays in examination and treatment of children.
The OCO recommends PSM 713-01 be amended to require that case conferences between CPS caseworkers and their supervisors be documented in narrative format in the case’s social work contacts.	MDHHS is working with appropriate experts to assess this recommendation. The department will thoughtfully research potential revisions to policy to provide additional guidance around documentation of case conferences between specialists and supervisors to avoid any unintended consequences that would negatively affect children.
This issue of not documenting narratives in case conferences has proven to be material in the OCO investigation into the administrative actions before Trinity’s death. Case conferences are the critical point in a CPS investigation where “gut” feelings are discussed and where knowledge from more experienced child welfare staff is passed onto new staff. It is these conversations where learning can occur, and critical thinking skills developed. The lack of documentation present for these case conferences can create a lack of priority and accountability for CPS supervision. Ensuring MiSACWIS has adequate notes from case conference discussions is integral to the exchange of information if a new CPS caseworker or supervisor joins the case. Because of this, the OCO recommends PSM 713-01 be amended to specify the importance of initial case conferences taking place soon after a new investigation is assigned, provide a guide that details a list of issues in the case to be discussed, viewed, and decided at the initial conference, and require that the initial case conference and all subsequent case conferences provide a detailed narrative in the investigative report. Anything less leaves room for recollection error and lack of accountability which is not in the best interest of Michigan’s children.	The MDHHS Children’s Services Administration has begun researching potential revisions to policy to include a timeframe for an initial case conference and further guidance around documentation. MDHHS has developed an intervention tool that requires regular communication between caseworkers and their supervisors during key points of an investigation as part of the department’s Keep Kids Safe Action Agenda. The department also is developing an ongoing quality assurance process focused on providing independent feedback to investigators to improve investigation quality.
The OCO recommends that DHHS require local county directors to: Develop processes in coordination with the local Multi-Disciplinary Team (MDT) to include detailed direction on how to request and access a second medical opinion. Develop a county specific protocol on how to obtain a second medical opinion in accordance with PSM 713-04. Train CPS caseworkers on the county specific protocols on how to obtain a second medical opinion in accordance with PSM 713-04. Train CPS caseworkers and supervisors about the impact of obtaining a second medical opinion in a timely manner so the injuries can be viewed by the medical practitioner before healing.	The Children’s Services Administration will collaborate with regional directors to determine what actions their local county directors can take to address these opportunities. Completing multiple real-time reviews of physical abuse cases to evaluate safety planning and ensure decision-making was appropriate is part of the Keep Kids Safe Action Agenda.
This OCO investigation shows that medical assessments of children in child abuse and neglect investigations are oftentimes the determining factor in the decision to substantiate or not substantiate child abuse and neglect. The facts presented in this case demonstrate the absolute necessity that all individuals in the medical field, who may encounter children in their practice receive ongoing training in order to better detect injuries attributable to child abuse and neglect. The OCO recommends that: The Department of Licensing and Regulatory Affairs (LARA) collaborate with the Michigan Boards of Medicine, Osteopathic Medicine and Surgery, and Nursing to promulgate rules to require continuing education for healthcare licensees on detection of injuries attributable to child abuse as a requirement of licensure. LARA share an annual message to all healthcare licensees providing training resources and information regarding the detection of child abuse injuries.	MDHHS agrees with the recommendation that all individuals in the medical field who may encounter children in their practice receive this type of ongoing training. Including outside expertise in child abuse and neglect cases where feasible can assist our CPS specialists to better protect children and families.
Child welfare investigations require law enforcement and CPS caseworkers be proficient in detecting abuse and neglect. Physical abuse may be overlooked or misdiagnosed in children under the age of 4 due to their vulnerable characteristics. Training enhancements to better equip our investigators is critically needed to best protect Michigan’s children. The OCO recommends SRM-103 be amended to mandate the annual in-service training include objectives on the detection of injuries attributable to child abuse.	The Children’s Services Administration is exploring a mandate for annual in-service training to include objectives on the detection of injuries attributable to child abuse.
The OCO recommends that DHHS provide assistance to families when a safety plan removes the support system currently in place. DHHS could independently search for and seek out relatives, other than those provided by the parent or caretaker, who can provide supports for families with open CPS investigations and ongoing cases. DHHS could provide state-available supports including, but not limited to, a childcare subsidy for families with open CPS investigations and ongoing cases.	The Children's Services Administration will explore this recommendation further and consider opportunities to enhance safety planning; however, there may be limitations to federal eligibility for benefits to meet the need for some types of services. The department does refer families to supports such as childcare subsidies; however, parents may not always follow through with these referrals. The department is developing a pilot program to help enhance collaboration between CPS staff and the department's benefits eligibility services staff to enhance economic supports to families. As part of its Keey Kids Safe Action Agenda, MDHHS is investing millions of dollars to create more Family Resource Centers. The number of Family Resource Centers recently expanded by 5 for a total of 11 in local communities. Family Resource Centers work with families who are at-risk of abuse and neglect to meet their needs sooner and strengthen their protective factors.
The OCO recommends that DHHS require local county directors to: Collaborate with their MDT to develop a working list of medical practitioners who have specialized training in detecting child abuse and neglect, examining, and interviewing children in accordance with PSM 713-04. Maintain and update the list of statewide and local child abuse medical experts with CPS caseworkers and supervisors. Train CPS caseworkers and supervisors on the critical importance of using the child abuse medical expert list when scheduling initial and second opinion medical examinations. Instruct CPS caseworkers on what medical practitioners, who have specialized training in detecting child abuse and neglect, are available to conduct medical assessments after hours within their respective counties. Invite the medical practitioners from the child abuse and neglect list to MDT meetings and case reviews.	The Children’s Services Administration is collaborating with regional directors to determine what actions county directors can take to address these opportunities.
The OCO recommends county prosecuting attorneys, or their designee, conduct regular MDT meetings to increase communication among members. The OCO has seen positive outcomes when the MDT is actively involved in case-by-case decision-making to facilitate and support the work of its members. The MDT should include members of law enforcement, medical personnel, mental health personnel, and Child Advocacy Centers. The OCO recommends the Michigan Legislature fund and DHHS hire liaisons to the MDT for each county. Liaison duties could include but are not limited to, serving as a bridge between MDT members, assisting the MDT leader in facilitating monthly MDT case review meetings, collaboration with DHHS central office on policy changes, and actively participate in the investigation as an advisor to the MDT when the child presents with abnormal or suspicious bruising or injury, severe injury, sexual assault or death.	MDHHS is always willing to help work with our legislative partners on any funding or policy that will help us protect children.
The OCO recommends anyone identified as a person with firsthand knowledge of the allegations when the complaint is called into Centralized Intake must be contacted directly by the CPS caseworker in a timely manner. These individuals should be identified as a primary reporting source.	The MDHHS Children’s Services Administration will explore a potential revision to policy requiring CPS specialists to contact the primary reporting source in a timely manner in all active CPS investigations. The department wants to ensure this practice would result in the intended benefits for children and families.

PDF Version of Report:  Case No. 2020-0440

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
January 30, 2023	May 8, 2023	May 12, 2023	2020-0225 & 2021-0416

Summary of recommendations:

The OCO recommends that Marquette County DHHS follow MCL 722.628d by using safety plans, voluntary arrangements, and powers of attorney only when appropriate and not as substitutes for filing a petition when removal is warranted. The OCO further urges child welfare partners in Marquette County to establish regular multidisciplinary meetings to clarify roles, align local procedures, discuss case information, and strengthen collaboration among CPS, law enforcement, the courts, medical and mental health professionals, and child advocacy centers. Finally, the OCO recommends that DHHS develop a new process to ensure that allegations reported during an open investigation or services case are fully investigated rather than rejected or overlooked.

Ombudsman's Note:

May 12, 2023 

Office of Children’s Ombudsman (OCO) Case No: 2020-0225 and 2021-0416

The attached report of findings and recommendations is being made public pursuant to the Children’s Ombudsman Act. The report has been redacted as required by Michigan law. 

Two OCO investigations found similar evidence and circumstances in two separate children’s protective services cases. All personal identifying information has been redacted. Initials were not redacted to allow the reader a better understanding of the separate investigations. 

The OCO investigation was conducted during my tenure as the OCO deputy director. The report of findings and recommendations was authored by a multidisciplinary team at the OCO. As acting children’s ombudsman, I support the findings and recommendations made in this document. 

Ryan J. Speidel 
Acting Children’s Ombudsman

Case Background:

The OCO opened investigations of Marquette County CPS on June 11, 2020, and May 21, 2021, based on allegations that the agency failed to protect children and families when the agency delayed filing petitions to remove children from their homes despite numerous reports of substance abuse, domestic violence, physical abuse, and neglect.

The OCO review included reading confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), service reports, medical records, social work contacts, court documents, photographs, text messages, drug screens, and law enforcement reports. The OCO also interviewed complainants, DHHS staff, guardians, lawyer-guardian ad litem (LGAL), foster parents, prosecutors, medical personnel, and law enforcement personnel. Due to the confidentiality of OCO investigations, the OCO cannot disclose the identity or sources of statements and evidence.

Case Objective:

The objective of this review is to identify areas for improvement in the child welfare system by looking at how the families' cases were handled by Marquette County CPS (CPS), and the involvement of staff, court personnel, physicians, and law enforcement. This review reinforces that the safety and well-being of a child is the shared responsibility of the family, community, and both law enforcement and medical personnel aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of the investigations; inform policy, procedure, and practice of DHHS; and advocate for changes in the child welfare system on behalf of similarly situated children.

OCA Investigation 1: LV

Background & History:

AV and DV are the parents of LV and KV. The V s also had an older daughter named K to which their parental rights were voluntarily terminated in 2016 due to substance abuse. K was later adopted by her paternal grandfather.

In 2017, L was removed from D and A’s care because they did not cooperate with services after it was determined the V home was not a safe place for L due to drug use and the condition of the home. L was reunified with her parents one year later, after they successfully completed and benefitted from reunification services.

From 2014 to 2020, Child Protective Services Centralized Intake (Centralized Intake) received numerous complaints concerning A and D ’s substance abuse and related issues. The following history is meant to inform the reader of the pattern of drug use that the OCO uncovered during the investigation. Although the history from 2014 to 2020 is not the basis for this OCO investigation, it is important to provide a full picture of the V family’s history and frequent interactions with CPS. The OCO did not investigate the cases from 2014 to 2020 and therefore issues no findings relating to the CPS investigations completed during that timeframe.

• 2014
  • December 30, 2014. A complaint was made to CPS alleging that K was born with Subutex and Neurontin in her system and was receiving methadone to treat her withdrawal from these drugs. After investigating this complaint, CPS found that no preponderance of evidence of child abuse and/or neglect existed because A was prescribed the drugs K was born with in her system.
• 2015
  • January 12, 2015. A complaint was made to CPS alleging that A and D were addicted to opioids which impacted their ability to safely care for K, because it was alleged when they get high, they are “extremely high.” This complaint was not investigated because the December 30, 2014, complaint was still open and alleged similar allegations.
  • February 2, 2015. A complaint was made to CPS alleging that A and D were found intravenously injecting drugs in a car with K where needles were strewn about the car. When this happened, police took K into protective custody. After investigating this complaint, CPS found that a preponderance of evidence existed that A and D improperly supervised and placed K in a situation of threatened harm. K was subsequently removed from their care and placed into relative foster care. While K was in relative foster care, A and D failed to participate in services to address their substance abuse issues. Subsequently, A and D released their parental rights to K and she was later adopted by her paternal grandfather.
• 2017
  • January 28, 2017, and February 3, 11, and 13, 2017, complaints were made to CPS alleging A and D had another child, L , and that they were struggling with drug addiction and maintaining stable housing. L was also born with prescription medications in her system and was going through withdrawals. After investigating these complaints, CPS found that there was a preponderance of evidence that both A and D improperly supervised and placed L in a situation of threatened harm because they did not have suitable housing for themselves and L .
  • March 9, 2017. A complaint was made to CPS alleging that L was born with drugs
    in her system and that her respiratory rate was too high. An in-home nurse told A to take L to the emergency room, but A refused. After investigating this complaint, CPS found a preponderance of evidence existed that A medically neglected L after A failed to follow medical advice to take L to the emergency room. This case was closed because the January 28, 2017 complaint was still open, and the family was working with service providers.
  • June 7, 2017. A complaint was made to CPS made alleging that L presented with a yeast infection and dirt all over her body, including in the folds of her skin and under her toes and fingernails. After investigating this complaint, CPS found that
    no preponderance of evidence of child abuse and/or neglect existed that A or D physically neglected L because each time CPS visited the home, including two unannounced visits, the caseworker observed that L appeared to be healthy and clean.
  • July 14, 2017. A complaint was made to CPS alleging that D drove L to the doctor’s office and was high or intoxicated to the extent that he could not stand straight and was slurring his speech. After investigating this complaint, CPS found a preponderance of evidence existed that A and D physically neglected, improperly supervised, and placed L in a situation of threatened harm because D admitted to driving L to the doctor’s office while high or intoxicated and was unable to appropriately care for her. The parents also failed to comply with CPS’s safety plan to clean up their home which had needles throughout, follow safe sleep practices, and work with service providers. Consequently, L was removed from her parents’ care and placed into foster care.
  • September 3, 2017. A complaint was made to CPS alleging that A and D ’s substance use had gotten worse since L entered foster care. It was also alleged that A once shook L and D had to hit A to get her to stop shaking L . The foster care staff were notified of this complaint. Over the course of the foster care case, A and D gradually complied with services and L was returned to their care on June 7, 2018, with family reunification services in place.
• 2018
  • June 28, 2018. A complaint was made to CPS alleging that needles were observed in the V home, and it was suspected that A and D were using drugs again even though L had just been returned to their care. There were also
    concerns with the cleanliness of the home, as it was reported there was clothing and garbage all over. The foster care staff were notified of this complaint.
  • The court dismissed jurisdiction over L in September 2018 due to A and D complying with services.
• 2019
  • On February 26, 2019. A complaint was made to CPS alleging A and D are regularly using drugs while caring for L . There were also concerns with the condition of the home. After investigating this complaint, CPS found no preponderance of evidence existed because A and D denied using substances they were not prescribed, their drug screens came back positive only for their prescribed medications, and they cleaned up the home.
  • May 2, 2019. A complaint was made to CPS alleging that A and D were drug users, were selling drugs out of their home, and using them in front of L. Centralized Intake rejected the complaint after their preliminary investigation revealed that law enforcement did not receive any calls about the V home for drug related issues.
  • May 28, 2019. A complaint was made to CPS alleging A and D were drug users and were selling drugs out of the home. There was also frequent traffic in and out of the home. This complaint was not investigated by CPS because the allegations were documented to be “vague and speculative.”
  • June 24, 2019. A complaint was made to CPS alleging that A and D were using methamphetamine and Suboxone with L present. It was also alleged that there were needles, cigarettes, and garbage throughout the home. After investigating this complaint, CPS found that no preponderance of evidence existed because when CPS visited the home there were no safety hazards observed. L appeared to be adequately cared for, the parents denied using drugs that were not prescribed to them and only tested positive for marijuana and drugs they were prescribed.
  • December 13, 2019. A complaint was made to CPS alleging that D appeared to be under the influence of some substance while caring for L, including driving with her in the car. This complaint was not investigated because the allegations were “vague” and there were two recent investigations of the parents regarding substance abuse that were denied.
• 2020
  • October 22, 2020. A complaint was made to CPS alleging that A had given birth to K and K had been started on methadone due to her Neonatal Abstinence Syndrome (NAS) scores. A used Subutex and Neurontin while pregnant with K . After investigating this complaint, CPS found that no preponderance of evidence existed that child abuse and/or neglect occurred because K was only born positive for substances A was prescribed and A had all the necessary baby items to adequately care for K .

Summary of OCO Investigation into DHHS' Actions (V Family)

A complaint was made to the OCO alleging CPS received and failed to properly respond to a complaint involving the V family on May 2, 2021. The OCO investigation centered around CPS’s handling of the May 2, 2021 complaint, alleging that L, age 4, was observed crossing a street near a busy highway and went to a park unsupervised.

On May 2, L was observed alone in a park by a bystander who called 911. Shortly after police arrived at the scene, A called 911 because she could not find L. The Vs were told that law enforcement was with L at the park, and the Vs could meet there to pick L up. Law enforcement noticed that there were needles on the floor of the V ’s car. Police reports note that the V s did not appear to be under the influence of drugs or alcohol, and L was returned to them. This incident was called into Centralized Intake and a complaint was assigned to CPS for investigation. As a result, CPS created a safety plan requiring A and D to install a dead bolt in the home so L could not run loose and go to the park. CPS informed the family they would check the home in a few days to see if the lock was installed.

On May 7, 2021, law enforcement contacted CPS to request immediate assistance at the V home. D was arrested following a domestic altercation with A . According to the CPS Investigation report, A told CPS that she and D fought over money, he trashed the home, and choked and hit her. D appeared to be under the influence of an unknown substance and law enforcement had concerns that A was unable to properly supervise L and K . The house had a foul odor, garbage bags were piled waist high around the house, there was a container full of needles in the bathroom, and the deadbolt was not yet installed on the front door as agreed upon in the safety plan.

On May 11, 2021, CPS received a second complaint about the same domestic altercation. The second complaint was rejected as already investigated. There is no indication that the CPS specialist investigating the allegations attempted to contact or interview the medical professional who filed the complaint. This second complaint added more detail to the May 7, 2021, incident. The complainant informed Centralized Intake that A disclosed that when she woke up on May 7, D was “inside her" and started beating her. According to the complaint, D was hitting A while she was holding their one-year-old daughter, K . Because of this, A  had to toss K on the bed. After this occurrence, K had a bruise on her head. A was physically abused in the bedroom and living room, causing her pain and bruises. D allegedly stole  $4,000.00  out  of A ’s bank account and smashed her phone. The children were not physically harmed; however, they may have witnessed some or all of the violence.

In response to the domestic violence incident, CPS created a safety plan requiring A to change the locks on the door to prevent D from returning. The agency and law enforcement recommended that A, L, and K move in with A ’s mother, and not return until the house is clean, there were new locks installed, and CPS verified compliance with this safety plan.

CPS had a case conference on May 12, 2021. According to the conference report, the caseworker was supposed to go to the home that day, however the OCO was unable to find any record in MiSACWIS showing the visit happened.

On May 17, 2021, L was found alone a block and a half from her home. Law enforcement was called and responded to retrieve L and return her home. Law Enforcement again reported this to CPS. According to law enforcement and CPS reports, A was home, lethargic, and had slurred speech. A was not aware that L was missing. Reports show that L wandered off because she was hungry and searching for food as there was no food in the home. A was not in compliance with the safety plan created on May 3, 2021, because she had not yet installed the dead bolt that would prevent L from wandering off.

CPS made a home visit on May 18, 2021. During this visit, CPS provided the V family with a lock for the door and asked A to install it by the end of the day. The caseworker asked A why she wasn’t following the safety plan, which included installation of the lock and staying with maternal grandmother until the house was cleaned. A said that she was only in the house to clean, she fell asleep, and L wandered off again. It was noted that there was dirty laundry lying around the house.

On May 21, 2021, the agency received D ’s drug screen results from his May 14, 2021, drug screen. The drug screen was positive for amphetamine and Buprenorphine. D told CPS he had a prescription for both drugs.

A CPS complaint was made on May 21, 2021, stating that law enforcement was dispatched to the V family’s residence on May 20, 2021, for a well-being check regarding rumors that A was under the influence while caring for the children. Both children appeared unharmed, but there were two syringes observed in the home that were accessible to the children. A appeared “slightly” under the influence but capable enough to care for the children. The syringes were disposed of. This complaint was rejected for investigation because the earlier complaints assigned in May 2021 dealt with similar issues. CPS visited the home on May 21, 2021. CPS created another safety plan with A because of the concerns that were reported by law enforcement the previous day. The safety plan stated that A was not to use drugs, not leave her children unsupervised, and they were not to return to the home with the children before the case is closed and CPS verifies it for habitability and cleanliness. During this visit, CPS found the house was still unsanitary and the dead bolt, that was agreed upon in the safety plan created on May 7, 2021, and provided to A on May 18, 2021, was still not installed.

The OCO received a complaint on May 21, 2021, due to unaddressed safety concerns regarding the V children.

On May 28, 2021, the OCO was made aware the children had a routine medical wellness examination on May 26, 2021. The Children’s Ombudsman contacted the health care provider on May 28, 2021. The provider stated that during this examination, they observed new injuries on K ’s head. One injury was a grape-sized red contusion on the left side of her head, between the ear and forehead. During the two-hour long exam, the contusion changed color and got darker. The provider also discovered a baseball-sized contusion on the right side of K ’s head. The provider stated she had been a pediatric nurse for over a decade and had never seen anything like this injury before. The provider believed that the contusion on the left side of the K ’s head was consistent with A ’s explanation that L hit K with a buckle. The provider said that the contusion on the right side of K’s head was not consistent with being hit by a buckle. The provider ordered x-rays and bone scans. The medical provider explained they were aware of the domestic violence incident from May 7, 2021, and the contusions discovered during this examination were more recent than that. The provider told the Children’s Ombudsman that the current injuries were quite urgent. The provider shared concerns about A ’s follow through regarding the children’s medical appointments because it took her 16 days to bring the children to the emergency room after the May 7, 2021 domestic violence incident.

The OCO became aware of the head contusions because the Children’s Ombudsman contacted the medical provider and asked questions. There was no information in MiSACWIS regarding these injuries. At the completion of this investigation, the only documentation of the head contusions in MiSACWIS are listed in the petition that CPS filed on May 28, 2021, requesting removal of the children. Based on the new information provided to CPS by the OCO, CPS found that a preponderance of evidence existed that D and A improperly supervised, physically neglected, and placed the children in threatened harm. This decision was based on L wandering away from the home unsupervised on two occasions, D and A getting into a physical altercation while under the influence with the children present, the unsuitable conditions of the V family home, D and A’s continued substance abuse, and their failure to follow the agreed upon safety plans. The investigation was classified as Category I, and the children were removed from home and placed in foster care.

OCA Investigation 2: V & K

Background & History

KC is the biological mother of KM and VK. KM’s biological father is MM and VK’s biological father is CK. 

From 2015 to 2018, Centralized Intake received numerous complaints concerning KC’s substance abuse and related issues. The following history is meant to inform the reader of the pattern of substance abuse and related issues that the OCO uncovered dm-ing the investigation. The history from 2015 to 2018 is not the basis for this OCO investigation but is included to provide a full pictm·e of CPS history and frequent interactions between CPS and K and C. The OCO did not investigate the cases from 2015 to 2018 and therefore issues no findings relating to the CPS investigations completed during that timeframe.  K and C have extensive CPS histories including struggles with drug use, mental health, housing, and domestic violence.

• 2018
  • May 23, 2018. CPS was contacted and initiated an investigation because K tested positive for marijuana, morphine, and benzodiazepines while pregnant with V. K tested positive for marijuana when V was born positive for Buprenorphine, Norbuprenorphine, and Gabapentin. All the medications V tested positive for were prescribed to K. V and was hospitalized for approximately a month and a half due to the withdrawals from the medication. Because K was prescribed all the medication V tested positive for, CPS found that K did not abuse or neglect the May 23, 2018, CPS investigation was then closed on August 31, 2018.
  • May 31, 2018, June 28, 2018, July 27, 2018, and August 16, 2018. While the May 23, 2018 CPS investigation was open, four additional CPS complaints were made against K and C alleging substance abuse and domestic violence between them. The CPS complaints made on May 31 and June 28, 2018, were rejected by CPS for investigation. The July 27 and August 16, 2018, complaints were assigned for investigation.
  • July 27, 2018. The CPS investigation revealed that V was present for a domestic violence incident that took place between K and C Based on this, CPS opened an ongoing case to monitor the family and provide them with services to address these issues. The case was open until June 25, 2019. CPS found that no abuse or neglect took place in the July 27, 2018, investigation.
  • July 27, 2018. During the eleven months of the July 27, 2018, ongoing CPS case, there were eight additional CPS complaints made against either K or C involving their care of V. These complaints involved allegations of substance abuse, homelessness, and improper supervision. Of the eight complaints made, two were assigned for investigation while the other six were rejected. MiSACWIS shows that the six complaints were rejected since they could be addressed by the CPS worker assigned to the July 27, 2018, ongoing case. No abuse or neglect was found in the two complaints that were investigated.
  • July 27, 2018. During the ongoing CPS investigation, V was in an unstable environment because she was moved around between K, C, and other people’s care. These other people were relatives and others who K and C met through their service providers. One of these individuals was MH. At one point during this timeframe, V was cared for by relatives in a POA.

  The OCO’s focus for this investigation stems from a complaint made to CPS on July 24, 2019. The complaint filed with Centralized Intake stated that the home K and C were living in was a drug house and both parents injected methamphetamine and Suboxone in front of V who was 14 months old at the time. The complaint states that needles were left out where V could access them while K and C slept for extended periods of time, ignoring V when she cried. The complainant also informed CPS that C purposefully poked V in the neck with a needle and was planning to blame K so she would be in trouble. Additionally, the complainant stated there was no running water in the home. CPS found a preponderance of evidence existed that K and C improperly supervised, physically neglected, and placed V in a situation of threatened harm. The threatened harm preponderance was a result of K and C continually exposing V to instability when they removed V from safety plans and POAs. The case was identified as a Category II and an ongoing case was opened for monitoring and services. Another POA was used to place V with MH.

  When the July 24, 2019 ongoing case was opened, V was in a POA with M, while her parents were in inpatient substance abuse treatment. Records indicate that C left his program early and retrieved V from M on September 6, 2019. On September 12, 2019, CPS found C, K, and V at an apartment. C and K appeared to be under the influence and had been involved in a recent domestic violence altercation. CPS convinced K and C to agree to place V back in a POA with MH while they received help through services. A safety plan was developed with K. She agreed to leave V in the care of M. K agreed that if the safety plan is not followed, then CPS will file a petition to remove V from her care. She also agreed to supervised visits with V.

  K and C located housing and employment in Houghton County, Michigan, in October 2019. They agreed to participate in drug screens and co-occurring mental health and substance abuse counseling. A CPS courtesy worker from Houghton County was assigned to their case with Marquette County still having primary responsibility.
  
  K completed a substance abuse assessment on October 21, 2019, and was diagnosed with severe opioid, amphetamine, alcohol, cocaine, and cannabis use disorders. Due to her diagnosis, the service provider recommended K complete bi-weekly/monthly individual therapy sessions and weekly group sessions. The provider also recommended she address her legal and mental health concerns. C also completed a substance abuse assessment and was diagnosed with severe opiate, methamphetamine, and alcohol use disorder and mild cannabis use disorder. The provider also recommended he complete bi-weekly outpatient substance abuse therapy.

  K and C partially participated in treatment; they would attend some appointments and not others. They were still testing positive for THC, which their treatment provider informed them they should stop using. K also tested positive for Dextrorphanol, and both K and C tested positive for Kratom. K was no longer employed, and they were considering a potential move. K was eventually discharged from treatment for missed appointments.

  In May 2020, C and K wanted V back from M. CPS responded to this by developing a safety plan for this to occur gradually over time. However, K and C were not in favor of this plan and wanted V to return to them right away. Out of concern for the welfare of V, and CPS’ response to the situation, M filed for guardianship.

  On November 30, 2020, during the open services case, a complaint was made to Centralized Intake stating on November 28, 2020, C and K had a visit with V and there was concern they were using marijuana while V was in their presence. Their vehicle smelled strongly of marijuana, but it was unknown if K and C were under the influence. After the visit, V was coughing intermittently for an hour.

  Due to the parents refusing to agree to a limited guardianship, a trial was held on the guardianship petition. On March 29, 2021, a decision was rendered by a judge ordering M to serve as temporary guardian of V while a transition back to the parents occur. The transition was to include all the parties participating in mediation to work on issues of increased parenting time. In the meantime, parenting time was to occur every other weekend. The guardianship was to be reviewed on June 2, 2021. The parents chose not to participate in the court-ordered mediation. As a result, the parenting time order consisted of overnights every other weekend. There were some video visits that took place.

  K and C found a new home and moved in February 2021. They continued to work intermittently. They also continued to participate in counseling and substance use services, which they reported they planned to continue with once the CPS case closed. The July 24, 2019, ongoing case closed on April 10, 2021, based on the granting of the temporary guardianship and the parents’ compliance with services.

  • 2019
    • June 25, 2019. By the time the July 27, 2018, ongoing case was closed on June 25, 2019, V was under the care and supervision of her father, C. C, however, had been using MH and others to care for V for extended periods of time. The CPS Updated Service Plan stated that the July 27, 2018, ongoing case was closed because V had been with C for six months without a POA and no concerns were expressed by anyone. CPS found that C participated in services and closed the case on July 27, 2018.
    • July 2019. Within a month of the July 27, 2018, ongoing case closing, three additional CPS complaints were made (July 2, 9, and 24, 2019) against K , C , or both. These complaints alleged that C and K were back together using substances and, consequently, were not adequately caring for V. The  allegations said they did not have stable housing, were not attending to V’s needs, were using drugs in front of V, and were leaving drugs and drug paraphernalia within V ’s reach. The July 2 and 24, 2019, complaints were assigned for investigation and the July 9, 2019, complaints were rejected for investigation. The CPS investigations on July 2, 2019, and July 24, 2019, found a preponderance that C and K neglected V. The July 2, 2019, investigation was closed on August 14, 2019.

Summary of OCO Investigation into DHHS Actions (K)

This investigation originated after a complaint was made to the OCO alleging the agency failed to file a timely petition to keep V safe after continued exposure to substance abuse, homelessness, and domestic violence. The OCO found that the parents’ failure to comply with appropriate services caused V to be unsafe in their custody. Instead of filing a petition for removal, the agency allowed K and C to create a temporary POA, placing V with MH in July 2019 and again in September 2019. While under the POA, K and C did not comply with CPS services and often did not want to increase the frequency of parenting time. In June 2020, K and C wanted to dissolve the POA because they wanted V back in their care. After K and C requested that M return V to their custody, M filed a petition for guardianship of the child, which after several months, was granted by the court.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
Use of Safety Plans or Power of Attorney in Lieu of a Petition for Removal During Marquette County’s involvement with each family, safety concerns involving these children increased in frequency and severity. Safety plans and guardianships were used by CPS in lieu of filing a petition to address the escalated abuse and neglect. CPS continued to use safety plans that the families failed to adhere to on multiple occasions. Regarding V, a POA was utilized as a safety plan. The child’s parent wanted to take V back and dissolve the POA. Concerned for V ’s safety due to her parents’ history of non-compliance with services, continued substance abuse, and domestic violence, the agent of the POA applied for full guardianship to prevent V from being returned to her parents.	Agree
Use of Safety Plans or Power of Attorney in Lieu of a Petition for Removal Failure of safety plans, a dissolution of a POA, and additional evidence obtained throughout the course of these investigations unequivocally show that the individuals responsible for the children in these investigations were abusive and/or neglectful towards them, and a petition for removal was required under MCL 722.628d(1)(e)(ii).	Agree
Use of Safety Plans or Power of Attorney in Lieu of a Petition for Removal After the OCO communicated with Marquette County DHHS management about concerns regarding the V case, a petition was filed by Marquette County DHHS which was subsequently granted by Marquette County Circuit court.	Agree
The Multidisciplinary Team Contrary to the Multidisciplinary Team (MDT) best practice model1, evidence in the OCO’s investigation highlights a substantial lack of communication and cooperation among the county’s child welfare partners including child protective services and law enforcement. Through its investigations, the OCO found that the relationship between Marquette County DHHS management and the law enforcement in Marquette County, was and continues to be strained. In interviews the OCO conducted, it was reported that law enforcement officers develop their own safety plans with relatives of children directly rather than calling allegations into Centralized Intake due to the breakdown of the MDT relationship. [1] MCL 722.627b(4); State of Michigan Governor’s Task Force on Child Abuse and Neglect: A Model Child Abuse and Neglect Protocol Utilizing a Multidisciplinary Team Approach, DHS-Pub-794.	Agree
Rejected Complaints During an Open Investigation or Ongoing Services Case Specific to the V family, the OCO found that between 2015 and 2021, there were twelve occasions new allegations were called into Centralized Intake during an open active abuse/neglect investigation or an open ongoing services case. The new allegations were rejected or accepted and linked to the current case. The allegations were only emailed to the current CPS or ongoing services specialist. In those twelve instances, the OCO did not find evidence that the CPS or ongoing specialists either reviewed or investigated the new allegations. By policy2, DHHS is not required to investigate rejected allegations, only accepted and linked allegations. In May of 2021, the central part of the OCO investigation, new allegations of severe physical abuse were called in to Centralized Intake by a medical practitioner. Due to the open CPS investigation, these allegations were accepted and assigned for investigation with a notice going to the CPS specialist assigned to the current investigation. The OCO found that in May of 2021 the CPS specialist did not promptly investigate these new allegations. It was only after the Children’s Ombudsman spoke to the reporting source in May of 2021, and informed Marquette County DHHS management, was a petition for removal filed for the V children. Specific to the K family, the OCO found that between 2018 and 2019 there were nine occasions new allegations were called into Centralized Intake during an open active abuse/neglect investigation or an open ongoing services case. The new allegations were rejected and emailed to the current CPS or ongoing services specialist. [2] PSM 711-2 - Reject the complaint. A decision is made not to investigate the complaint and the complaint is not appropriate for transfer to another agency. PSM 712-5 (Multiple Complaints) If there is already an assigned investigation or an open case, a copy of the rejected complaint must be forwarded to the assigned worker for his/her information and any necessary follow-up regarding the allegations. See PSM 712-8.	Agree
Rejected Complaints During an Open Investigation or Ongoing Services Case The OCO found the reject and email process allows a gap for an employee working with the family to do what the employee chooses with little oversight. The OCO found that when new allegations are rejected and emailed to the current CPS specialist there are instances where the new allegations are not addressed in the current investigation. The OCO found that regardless of whether new allegations were accepted or rejected, it was unclear if the current investigator or ongoing case services specialist addressed the new allegations.	Agree. Currently, Children’s Protective Services (CPS) specialists receive notification of rejected referrals through an automated email notification process and CPS policy provides detailed guidance for responding to “accept and link” referrals including requiring contact with the victims, identified perpetrators, and other relevant collateral contacts. However, MDHHS agrees to further review and assess the need for policy enhancements to ensure CPS clearly addresses, assesses, and documents rejected and transferred referrals. MDHHS will also explore enhanced technical solutions as they develop the new Comprehensive Child Welfare Information System (CCWIS) technology. Although the department has been working to improve this area through the strategies noted above, the department will continue to work to improve in this area.

Recommendations:

Recommendation	MDHHS Response to Recommendation
Regarding the use of safety plans or power of attorney in lieu of a petition for removal, the OCO recommends Marquette County DHHS adhere to MCL 722.628d in determining when to file a petition. Safety plans, temporary voluntary arrangements altering custody, powers of attorney, and guardianships, both limited and full, be used when appropriate, but not as a replacement for filing a petition.	Agree
Regarding the findings surrounding the multidisciplinary team, the OCO recommends that child welfare partners in Marquette County set a standing monthly or bi-monthly meeting to: Clarify local policies and procedures to determine the role and responsibilities of each child welfare partner regarding the use of formal and informal dispositions and identifying when formal proceedings should be used to achieve the goals of obtaining safe and timely permanency for children. Discuss case specific information with all child welfare partners. Develop partnerships and communicate openly and freely with each other regarding child welfare policy and work to agree on how each profession, including but not limited to, law enforcement, DHHS CPS/Foster care, the courts, medical professionals, mental health professionals, and child advocacy centers, will work together to keep children safe in Marquette County.	Agree. Marquette DHHS recognizes the importance of collaboration with law enforcement during joint investigations and acknowledges the lack of communication that currently exists between the local DHHS and law enforcement agencies. To improve collaboration efforts, Marquette administrators have established ongoing monthly meetings with local law enforcement and have offered training to all Marquette law enforcement, including the recruit school at Northern Michigan University, regarding the requirements of mandatory reporters, the code to bypass the Centralized Intake queue, as well as steps to report referrals electronically. The department will continue to work to improve in this area to increase communication and collaboration.
Regarding Rejected Complaints During an Open Investigation or Ongoing Services Case, the OCO found that the ability for Centralized Intake to reject or accept and link to the current case allows the new allegations to go uninvestigated. The OCO recommends that DHHS develop a new process to ensure case specialists are adequately investigating and addressing new allegations that come in during an open investigation or open services case.	Agree. CPS specialists receive notification of rejected referrals through an automated email notification process and CPS policy provides detailed guidance for responding to “accept and link” referrals including requiring contact with the victims, identified perpetrators, and other relevant collateral contacts. However, MDHHS agrees to further review and assess the need for policy enhancements to ensure CPS clearly addresses, assesses, and documents rejected and transferred referrals. MDHHS will also explore enhanced technical solutions as they develop the new CCWIS technology. The department will continue to work to improve in this area to ensure that case specialists are adequately investigating and addressing new allegations.

PDF Version of Report:  2020-0225 and 2021-0416

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
November 22, 2021	April 25, 2022	July 15, 2022	2021-0362

Summary of recommendations:

The OCO recommends strengthening Michigan’s relative placement practices by enhancing MDHHS oversight of contracted agencies, ensuring timely and lawful engagement with relatives, and holding providers accountable—including through options such as provisional licensing—when relatives are overlooked. The OCO further urges MDHHS to amend FOM 722‑03B to reinforce the importance of meeting deadlines and documentation requirements during the critical first 90 days after removal. Finally, the OCO recommends that the Legislature amend MCL 722.954a to require courts to determine, within that same 90‑day period, whether agencies made diligent and timely efforts to identify, notify, and consult with relatives interested in placement or contact.

Case Background:

On May 12, 2021, the Office of Children's Ombudsman (OCO) opened an investigation into the involvement of Spaulding for Children, Samaritas, and Wayne County Department of Health and Human Services (DHHS) - North Central District with Child One and Child Two.

The OCO reviewed confidential records and information in the Michigan Automated Child Welfare Information System (MiSACWIS), which includes but is not limited to service reports, medical records, social work contacts, and MDHHS forms pertaining to relative foster care placement. The OCO also spoke with personnel from the involved agencies.

Case Objective:

The objective of this review was to identify areas for improvement in the child welfare system, specifically why the department and its contracted entities did not fully consider known relatives for placement of Child One and Child Two. This report is not intended to place blame, but to highlight areas of concern regarding the handling of this case and advocate for changes in the child welfare system on behalf of similarly situated children. 

Purpose and Scope: 

The purpose of this investigation was to ensure that the involved agencies complied with law and policy governing relative foster care placement of Child One and Child Two and to determine whether the children’s maternal grandmother was timely assessed for placement of her grandchildren. The OCO investigator reviewed case file documentation, interviewed personnel from each of the agencies involved in the case, and attempted to remedy identified policy violations. At the close of the OCO’s investigation, Child One and Child Two were placed with their maternal grandmother.

Family History: 

Mother and Father are the parents of Child One and Child Two. On February 25, 2021, a court authorized a petition concerning Child One and Child Two after a Children’s Protective Services (CPS) investigation determined that four-month-old Child Two had sustained multiple rib fractures. Medical officials reported that the explanation provided by the parents was inconsistent with the nature of the injuries. Child One and Child Two were removed from parental custody on February 25, 2021, and subsequently placed in two separate licensed foster homes through two different child placing agencies, Spaulding for Children and Samaritas. Meanwhile, a criminal investigation into what happened to Child Two was ongoing.

On February 19, 2021, Child One and Child Two’s maternal grandmother requested emergency placement of the children from the Wayne County DHHS CPS worker, but this request was denied. According to the investigating detective, medical officials concluded that Child Two’s injuries were seven to ten days old. Case file documentation and statements by the CPS worker showed that the maternal grandmother had cared for the children periodically for three months prior to the discovery of Child Two’s injuries, and therefore had not been ruled out as a perpetrator of child abuse. However, on March 26, 2021, Wayne County DHHS concluded its investigation and substantiated Child Two’s parents for child abuse and neglect. CPS did not substantiate the children’s maternal grandmother. The criminal investigation remained ongoing.

Despite being found not responsible for the injuries to Child Two, Child Two and Child One’s maternal grandmother was not assessed for placement. To better understand this, the OCO conducted interviews with all parties involved. These interviews confirmed that Child Two and Child One’s maternal grandmother notified CPS, early in the case, that she wanted placement of both grandchildren. This was further confirmed through multiple emails the OCO obtained. 

Additionally, where a relative is seeking placement in a case such as this, specific forms, namely the DHS-987, DHS-990, and potentially a DHS-3130-A are required to be uploaded to MiSACWIS. However, these forms were not found in MiSACWIS. During the course of the OCO’s investigation, the OCO obtained evidence to support that maternal grandmother made it known to all agencies involved that she wished to be assessed for relative placement. Despite this, there was no home study conducted, and no DHS-3130-A form provided. The OCO found during its investigation, that the maternal grandmother was not assessed because CPS verbally informed the foster care agencies not to place the children with the maternal grandmother.

After several months of contact with the foster care agency and 34 days after the CPS investigation was closed, Spaulding for Children began an assessment of the maternal grandmother’s home on April 29, 2021. Spaulding for Children employees told the OCO that the agency delayed assessing the maternal grandmother for placement because they believed CPS was still investigating the maternal grandmother’s possible involvement in Child Two’s injuries. Spaulding for Children approved her home for placement on June 10, 2021. 

Child One’s and Child Two’s foster care agencies notified the children’s foster parents of the agencies’ intent to re-place the children. There is no record of Child One’s foster parent appealing her planned re-placement to the Foster Care Review Board (FCRB). Child One was placed with her maternal grandmother on June 30, 2021. Child Two’s foster parent appealed her planned re-placement to the FCRB, which issued a decision disagreeing with the proposed re-placement on July 13, 2021. Because Child Two’s foster care agency and the FCRB disagreed, the court was required to resolve the dispute. On July 28, 2021, the court found that it was in Child Two’s best interest to be placed with her maternal grandmother. Child Two was placed in the maternal grandmother’s home on August 6, 2021.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The OCO finds that MCL 722.954a(5) requires a child's foster care supervising agency to "give special consideration and preference to a child's relative or relatives who are willing to care for the child, are fit to do so, and would meet the child's developmental, emotional, and physical needs." This preference applies only during the first 90 days following a child's removal from parental custody. In re COH, 495 Mich 184 (2014). The OCO also finds that because of the limited time period in which the "relative preference" applies, agency adherence to policy deadlines is crucial to implementing the statutory preference for relative placement.
Primary Agency of Focus: Spaulding for Children Secondary Agency of Focus: Wayne County DHHS - North Central The OCO uncovered evidence showing that each individual involved with placement decisions and assessments did not know that after 90 days of placement into a foster care family, if a replacement decision is made (even into a relative home), the unrelated foster family has the ability to appeal any replacement decision to the Foster Care Review Board. Spaulding for Children was required to assess the relatives but was not aware that after 90 days of placement with the original foster family, the original foster family then has the ability to request a review from the Foster Care Review Board.
Primary Agency of Focus: Wayne County DHHS - North Central The OCO finds during the February 12, 2021, CPS investigation, the CPS worker did not complete and send the DHS-990 to Child One and Child Two's maternal grandmother, who expressed interest in placement. FOM 722-03B requires CPS and foster care workers to use forms DHS-987, DHS-990, and DHS-991 to identify, notify, and receive responses from relatives.
Primary Agency of Focus: Spaulding for Children Secondary Agency of Focus: Samaritas, Wayne County DHHS - North Central The OCO finds that Spaulding for Children did not comply with provisions of FOM 722-03B pertaining to timely completion of the DHS-5770 Relative Placement Safety Screen and DHS-3130-A Relative Placement Home Study when evaluating Child One and Child Two's placement with their maternal grandmother. Because Wayne County DHHS - North Central District did not send the maternal grandmother a DHS-990 form, she was unable to provide a more timely written request for placement of the children. However, she provided Spaulding for Children her own written request for placement on April 21, 2021. FOM 722-03B, Relative Engagement and Placement, p. 5 requires an agency to complete a DHS-5770 "within five business days of the relative's written request for placement consideration." Spaulding for Children completed a DHS-5770 on the children's maternal grandmother on May 25, 2021, 34 days later. FOM 722-03B, Relative Engagement and Placement, p. 15 requires an agency to complete a DHS-3130-A "within 30 calendar days of the written request." Spaulding for Children completed its home study on the maternal grandmother on June 30, 2021, 70 days after the written request.
Primary Agency of Focus: All Agencies Involved The OCO finds that turnover of employees created multiple resets in this case. It took time to bring each new foster care worker and supervisor up to speed. The lack of congruent employees to work this foster care case contributed to the delays in assessing relatives for placement, thus allowing 90 days to be exceeded.

Recommendations:

Recommendation	MDHHS Response to Recommendation
Primary Agency of Focus: Michigan Legislature The OCO recommends the Michigan Legislature amend MCL 722.954a to require a court to determine within 90 days of a child’s removal from parental custody whether the supervising agency made diligent and timely efforts to identify, locate, notify, and consult with relatives interested in placement of or contact with a relative child.	MDHHS Response to Recommendation: MDHHS agrees with and supports this requirement. Additionally, MDHHS policy requires ongoing searches for relatives interested in possible placement of their relative child beyond the 90-day timeframe.
Primary Agency of Focus: Children's Services Administration The OCO recommends that MDHHS Children's Services Agency amend FOM 722-03B to emphasize that adherence to deadlines and documentation requirements are crucial to fully implementing the preference for relative foster care placement in effect during the 90 days following removal of a child from parental custody.	MDHHS Response to Recommendation: MDHHS will update FOM 722-03B, Relative Engagement and Placement Policy, to include a note under “Diligent Search and Notification Process” that emphasizes adherence to deadlines documentation requirements are crucial to fully implementing the preference for relative foster care placement in effect during the 90 days following removal of child from parental custody.
Primary Agency of Focus: Children's Services Administration The OCO recommends that MDHHS Children's Services Agency develop an internal review, oversight, or quality assurance mechanism regarding contracted entities’ compliance with law and policy on relative placement processes. Timely adherence to law and policy regarding relative placement is in the best interest of the child, and to that end, achieving greater compliance is necessary. Furthermore, the OCO strongly recommends that MDHHS finds meaningful ways, including provisional licensing, to hold these contracted agencies accountable when relatives are routinely ignored when seeking placement of children.	MDHHS Response to Recommendation: The Children’s Services Agency (CSA) recognizes the importance of implementing internal review, oversight, and quality assurance mechanisms for contracted agencies compliance with law and policy in all areas including relative placement processes. Currently, the Division of Child Welfare Licensing (DCWL) audits for compliance with Rule 400.12404 Placement and 400.12404 Change of Placement, specific to relative placement. The rules require that agencies consistently consider relatives for placement and replacement. They also audit for compliance with policy FOM 722 03B, Relative Placement and Engagement. Policy is more specific about timeframes and the specific requirement needed to fully engage relatives. Provisional license recommendations are outlined in Act 116 as only being used for willful and substantial non-compliance with the act or rules. The Division of Child Welfare Licensing cannot make a license recommendation based on policy or contract violations. Additionally, CSA is beginning a new quality improvement process called Sustaining Performance Improvement (SPI). SPI will improve outcomes for children and families by bringing CSA and agency leaders together regularly to review key data trends, identify and problem solve challenges before they magnify, and strengthen partnerships through improved communication, transparency, and collaboration.

PDF Version of Report:  Case No. 2021-0362

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
November 3, 2021	January 18, 2022	February 16, 2022	2021-0108

Summary of recommendations:

This case highlights the need for Children’s Protective Services, law enforcement, and the courts in Mason and Manistee counties to revisit and align their protocols with Michigan law governing emergency child removals. Because law enforcement’s authority and responsibilities differ from those of CPS, these partners should jointly review those distinctions, along with the courts’ obligations under MCR 3.963, and update local practices accordingly. The OCO recommends that all three entities come together to examine this case in the context of governing law, policy, and procedure, and further recommends that the MDHHS Children’s Services Agency review the matter and consider issuing statewide guidance on county responsibilities when law enforcement removes a child from parental custody.

Case Background:

On February 11, 2021, the Office of Children's Ombudsman (OCO) opened an investigation into the involvement of Mason County Department of Health and Human Services (DHHS) with The Child.

The OCO reviewed confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), which includes but is not limited to service reports, medical records, social work contacts, police reports, and court orders. The OCO interviewed family members, department personnel, and law enforcement personnel.

Case Objective:

The objective of this review was to identify areas for improvement in the child welfare system. By looking at how this family’s case was handled by Mason County DHHS, and the involvement of staff, court personnel, physicians and law enforcement, this review reinforces the safety and well-being of a child is the shared responsibility of the family, community, and both law enforcement and medical personnel aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of this case and advocate for changes in the child welfare system on behalf of similarly situated children.

Family History: 

Two-year-old Child is the daughter of Mother and the legal daughter of Father. Mother and Father are divorced, and it is alleged that The Child’s biological father is a man her mother met while she was a counselor at a substance abuse program.
 
The Child has been the subject of three Children's Protective Services (CPS) investigations since April 2020, all involving her use of controlled substances. The first investigation was closed as a category IV and the second closed as a category III open/close. The third investigation, which is the focus of this OCO investigation, was initiated in January 2021 and closed as a category II.

Purpose, Scope, and Summary of Investigation:

This case was brought to the attention of the OCO due to concerns for The Child’s safety. The OCO's investigation focused on a January 27, 2021 CPS investigation to determine whether the involved agencies followed law and policy governing emergency removal of children from parental custody.

On January 27, 2021, CPS centralized intake received allegations that Mother and the Child were asked to leave a recovery home in Charlevoix County because drug paraphernalia was found in their room and they left the home but their location was unknown. On February 3, 2021 family members informed Charlevoix County CPS that they were at a relative’s home in Manistee County. The CPS investigation was transferred to the Mason County DHHS office.¹ 

Mason County CPS made contact with Mother and Child and family members. Family members reported that they were going on vacation and had installed hidden cameras in the home. On February 9, 2021, a family member reported to Mason County CPS that Mother was observed on camera "smoking substances" in the Child’s presence. Mason County CPS advised the family member to ask law enforcement to verify the Child’s well-being.

A Michigan State Police (MSP) trooper visited the home and informed a Mason County CPS worker that Mother appeared to be under the influence of drugs, and he found evidence of drug use in the home. The trooper told the CPS worker he had taken the Child into protective custody and asked the worker to assume custody of the Child. Mason County CPS responded that CPS could not take custody of a child without a court order, which must be obtained through a petition. The Mason County CPS worker told the OCO that he advised the MSP trooper that he would contact the Manistee County prosecutor's office to discuss filing a petition. The MSP trooper then contacted the Child’s legal father, who assumed custody of the Child.

The following day, Mason County CPS and a Manistee County assistant prosecuting attorney concluded that no petition would be filed because Child was safe with her legal father, and because DHHS policy states that parental drug use alone does not constitute child abuse or neglect.

The Mother and Child were subsequently located at a relative’s home in Chippewa County. Mother admitted to a CPS worker that she was under the influence of heroin when the MSP trooper took protective custody of Child. Mason County CPS substantiated Mother for improperly supervising Child and opened a services case. The Chippewa County relative later obtained guardianship of Child and Mother sought substance abuse treatment.

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_{[1] Due to a conflict of interest within Manistee County DHHS, the investigation was transferred to Mason County DHHS.}

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Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding

MDHHS Response to Finding

Primary Agency of Focus: Mason County DHHS The OCO finds that Mason County CPS did not take the necessary action of contacting the designated judge or referee, as required by policy and law, to obtain a court order after being told by an MSP trooper that Child was being taken into protective custody. It may be argued that Child was released to her legal father by the trooper through the help of Mason County CPS, but this occurred after the agency told the trooper they could not come and pick Child up.

Notice to DHHS under MCL 712A.14(a)(1) is not a mandate to MDHHS to take or seek custody of the child. Additionally, there is no legal mandate for MDHHS to notify the court under MCL 712A.14(a)(2) when law enforcement has custody of the child and MDHHS only has notice of that custodial situation. MCL 712A.14(a)(2) applies only when a decision has been made that the child cannot be safely released to a parent, guardian, or legal custodian. In this case, after initial contact with Child Protective Services (CPS), the trooper and CPS contacted the legal father and law enforcement released the child to him less than an hour later.

Recommendations:

Recommendation

MDHHS Response to Recommendation

Primary Agency of Focus: Mason County DHHS Secondary Agency of Focus: Children's Services Agency This case presents an opportunity for the three key child welfare partners, Children’s Protective Services, law enforcement, and the courts in Mason and Manistee counties, to revise their protocols to align with Michigan law governing emergency removal of children from parental custody. Law enforcement’s role differs from CPS’ role in these situations. Child welfare partners in Mason and Manistee counties should discuss those differences. The courts in these jurisdictions play a critical role as well, and the parties may wish to review Michigan Court Rule (MCR) 3.963 and revise their protocols consistent with that court rule. Thus, the OCO recommends that these partners come together to review this case and discuss it in the context of guiding law, policies, and protocols. The OCO also recommends that MDHHS Children’s Services Agency review this case and consider providing guidance to all county offices on their legal responsibilities after a law enforcement officer has removed a child from parental custody.

Mason County administration has reached out to their local partners to discuss the situation to determine how law enforcement and the local office can better partner. Although MDHHS believes the county acted appropriately, we recognize practices regarding partnering with local law enforcement may vary and the department will review the case to identify if any statewide communication is necessary

PDF Version of Report:  Case No. 2021-0108

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
September 21, 2021	November 24, 2021	January 11, 2022	2020-0044

Summary of recommendations:

The OCO recommends that MDHHS strengthen CPS policy and practice when a caregiver’s mental health condition may place a child at risk. This includes amending PSM 713‑08 to establish clear guidance for responding to these situations, such as expedited collateral contacts with mental health providers, flexibility in investigation timelines to obtain records, and the use of structured assessment tools to evaluate a caregiver’s ability to meet a child’s needs. Additional recommendations include requiring CPS to obtain and review all relevant mental health records, providing access to databases that identify involuntary hospitalizations, and ensuring automatic referrals to preventative services regardless of case disposition. The OCO believes these enhancements would give CPS workers clearer direction and improve consistency and safety in cases involving caregiver mental health concerns.

The OCO further recommends expanding training and statutory requirements to support this work. MDHHS should incorporate comprehensive mental‑health‑focused training for all new and ongoing child welfare staff, emphasizing symptoms, treatment options, and how caregiver mental illness can affect child safety. The OCO also urges the Legislature to amend MCL 330.1748a to require mental health records be released to CPS within seven days, and to amend MCL 722.629 to require recurring mandated‑reporter training. Finally, the OCO recommends statewide training for CPS and mental health professionals on the legal requirements governing the release of mental health records during abuse and neglect investigations, ensuring consistent understanding and compliance across systems.

Case Background:

The Child died on June 28, 2020. Pursuant to MCL 722.627k, the Michigan Department of Health and Human Services (MDHHS) notified the Office of Children's Ombudsman (OCO) of the child fatality. On July 9, 2020, and pursuant to its statutory duties, the OCO opened an investigation into the handling of this matter by Kent County DHHS.

The OCO reviewed confidential records and information in the Michigan, Statewide Automated Child Welfare Information System (MiSACWIS), which includes but is not limited to: Children's Protective Services (CPS) complaints and investigation reports, court documents, police reports, and mental health records. The OCO also interviewed DHHS staff, mental health providers, and a reporting source.

Case Objective:

The objective of this review was to identify areas for improvement in the child welfare system. By looking at how this family's case was handled by Kent County DHHS, and the involvement of staff, court personnel, physicians and law enforcement, this review reinforces the safety and well-being of a child is the shared responsibility of the family, community, and both law enforcement and medical personnel aiding children and families. This report is not intended to place blame, but to highlight areas of concern regarding the handling of this case and advocate for changes in the child welfare system on behalf of similarly situated children.

Purpose, Scope & Summary of the investigation:

The Mother and her family came to the attention of the OCO after she murdered her son and then committed suicide on June 28, 2020. Prior to her son’s death, Mother had one investigated CPS complaint within the 24 months preceding death, and an open CPS investigation at the time of their deaths. Based on this and pursuant to MCL 722.926(2)(a), the OCO opened a full investigation in accordance with our statutory responsibilities on July 9, 2020.

Family History: 

According to mental health records gathered from -- mental health provider, Network 180, -had a history of receiving counseling services prior to October 2019. Network 180's records do not reflect when she sought counseling services or what they entailed. In October 2019, Mother self-reported to a Licensed Master of Social Work (LMSW) at Network 180, that she began to experience higher than normal levels of anxiety, began having sleep problems, disruptive ruminations, and frequent panic attacks. Consequently, and at the advice of her father and boyfriend, she sought out mental health services through Network 180 on October 23, 2019.

Mother had her initial assessment on November 5, 2019. Her symptoms were identified in those records as obsessing, depression, anxiety, panic attacks and some delusions and paranoia. She was also making quasi-suicidal and fatalistic statements. The OCO found no specific details about the actual statements made by Mother. She agreed to a psychiatric evaluation for a medication assessment and accepted a referral for outpatient therapy in a crisis intervention program. She completed the psychiatric evaluation on November 6, 2019. She was diagnosed with major depressive disorder with anxiety and prescribed Abilify and Ativan.

Mother’s mental health records indicate she never took her medication as prescribed. She took the Ativan more often than the Abilify. When she did take the Abilify she only took half of the prescribed dose. To achieve more symptom relief, her psychiatrist added Zoloft to her medication regimen. Mother never took the Zoloft. She commonly expressed opposition to being dependent on medication.

Mother completed the crisis intervention program in December 2019. She continued to be seen by the psychiatrist there after this, but her condition was reported to continue to deteriorate. By January 13, 2020, she had stopped taking the Abilify and was beginning to express suicidal ideations. She, however, did not make any suicide attempts because she expressed concern about who would take care of her son if she were gone.

By January 21, 2020, Mother’s condition deteriorated to such an extent that the mental health professionals treating her wanted her to enter a partial hospitalization program. Ultimately, she refused even though two such programs had been identified for her. She did, however, continue to see her psychiatrist for her medication reviews, although she was still not complying with her medication regimen.

There is documentation in Mother’s records that on February 11, 2020. Her mother contacted the community mental health facility that had been seeing Mother. Her mother told the facility that she had expressed suicidal thoughts to her, and that she said she was “taking her 10 year old son with her”. It is also documented in the records that her mother contact CPS for advice about her comments but did not make a formal report to CPS. The facility records do not specify who her mother called at CPS or what she told them. There is no record of her mother’s call to CPS in the MDHHS internal database, MiSACWIS. 

At this point in time Mother’s mental health records indicate there is no contact between her, the facility, or any other mental health provider again untli April 11, 2020. Mother failed to enroll in the facility crisis intervention program on April 11, 2020. On April 12, 2020, Mother attempted suicide by overdosing on pills. Mother’s boyfriend at the time intervened, and Mother was unsuccessful in this suicide attempt. On April 13, 2020, her father was with her when she stated that she was going to kill her son and then kill herself. During this incident Mother attempted to cut her wrists with keys and attempted to jump in front of moving traffic and then eventually from a moving vehicle. None of these suicide attempts were successful. 

After these failed suicide attempts, Mother was admitted to Forest View Hospital on April 13, 2020. This occurred after her father and the Network 180 psychiatrist petitioned the court for involuntary hospitalization. The petition led to Mother accepting a deferral to the court hearing for her involuntary hospitalization. The deferral would last so long as she complied with treatment. 

Because of the deferral of her hearing, Mother was at Forest View Hospital from April 13, 2020, to April 21, 2020. During her stay, on April 15, 2020, the first CPS complaint was made against Mother for the things she said to her father about killing herself and Child. It should be noted that the case manager at Forest View did not receive the suicidal statements directly from Mother and only knew of them because Mother’s father told the case manager. 

Mother’s discharge from Forest View on April 21, 2020 occurred because she had a dental appointment. Forest View originally planned to allow her to go to the dentist appointment and then she was supposed to return but this did not happen. While she was at the dental appointment, she was told by Forest View that if she wanted to come back to inpatient she would have to go through the intake screening process again at the previous facility.

At first, Mother attempted to do this but by the time she had completed the intake process she had changed her mind about hospitalization and left. The facility responded by completing a demand for hearing and notified the police to pick her up.

Mother was never picked up by the police and eventually showed up for an intake screening at Hope Network on April 27, 2020. This occurred because her boyfriend discovered Mother researching ways to commit suicide on the internet. On this date, she entered Hope Network’s Pivot Crisis Residential program. The Pivot Crisis Residential program is noted to be an alternative service to in patient hospitalization for an individual in a mental health crisis. Hope Network’s records indicate Mother was released from this program on May 1, 2020.

On May 4, 2020, CPS closed the April 15, 2020, investigation as a Category IV with a finding of no preponderance of evidence because Mother was actively receiving mental health care and Child was in the care of Mother’s father. 

Police reports indicate that on May 11, 2020, police did a welfare check on Mother because she was expressing suicidal ideations. On May 12, 2020, Mother’s father and her boyfriend went to Metro Health Hospital Emergency Department because of her suicidal ideations. According to the records, Metro Health Hospital petitioned the court for hospitalization since Mother was not being truthful about her mental health history or suicidal attempts. 

Due to the petition filed by Metro Health Hospital, Mother was involuntarily admitted to Forest Pine on May 12, 2020. During her stay there, she denied having a child, suicidal or homicidal ideations, intent or plans of suicide and minimized her symptoms. Her status was, moved to voluntary due to her willingness to cooperate with treatment. At this point, Mother’s medications were adjusted, and she was taken off Zoloft and placed on Cymbalta. She refused to allow anyone to contact her father without her present. She was to continue services through Hope Network upon discharge. Mother returned to Pine Forest Urgent Care via telehealth on June 17, 2020, due to concern over how her Cymbalta was making her feel. The decision was made during this meeting to keep her medication where it was even though Mother wanted to discontinue its use. Mother was discharged on May 15, 2020.

According to a police report dated June 21, 2020, Mother told her friend and neighbor, that she had been researching ways to kill her son and herself, her neighbor called the police, and Mother was taken to St. Mary's hospital because of this and her “history of suicidal threats and metal [sic] [mental] pick up orders .... " After evaluation of Mother, St. Mary's allowed her to leave because she denied ever making suicidal or homicidal comments about herself or her son to St. Mary's.

A second CPS complaint was made on June 22, 2020, alleging again that Mother was sa in she was oing to kill herself and her son. CPS made face-to-face contact with Mother, her father, and Child, and they all denied the allegations. CPS also concluded that since Mother was not hospitalized from the recent incident, she must not be a threat to herself or anyone else.

During the weekend of June 26, 2020, Mother and Child went on a vacation to Mackinaw City with her boyfriend and his two daughters. When her boyfriend was checking out of the hotel on June 28, 2020, Mother and Child went on a walk. They never returned from the walk. The boyfriend looked for them and found them both dead in a storage shed in an apparent murder-suicide by Mother. Records indicate Mother used her boyfriend’s gun to shoot Child and herself in the forehead.

Mother and Child’s deaths were reported to CPS Centralized Intake on July 7, 2020 by the CPS worker assigned to the case, which was still an open CPS investigation. As you will read below, the June 22, 2020 CPS investigation was concluded on July 30, 2020 with a finding  of no preponderance of evidence. CPS stated the reason for the no preponderance of evidence finding was because Mother was deceased, and she had no surviving children.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
Primary Agency of Focus: Forest View Hospital MCL 330.1748a, MCL 333.2640, and MCL 333.16281 grant mental health professionals the legal authority and obligation to share their records with CPS during an investigation of suspected child abuse or neglect, even without the consent of a client. Despite this, CPS was denied access to mental health records pertaining to Mother by Forest View Hospital during the April 15, 2020 CPS investigation because Mother refused to sign a release of information
Primary Agency of Focus: Kent County DHHS MCL 330.1748a, MCL 333.2640, MCL 333.16281 and form DHHS 1163-P, grant CPS the authority to obtain a client's mental health records without their consent. Kent County CPS did not utilize these laws, policies, or the relevant form to obtain Mother’s mental health records after they were denied access by Forest View Hospital during the April 15, 2020 CPS investigation.
Primary Agency of Focus: Kent County DHHS Secondary Agency: Children’s Services Administration The OCO finds that for the better protection of children at risk of harm, CPS must secure mental health records in a timely manner and be given adequate time to review these records thoroughly and accurately. The OCO determined that Mother sought services from at least seven different providers within the six months preceding her and Child’s deaths. The combined records exceeded 500 pages in length and took the OCO two to twenty-eight days to obtain.
Primary Agency of Focus: Children’s Services Administration The OCO finds that current CPS policy is limited when providing instruction to CPS workers on what to do when allegations are received that a caregiver's mental health is placing a child in harm's way. Policy is limited to discussing the need to make collateral contacts with mental health professionals if needed, what constitutes threatened harm, how to request mental health records, and about the possibility of getting a psychiatric and/or psychological evaluation of a caregiver. CPS policy does not offer concrete ways to address a caregiver's mental health and its effects on a child’s safety. Such clarification exists in policy when it comes to other similar situations like domestic violence, substance abuse, child deaths, and when a child is found home alone.
Primary Agency of Focus: Kent County DHHS The OCO finds, given the facts and circumstances obtained by CPS, death could not be prevented through CPS action. This case illustrates the need for policy and law enhancement as outlined in the OCO’s recommendations to make similar deaths less likely in the future.

Recommendations:

Recommendation	MDHHS Response to Recommendation
Primary Agency of Focus: Michigan Legislature The OCO recommends that the Michigan Legislature amend the Child Protection Law, MCL 722.629, so that it requires all mandated reporters receive training in child abuse and neglect detection and mandated reporting obligations on a regularly reoccurring basis as determined by the legislature.	MDHHS supports this recommendation to the legislature and is pursuing a contract to review the existing mandated reporter training curriculum and develop new and enhanced materials with a specific focus on addressing implicit bias and disproportionality. Should the Legislature support this recommendation, MDHHS may need additional funding to ensure all mandated reporters receive the updated curriculum on a regular and reoccurring basis.
Primary Agency of Focus: Children’s Services Administration The OCO recommends that MDHHS Children’s Services Administration develop and implement a new training to be offered to all CPS staff and mental health workers statewide. This training should help ensure compliance with MCL 330.1748a, MCL 333.2640, and MCL 333.16281 regarding the sharing of clients’ mental health records during an investigation of suspected child abuse or neglect, even without the client’s consent. This training should focus on when these laws and policies are applicable, how to utilize and comply with their requirements, and what to do if CPS experiences resistance from mental health care providers.	Though MDHHS does not have the capacity or mechanism to train all mental health professionals statewide, it does agree that providing information regarding the legal obligation of sharing mental health records during a CPS investigation is vital to assessing child safety. As such, the Child Welfare Medical and Behavioral Health (CWMBH) division within the Children’s Services Agency (CSA) will develop a new webpage on the public MDHHS website which will include information on policy and procedure regarding the sharing of mental health records during a CPS investigation. CPS staff, mental health providers, and anyone in the public that has questions about the sharing of mental health information will be able to access the webpage. Additionally, CWMBH will work with the Behavioral Health and Developmental Disabilities Administration to ensure the webpage and information is shared with local community mental health partners.
Primary Agency of Focus: Michigan Legislature Currently, the Michigan Mental Health Code, MCL 330.1748a. states that mental health providers shall release pertinent mental health records to CPS workers involved in an investigation within 14 days after receipt of the request for such records. Given that these records are sometimes voluminous and the standard of promptness for completing a CPS investigation is 30 calendar days, the OCO recommends that the Michigan Legislature amend the Mental Health Code, MCL 330.1748a, so pertinent mental health records are turned over to CPS within 7 calendar days of the request for such records.	MDHHS supports the recommendation requiring release of mental health records to CPS within 7 calendar days of the request.
Primary Agency of Focus: Children’s Services Administration The OCO recommends that MDHHS incorporate into their training of new and ongoing child welfare staff a portion dedicated to mental health and illness of clients. This aspect of training should focus on understanding the types, causes, and symptoms of mental illness, what treatment modalities are available to care for such individuals, and the impact a caregiver’s mental illness can have on the child(ren) in their care. In doing so, an emphasis should be placed on the assessment and response to a client’s propensity to harm or neglect themselves or others, particularly the child(ren) the client is caring for. This training should occur for all new child welfare staff and be repeated on a regular basis, so workers are adequately prepared to assess and react to such situations should they arise in a case.	MDHHS agrees sound assessment of mental health factors is critical to assessing child safety and is currently working with multiple stakeholders to enhance its mental health training for child welfare staff. Current training for newly hired child welfare staff does include a mental health training module and the module can be updated to include policy and procedure enhancements as identified by Children’s Services Agency (CSA) and can be offered annually to staff. MDHHS, along with a consortium of 16 Michigan universities, is updating the core competencies college students must learn to earn a child welfare certificate. The updated competencies include recognizing and assessing developmental delay and disability, understanding the characteristics, behavioral indicators, and preferred treatments for mood disorders, trauma and post-traumatic stress disorder, emotional disturbances, as well as how parental mental illness can affect parenting, and when/how to make a referral for additional mental health assessment. Additionally, CSA in partnership with the Office of Workforce Development and Training and the consortium of universities has begun a redesign of the Pre-Services Institute (PSI) for newly hired child welfare professionals in which mental health assessment is one of many areas to be updated. Input regarding the training redesign will involve numerous community partners including the Office of Children’s Ombudsman.
Primary Agency of Focus: Children’s Services Administration The OCO recommends that the MDHHS Children’s Services Administration consider amending the Children Protective Services Manual, PSM 713-08, Special Investigative Situations, to include a section that addresses how CPS should respond when a caregiver’s mental health condition is potentially placing a child in harm’s way. The Children’s Ombudsman recommends this section could include the following items: An expedited timeframe for when to make collateral contacts, such as with mental health providers. Instead of a discretionary timeframe for making collateral contacts as in PSM 713-01, this section could prescribe that such contacts be made within 24 to 48 hours of receipt of the complaint when the complaint alleges potential harm to a child due to a caregiver’s mental health issues. Allow for extensions of the 30-calendar day standard of promptness to obtain and review mental health records of the client. Provide an assessment tool or other way to assess a caregiver’s ability to continue to meet the needs of the child(ren) in their care. This could include questions like those in PSM 716-7, Decision Making for Cases Involving Substances, and include, but not be limited to, the following: Is there evidence to demonstrate difficulty regulating emotions or controlling anger? Does the caregiver’s mental health condition reduce their capacity to respond to the child(ren)’s cues and needs? Are there supports such as family and friends who can care for the child(ren) when the parents are not able to? Are the parents willing to use their supports when necessary? Is the caregiver taking their medications as prescribed? If not, does this present a possible harmful situation for the caregiver or others? Has the caregiver’s mental health condition caused substantial impairment of judgement or irrationality to the extent that the child(ren) was abused or neglected? A requirement to obtain and review all records from each mental health provider of the caregiver. Access to databases, such as the Judicial Data Warehouse (JDW), where CPS can check for any involuntary hospitalizations or commitments. An automatic referral to preventative services whether a preponderance of evidence is found or not. The OCO believes that policy addressing allegations that a caregiver’s mental health is placing a child in harm’s way could be expanded and enhanced to provide CPS workers with better guidance when handling such situations.	MDHHS reviewed current policy and determined that an allowance for an extension to request and review mental health records currently exists in policy and that current time frames regarding completing collateral contacts and collecting mental health records are sufficient. Additionally, after consultation between the In-Home Bureau, Policy Unit, and the CPS Advisory, MDHHS determined enhancements to mental health training, and the creation of a job aide/assessment tool would best address the issues highlighted in this case. The In-Home Bureau will develop the tool, and CSA will notify the OCO when completed.

PDF Version of Report:  Case No. 2020-0044

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
May 11, 2021	June 30, 2021	August 12, 2021	2020-0343

Summary of recommendations:

The OCO recommends that MDHHS strengthen firearm‑safety support for families by developing a statewide plan to identify, provide, or purchase secure‑storage devices, such as trigger locks and lock boxes, for CPS‑involved households. Local DHHS offices should be equipped to refer families to free community resources and have access to funds for purchasing and distributing safety devices when needed. The OCO further recommends that MDHHS work with its partners to determine which families may need gun‑safety assistance and create an accessible flyer or pamphlet, modeled on existing materials such as those from Mott Children’s Hospital, that CPS workers can share during Category III and IV contacts. This resource should explain safe‑storage practices, list available free devices, and outline how families can request financial support for obtaining secure‑storage tools.

Case Background:

The Child died on October 30, 2020. Pursuant to MCL 722.627k, the Michigan Department of Health and Human Services (MDHHS) notified the Office of Children’s Ombudsman (OCO) of the child fatality. On November 4, 2020, the OCO opened an investigation into the handling of this matter by Wayne County Department of Health and Human Services (DHHS) - North Central, pursuant to its statutory responsibilities.

The OCO reviewed confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS), which includes but is not limited to service reports, medical records, and social work contacts; conducted searches in the Judicial Data Warehouse and central registry; and reviewed MDHHS child death notifications received by the OCO between June 2020 and April 2021 involving children who died from gunshot wounds. The OCO also spoke with CPS personnel involved in three investigations concerning The Child’s family, completed in 2020, and interviewed the detective in charge of the homicide investigation.

Case Objective:

The objective of this review was to identify areas for improvement in the child welfare system. By looking at how this family’s case was handled by Wayne County DHHS - North Central, and the involvement of staff, court personnel, physicians and law enforcement, this review reinforces the principle that the safety and well-being of a child is the shared responsibility of the family, community, and both law enforcement and medical personnel aiding children and families. It is not intended to place blame, but to highlight areas of concern regarding the handling of this case and advocate for changes in the child welfare system on behalf of similarly situated children. 

Family History:  

Mother is the mother of The Child, Sibling One, Sibling Two, and Sibling Three. Father is The Child's father; Sibling One’s Father is Sibling One's father; Sibling Two’s Father is Sibling Two's father; and Sibling Three’s Father is Sibling Three's father. At the time of The Child's death, Mother and her four children resided together with Sibling Three’s Father. Sibling One’s Father and Sibling Two’s Father had sporadic contact with Sibling One and Sibling Two. The Child’s Father was incarcerated in Arizona during the 2020 investigations under review.

Mother was the subject of eight CPS investigations prior to The Child's death. Five of those investigations were placed in category IV, including a complaint alleging that Sibling Three was born positive for Tetrahydrocannabinol (THC, an active ingredient of marijuana) and morphine on September 28, 2020. Three investigations were placed in category III: a 2017 case involving domestic violence, a 2017 case involving a THC-positive newborn (Sibling Two), and a 2020 case involving improper supervision for leaving the children home alone.

Sibling Three’s Father was the subject of two prior investigations. A 2014 complaint involved domestic violence against a living-together-partner. According to case file documents, during this investigation, it was determined that Sibling Three’s Father hid firearms inside the home, which were discovered by a 12-year-old boy who resided in the home. This complaint was placed in category IV. A 2011 complaint alleged the unsafe sleep death of Sibling Three’s Father's son, was placed in category III.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
The OCO finds that between June 2020 and April 2021, the OCO received 11 child death notifications from MDHHS that a child had died because of a gunshot from an unsecured firearm within a home.

Recommendations:

Recommendation	MDHHS Response to Recommendation
Primary Agency of Focus: Children's Services Administration The OCO recommends that MDHHS develop a plan to provide free resources or for the department to purchase resources to help families secure firearm. For example, an MDHHS plan could task local DHHS offices with identifying sources of free trigger locks and lock boxes in their communities so that CPS clients may be referred to those sources. The OCO also recommends that MDHHS make funds available to local offices for purchase and distribution of such safety devices to CPS clients. The OCO also recommends MDHHS utilize its partners to develop the safest and most effective way MDHHS can determine which families are in need of gun-safety devices.	MDHHS agrees that workers should have access to information related to firearm safety and resources when opportunities to discuss the topic arise or for families who request such information. MDHHS reviewed the 10 cases referred to by the OCO where a child died because of a gunshot from an unsecured firearm within a home. Five of the 10 cases involved a youth who was shot after playing with an unsecured firearm found in the home. Four of the 10 cases involved a teenager who used a firearm to complete a suicide. One of the 10 cases involved a youth who was shot in public by an unknown person. As a result of this OCO recommendation and the review of the five cases which involved an unsecured firearm, MDHHS’s Children’s Services Agency (CSA) reached out to the MDHHS Department of Communications regarding the creation of a webpage workers and community members will have access to through the MDHHS website which will contain links to sites such as Mott’s Children’s Hospital and the University of Michigan’s Firearm Safety Among Children and Teens (FACTS), information related to firearm safety, how to access free safety devices such as trigger locks in each local community, suicide prevention resources, and useful instructional aids. CSA will continue to consult with our stakeholders to assist in the development of the webpage which should be available within 90 days. In 2019, CSA developed a robust plan to reduce child fatalities in the state of Michigan that result from abuse, neglect, or suicide and has worked with several internal and external stakeholders including the Injury and Violence Prevention Unit at MDHHS, the Michigan Public Health Institute, the Michigan Association for Suicide Prevention, and the Depression Center at the University of Michigan to enact the plan. Additionally, Michigan is in its third round of federal funding from the Garrett Lee Smith Memorial Act which provides seed money towards suicide prevention efforts and is one of five states that are participating members of Child Safe Forward, hosted by the Department of Justice and federal Office of Victims of Crime. Child Safe Forward is a national initiative to reduce child abuse and neglect fatalities and injuries through a collaborative, community-based approach.
Primary Agency of Focus: Children's Services Administration The OCO recommends that MDHHS develop a flyer or pamphlet addressing gun safety that CPS workers may distribute to clients as part of the community resource materials for category III and IV complaints. The flyer or pamphlet may be based on that distributed by Mott's Children's Hospital, available at https://healthblog.uofmhealth.org/childrens-health/keeping-kids-safe-from-gun-accidents-6-strategies-for-families. The flyer should identify free sources of trigger locks and gun safes, if available, and instruct clients on how to request funds for purchase of such safety devices.	MDHHS agrees with this OCO recommendation and is working with the Depression Center at the University of Michigan to develop an informational pamphlet which will be made available to child welfare staff either through the aforementioned webpage and/or by assigning it a QR code. The pamphlet will outline strategies for firearm safety, resources families can access in their local communities and should be available to staff within 90 days.

PDF Version of Report:  Case No. 2020-0343

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
January 26, 2021	June 15, 2021	July 19, 2021	2020-0045

Summary of recommendations:

The OCO recommends strengthening oversight, documentation, and timeliness in relative‑placement decision‑making to ensure relatives receive the “special consideration and preference” required by Michigan law. This includes adding targeted monitoring responsibilities in PAFC‑managed cases where a relative has been identified, supported by CCWIS alerts to track required assessment deadlines, and amending FOM 722‑03B to establish clearer, more stringent timeframes for completing the DHHS‑5770 Relative Placement Safety Screen. The OCO further recommends updating the DHS‑31 Placement Decision Notice to require case‑specific written reasons when a relative is denied placement and to document when key assessment forms were provided. Together, these changes aim to improve accountability, transparency, and timely evaluation of relatives in accordance with state law and policy.

Case Background:

On August 6, 2020, the Office of Children's Ombudsman (OCO) opened an investigation into the involvement of Wellspring Lutheran Services (Wellspring) with The Child.

The OCO completed 27 case actions, including review of confidential records and information in the Michigan Statewide Automated Child Welfare Information System (MiSACWIS—the department’s computerized case file system), Department of Health and Human Services (DHHS) forms, foster care service plans, court orders, Children’s Protective Services (CPS) histories, a Foster Care Review Board (FCRB) report, and a packet of information that CPS provided to Wellspring foster care personnel.  The OCO completed 13 interviews, including interviews of the DHHS foster care monitor; the Wellspring foster care program manager, case worker, licensing worker and supervisor; the OCO complainant and other household family members; and the CPS worker.

Case Objective:

The objective of this review was to identify areas for improvement in the child welfare system.  By looking at how this family’s case was handled by Wellspring, this review reinforces the safety and well-being of a child is the shared responsibility of the family, community, and both law enforcement and medical personnel aiding children and families.  It is not intended to place blame, but to highlight areas of concern regarding the handling of this case and advocate for changes in the child welfare system on behalf of similarly situated children. 

Purpose, Scope & Summary of Investigation: 

On August 6, 2020, the OCO opened an investigation into Wellspring’s and Kalkaska County DHHS' involvement with The Child's foster care placement. The objective of this review was to investigate Kalkaska County DHHS' and Wellspring's handling of the processes and procedures mandated by law, policy and rules regarding relative foster care placement and the involvement of CPS and foster care staff, the court, Foster Care Review board (FCRB), and medical personnel.

Family History:  

The Child was born healthy on January 29, 2020 to her 17-year-old mother Mother and putative father Father.  The Child entered foster care upon discharge from the hospital due to hospital staff reporting that Mother was not feeding or changing The Child in the hospital; did not have provisions for The Child; and did not have a stable appropriate home to bring The Child home to.  On the day of The Child' s discharge from the hospital, on January 31, 2020, The Child's maternal great-grandfather and step-great-grandmother, came forward requesting CPS place The Child with them.  CPS advised that they could be explored as a potential relative placement but that for that night, The Child was being placed in the licensed foster home of an unrelated foster parent.

The Child was placed in a licensed foster home through Wellspring on January 31, 2020. As of the completion of this OCO investigation, The Child remains in that home. According to the CPS investigation report, CPS advised Wellspring and Kalkaska County’s DHHS foster care monitor of Maternal Great-grandfather’s interest in placement on February 3, 2020.  The maternal great-grandparents attended a Family Team Meeting (FTM) on February 6, 2020 where they were provided with a form to indicate their interest in taking placement of The Child. The maternal great-grandparents signed and returned the form that same day.  Kalkaska County DHHS received the form on February 10, 2020; according to social work contacts, the the maternal great-grandparents’ form was forwarded to Wellspring and the DHHS foster care monitor on February 10, 2020.

On February 18, 2020, Maternal Great-grandfather was present at a preliminary hearing during which The Child’s mother said she was in favor of having The Child placed with the maternal great-grandparents. The referee presiding at the hearing ordered that the Maternal great-grandparents’ home study be expedited. Wellspring completed an initial screening of the Maternal great-grandparents on  March 3, 2020,  and on March 4, 2020, placement was denied due to a finding that Maternal Great-grandmother was placed on the DHHS’ central registry in 1988. 
 
According to social work contacts, the Wellspring foster care program manager advised CPS that the maternal great-grandparents’ home was determined to be safe and appropriate but that they were waiting to verify Maternal Great-grandmother’s history that caused her to be placed on central registry. Wellspring’s licensing unit received a copy of maternal great-grandmother’s expungement from central registry on March 17, 2020, and on April 14, 2020, a licensing specialist verified with the DHHS expungement unit that Patricia was no longer on central registry. 

The maternal great-grandparents’ home study was approved by the Wellspring licensing unit on July 1, 2020; however, the Wellspring foster care program manager did not give final approval of the home study until August 6, 2020.

After Wellspring notified the unrelated foster parents that The Child would be placed with the relatives, the foster parents requested review of the planned re-placement by the FCRB, which recommended that The Child remain with the unrelated foster parents. The Wellspring foster care program manager wrote a letter to the court supporting the FCRB's recommendation to maintain The Child' s placement in her foster home, and the court adopted the FCRB's recommendation.

Violations:

Violation Type	Violation Of	Violation Details
Foster Care Policy	Children’s Foster Care Manual FOM 722-03B - RELATIVE ENGAGEMENT AND PLACEMENT	Policy states: "Relatives who meet all the requirements on the Relative Placement Safety Screen except for central registry history are not disqualified from placement consideration. Placement may be made upon central registry removal, amendment, or expunction and director approval of the Relative Placement Home Study.... If it is determined that further assessment is warranted, the Relative Placement Home Study must be completed within 45 calendar days of removal." The Child was removed from her parent’s custody on January 31, 2020. Wellspring received documentation of The Child’s step-great-grandmother’s expungement from central registry on March 17, 2020. However, the Relative Placement Home Study was not completed until July 1, 2020, and not approved until August 6, 2020, approximately six months after The Child’s removal from parental custody.
Administrative Rule	Michigan Administrative Rule 400.12404(2)	R 400.12404(2) states in relevant part that “[i]nitial consideration shall be given to placement with a relative . . ..” Wellspring did not give initial consideration to placing The Child with her maternal great-grandparents and delayed evaluating The Child's relative for placement by not timely resolving Maternal Great-grandmother’s unexplained placement on central registry and failing to approve the relative’s home study until approximately six months after The Child’s removal from parental custody.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
Primary Agency of Focus: Wellspring Lutheran Services Secondary Agency(ies): Kalkaska County DHHS Wellspring did not comply with time requirements in policy for evaluating proposed relative placements, which led to the relatives not getting placement of their great-granddaughter. Delay in beginning the relative safety screening led to the relatives not receiving initial placement consideration. In addition, the agency's failure to complete the maternal relative's home study within 45 days of 's removal led to that relative not receiving the "special consideration and preference" for placement provided to relatives in Michigan Compiled Laws, MCL 722.954a(5).
Primary Agency of Focus: Wellspring Lutheran Services Secondary Agency(ies): Kalkaska County DHHS From The Child’s birth, it took 188 days for Wellspring to finalize the great-grandmother and great-grandfather's home assessment for placement of . Wellspring recommended moving to the great-grandparents home. This decision was reversed when the Foster Care Review Board determined that should remain in the foster home. Wellspring changed their recommendation to align with the Foster Care Review Board. This case is a sample of growing evidence to indicate that child placing agencies often slow or otherwise inhibit relative placement on the basis of little evidence and with knowledge of a potential relative placement. As this is potentially a growing area of concern, the Office of Children's Ombudsman is going to track complaints of similar nature to ascertain if there is a pattern of behavior among child placing agencies that can be identified.
Primary Agency of Focus: Wellspring Lutheran Services Secondary Agency(ies): Kalkaska County DHHS In this case, the unrelated licensed foster parents were given all of the limited procedural rights pertaining to re-placement they were entitled to under Michigan law. Pursuant to Michigan Compiled Laws, MCL 712A.13b, Wellspring provided the foster parents notification of the intended re-placement of in August and the foster parents' right to appeal that re-placement; the Foster Care Review Board reviewed the foster parents' appeal of the intended re-placement; and the court conducted a hearing and issued an order regarding the foster parents' appeal. However, The Child's great-grandparents received none of the rights pertaining to relative placements they were entitled to under Michigan law and related DHHS children's services policy. Wellspring did not complete a home study within 45 days of removal as required by Children’s Foster Care Manual FOM 722-03B; Wellspring did not document in writing, making a final placement decision and the reasons for it; nor did Wellspring provide the necessary written notice of the decision and reasons supporting it to 's relatives within 90 days of removal as required by Michigan Compiled Laws, MCL 722.954a(4); and, most importantly, Wellspring's delays in implementing the rights due 's relatives undermined the preference in Michigan Compiled Laws, MCL 722.954a and Children’s Foster Care Manual FOM 722-03B for placement of children with fit and willing relatives.

Recommendations:

Recommendation	MDHHS Response to Recommendation
Primary Agency of Focus: DHHS Children’s Services Agency To help prevent the above findings from occurring in the future the OCO recommends that DHHS Children’s Services Agency amend the Children’s Foster Care Manual policy FOM 722-03B to establish clearer deadlines for completing the DHHS 5770 Relative Placement Safety Screen. Deadlines should be stringent enough to allow for more timely consideration of interested relatives and possible resolution of identified concerns.	MDHHS recognizes the importance of placing children with their relatives and prioritizes engaging them at every point during a foster care or adoption case. As a result of the recommendation, the Children’s Services Agency reviewed policy and determined that current deadlines, when followed, allow for timely investigation and licensure of interested relatives.
Primary Agency of Focus: DHHS Children’s Services Agency To help prevent the above findings from occurring in the future the OCO recommends that DHHS Children’s Services Agency update the Foster Care Placement Decision Notice form, also known as DHS-31 to require the following: A. Documentation of case-specific reasons for denying an identified relative placement of a child without disclosing confidential information. The current form only requires a caseworker to check a box next to a statement, such as, “attempts to identify relatives were unsuccessful” or “available relatives do not meet current DHHS standards for placement.” As a matter of basic fairness, a relative who has come forward to serve as a foster parent for the child deserves to receive in writing specific reasons for the agency’s refusal to place the child with him or her. This proposed amendment to the DHHS-31 would align practice regarding interested relatives with Michigan laws that require agencies to state in writing their reasons for denying any person a foster home license. B. Require an individual completing the form to select that either the Relative Placement Safety Screen form (form MDHHS-5770) and/or the Children’s Foster Care Relative Placement Home Study form (form DHS-3130a) were provided to the potential foster care family. The OCO also recommends the addition of a date box to complete after selecting form MDHHS-5770 and/or DHS-3130a. It is recommended that the date box be utilized to document the date in which the potential foster family was provided MDHHS-5770 and/or DHS-3130a. The OCO believes that the updates to form DHS-31 will assist the department in documenting and validating when the required home study and/or relative placement study forms were provided to the potential foster family allowing for greater compliance with Michigan law and department policy.	Foster care policy FOM 722-03B pg. 22 requires Child Placing Agencies to send the DHHS-31, which notifies a relative of the placement decision, and a copy of the Relative Placement Safety Screen (DHHS-5770) or Relative Placement Home Study (DHHS-3130A). Both reports have a “Placement Recommendation” section requiring the agency to write a “rationale and explanation for their placement recommendation”. MDHHS agrees to add a checkbox to the DHHS-31 where Child Placing Agencies can acknowledge they provided either the 5770 or 3130a to the family as well as the date the form was provided. Proposed enhancements to the form should occur within 90 days.
Primary Agency of Focus: DHHS Children’s Services Administration To ensure private agency foster care (PAFC) providers’ timely response to completing relative’s assessments, affording the relatives “special consideration and preference” as required by Michigan Compiled Laws, MCL 722.954a(5), the OCO recommends amending relevant policy to require additional oversight by the monitoring DHHS caseworker in cases where a relative has been identified and has expressed interest in placement. According to Children’s Foster Care Manual FOM 914, MDHHS Responsibilities for PAFC Managed Cases, the DHHS monitoring caseworker is not required to attend court hearings unless ordered to do so by the court. The monitoring caseworker is not required to approve service plans or court reports completed by the PAFC provider. The monitor does not have contact with the case members unless they contact the monitor, or the monitor becomes aware of a policy violation. The OCO is aware that in some counties monitoring caseworkers can have up to 90 cases, and it is not the intention of the OCO to add required responsibility to the monitors in general, but just in cases where a relative has been identified. The OCO recommends building alerts or ticklers into the new MDHHS case management tool, the Comprehensive Child Welfare Information System (CCWIS), to help the department hold a PAFC accountable for completing all relative assessments in accordance with timeframes in FOM722-03B.	As a result of this recommendation, the Children’s Services Agency reviewed areas where oversight exists regarding timely completion of relative home studies. On 9/30/20, MDHHS directed, through Communication Issuance CI 20-141, county and private agency staff to access the Data Warehouse Portal to create reports, including the CW-6025, which track and monitor upcoming and overdue initial and annual Relative Placement Home Studies. Additionally, MDHHS will request a tickler function for relative assessments be added to the new CCWIS system currently under development and will consult with the State Court Administrative Office on additional training regarding the importance of relative placements for the Foster Care Review Board.

PDF Version of Report:  Case No. 2020-0045

Recommendation Issued Date	Response Received Date	Recommendation Published Date	OCA Case Number
December 3, 2020	February 2, 2021	March 25, 2021	2020-0036

Summary of recommendations:

The OCO recommends a series of reforms to strengthen safety, staffing, and oversight within Michigan’s child‑caring institutions (CCIs). These include requiring a heightened DCWL response to repeated or serious violations involving restraint, staff physical abuse, or failure to report, and ensuring local DHHS offices are notified so they can reassess placements. The OCO further recommends raising qualifications for direct care workers by requiring relevant degrees or experience, and expanding training requirements to include PRIDE. To improve safety and quality of care, the OCO urges the Legislature to fund and mandate smaller CCI living units capped at 19 residents. Finally, the OCO recommends aligning direct care worker pay with comparable state civil service positions and establishing clearer, enforceable deadlines for completing the DHHS‑5770 Relative Placement Safety Screen. Together, these changes aim to enhance child protection, professionalize the workforce, and ensure safer, more responsive residential care settings.

Case Background:

The Child died on 05/01/2020.  Pursuant to MCLA 722.627k, the Michigan Department of Health and Human Services (MDHHS) notified the Office of Children’s Ombudsman (OCO) of the child fatality.  On 05/06/2020, the OCO opened an investigation into the handling of this matter by Lakeside Academy for Children (Lakeside Academy) and MDHHS pursuant to our statutory responsibilities.

The OCO reviewed confidential records and information that was in MiSACWIS, which includes but is not limited to service reports, medical records, social work contacts, investigative reports, incident reports, video recordings, facility policies, facility training materials, and court orders.  The OCO also spoke with The Child’ foster care worker and the worker’s supervisor, a maltreatment-in-care (MIC) worker and her supervisor, a licensing investigator and her supervisor, a Sequel Youth and Family Services employee, and numerous employees and managers of Michigan child caring institutions (CCI’s).

Case Objective:

The objective of this review was to identify areas for improvement in the child welfare system.  By looking at how this family’s case was handled by Lakeside Academy, and the involvement of staff, court personnel, physicians and law enforcement, this review reinforces the safety and well-being of a child is the shared responsibility of the family, community, and both law enforcement and medical personnel aiding children and families.  It is not intended to place blame, but to highlight areas of concern regarding the handling of this case and advocate for changes in the child welfare system on behalf of similarly situated children. 

Purpose, Scope & Summary of Investigation: 

The purpose of this investigation was to determine whether The Child' placement at Lakeside Academy was in his best interest; whether Lakeside Academy staff members complied with law, administrative rule, DHHS policy, internal facility policy, and internal facility procedure concerning a restraint of The Child on 4/29/20 that resulted in his death; whether the assigned MIC unit complied with applicable law and policy when investigating this restraint; and whether there are systemic issues necessitating recommendations to improve practice regarding CCI's and the use of restraint techniques in CCI's.

The scope of the OCO investigation included The Child' foster care case, the MIC and licensing investigations concerning the 4/29/20 restraint, MIC and licensing investigations concerning Lakeside Academy resident discipline that occurred in the two years prior to The Child' death, MIC and licensing investigations at other CCI's in the two years prior to The Child' death, and the requirements for direct care workers in Michigan CCI's.

During this investigation, the OCO investigator:

• Obtained and reviewed The Child' medical records from Bronson Methodist Hospital, which treated The Child immediately prior to his death
• Obtained and reviewed the report of an autopsy conducted on The Child
• Reviewed case file documentation in MiSACWIS concerning The Child' foster care case, The Child' adoption case, the MIC investigation concerning The Child' death, and the licensing special investigation concerning The Child' death and a previous restraint of The Child at Lakeside Academy
• Reviewed documentation in the Judicial Data Warehouse to confirm information describing the child protective proceeding involving The Child and his siblings and a delinquency proceeding involving The Child
• Interviewed The Child' foster care worker and her supervisor, the assigned MIC worker and her supervisor, and the assigned licensing investigator and her supervisor
• Obtained and reviewed video recordings of the restraint leading to The Child' death and a previous restraint of The Child at Lakeside Academy
• Obtained and reviewed internal Lakeside Academy policy concerning restraints and physical holds of residents at the facility and training materials used by Lakeside Academy to train staff on the use of restraints and physical holds
• Attempted to interview 11 former Lakeside Academy staff members involved in the 4/29/20 restraint of The Child
• Reviewed employment records of seven former Lakeside Academy staff members directly involved in the 4/29/20 restraint of The Child
• Reviewed law, policy, and documents describing restraint and positional asphyxia
• Reviewed 13 licensing special investigations and MIC investigations concerning Lakeside Academy staff that occurred in the two years prior to The Child' death
• Tallied the number and general nature of licensing special investigations and MIC investigations that occurred in all Michigan non-secure CCI's during the two years prior to The Child' death
• Obtained starting pay rates and education and experience requirements for direct care workers at a majority of Michigan non-secure CCI's.
  
   

Family History:  

According to foster care case file documentation, The Child' mother died on 9/27/13. Court records indicate that The Child and his four siblings were removed from their stepfather’s custody on 7/10/15. The petition filed in 2015 requested termination of the parental rights of The Child' father, and his rights were terminated on 5/8/17. With the exception of one 12-day court-ordered placement with fictive kin as a safety plan immediately following The Child' removal from the stepfather's custody, The Child was placed in various CCI’s and detention centers for the entire time he was in foster care.

Violations:

Violation Type	Violation Of	Violation Details
Administrative Rule	R 400.4159(2)	R 400.4159(2) states: "Resident restraint shall be performed in a manner that is safe, appropriate, and proportionate to the severity of the minor child’s behavior, chronological and developmental age, size, gender, physical condition, medical condition, psychiatric condition, and personal history, including any history of trauma, and done in a manner consistent with the resident’s treatment plan." The 4/29/20 restraint of The Child was conducted in an unsafe manner. Two Lakeside Academy staff members are seen on the video recording applying their body weight to The Child' chest and abdomen, and one staff member is seen applying body weight to The Child’ leg. The restraint was also disproportionate to The Child' behavior of throwing napkins and portions of a sandwich at other residents. Finally, the restraint was inconsistent with The Child' treatment plan, which required Lakeside Academy staff to assist The Child in using his anger management and coping skills.
Policy	Lakeside Academy for Children Policy, Emergency Safety Physical Intervention	This policy states in relevant part: "B. A Lakeside Academy student may only be placed in an Emergency Safety Physical Intervention if they are displaying behavior that meets one or more of the following criteria; 1. a danger to himself (imminently and immediately), 2. a danger to others (imminently and immediately), "C. When the student’s behavior meets these criteria employees may initiate a standing emergency safety physical intervention. This is an effort at keeping the student and others safe and also allow for de-escalation. . . ." "[P]hysical restraint time limits in excess of 10 minutes (unless specifically approved by a mental health professional and/or Director) are also prohibited." The Child's behavior in throwing napkins and a portion of a sandwich in the cafeteria did not pose an imminent and immediate danger to himself or other residents. Thus, no ESPI was permitted in the circumstances. Even assuming that an ESPI was warranted, the Lakeside Academy staff member who initiated the restraint did not attempt the permitted standing intervention: this staff member is seen on the video recording pushing The Child to the floor and immediately initiating a supine restraint. Finally, the 4/29/20 supine restraint of The Child lasted longer than ten minutes, and there is no documented approval from a mental health professional or director.

Factual Findings:

The child advocate shall prepare a report of the factual findings of an investigation and make recommendations to the department or the child placing agency if the child advocate finds one or more of the following:

1. A matter should be further considered by the department or the child placing agency.
2. An administrative act or omission should be modified, canceled, or corrected.
3. Reasons should be given for an administrative act or omission.
4. Other action should be taken by the department or the child placing agency.

The Child Advocate believes their findings should be further considered by the department, and additional actions by MDHHS and other child welfare partners are necessary.

Finding	MDHHS Response to Finding
Primary Agency of Focus: Lakeside for Children The OCO finds that Lakeside Academy staff violated Michigan Administrative Rules 400.4159 and 400.4142 and Lakeside Academy's internal policy governing the use of holds and restraints when restraining The Child on 4/29/20. This restraint was unwarranted, improperly executed, conducted without appropriate supervisory approval or oversight, and inconsistent with The Child' treatment plan. In addition, Lakeside Academy staff failed to obtain timely emergency medical care for The Child following the restraint.
Primary Agency of Focus: Lakeside for Children Secondary Agency of Focus: Children's Services Administration The OCO finds that a review of MIC substantiations and administrative rule violations concerning Lakeside Academy staff maltreatment of residents in the two years prior to The Child' death indicates a pattern of inappropriate use of restraint and assault to manage non-threatening behaviors. For example, the OCO reviewed confirmed allegations of Lakeside Academy staff members restraining a resident for over 30 minutes; dragging a resident across the floor for failing to respond to staff requests; challenging a resident to fight; pushing a resident into a brick wall because the staff member believed the resident was about to spit on him; yelling directly in a resident's face; and "backhanding" a resident in the face, in the presence of the resident's therapist, for calling the staff member a name. The OCO also finds that despite multiple rule violations concerning these and other incidents at Lakeside Academy, and despite the imposition of numerous corrective action plans as a result of the rule violations, the facility was still on regular license status at the time of The Child' death.
Primary Agency of Focus: Lakeside for Children The Michigan Administrative Code for Child Care Institutions (CCIs) defines qualifications for direct care workers in Rule 121 (R 400.4120). The minimum qualification for a CCI direct care worker is “A direct care worker shall have completed high school or obtained a general equivalency diploma (GED).” The OCO finds that of the seven employees most directly involved in the 4/29/20 restraint of The Child, none had child welfare experience prior to being employed by Lakeside Academy. One of the seven employees holds a bachelor's degree in criminal justice, sociology, and anthropology; one has an associate's degree in business and accounting; and five have high school diplomas. Employment records from Lakeside Academy also show that the average number of months the seven employees were employed by Lakeside Academy prior to 4/29/20 was approximately 12.
Primary Agency of Focus: Children's Services Administration The OCO finds that among 36 private non-secure CCI's that receive children under a Michigan court's jurisdiction for child abuse or neglect, the starting hourly pay rate for direct care workers ranges from a low of $9.50 per hour to a high of $18.77 per hour. In addition, the OCO finds that among these 36 CCI's, the average starting rate of pay for direct care workers, including pay differentials for education and relevant experience, is approximately $15.60 per hour.
Primary Agency of Focus: Children's Services Administration The OCO finds that MDHHS commissioned the Annie E. Casey Foundation’s Child Welfare Strategy Group to review MDHHS’ oversight of the safety and quality of Michigan CCI’s. One of the recommendations from this review was to limit the number of residents at CCI’s to 16. The OCO reviewed publicly available licensing special investigations and confidential MIC investigations occurring at non-secure CCI’s within the two years preceding The Child' death. Based on this review, the OCO finds a correlation between the number of children housed within a non-secure CCI and the likelihood that the CCI was found responsible for a rule violation or a CCI employee was substantiated for staff assault of a resident or an improper restraint. Those CCI's with a violation or substantiation for a staff assault or improper restraint in the last two years (21 total CCI's) have an average of 40 residents. Those CCI's without such a violation within the last two years (31 total CCI's) have an average of 19 residents. [1] The OCO reviewed reports available on MDHHS’ public website at https://cwl-search.apps.lara.state.mi.us/. Licensing special investigation reports and annual inspection reports are not generally available to the OCO via MiSACWIS.

Recommendations:

Recommendation	MDHHS Response to Recommendation
Primary Agency of Focus: Children's Services Administration The OCO recommends that MDHHS require a heightened response by DCWL to statutory or administrative rule violations regarding restraint, staff physical abuse of a resident, or failure to comply with the mandated reporting provisions of the Child Protection Law (CPL) by a CCI. This heightened response could include the following: For a second or subsequent violation of law or administrative rule concerning restraint, staff physical abuse of a resident, or failure to report, issuing a provisional license to the CCI; and For any violation of law or administrative rule concerning restraint, physical abuse of a resident, or failure to report, requiring DCWL to notify local DHHS offices of its findings to permit local offices to decide whether to seek re-placement of children under their care and supervision.	MDHHS intensified its response to rule violations by requiring the MDHHS Division of Child Welfare Licensing, prior to determining adverse action, to conduct a comprehensive review of a Child Caring Institution’s serious and safety-related violations for the previous twenty-four months. The goal is to identify patterns and trends that may necessitate a corrective action plan or other intervention to address concerns that impact child safety and wellbeing. Effective 7/16/20, MDHHS issued Emergency Rules for Child Caring Institutions restricting dangerous types of restraints and limiting use of restraints when necessary to prevent serious injury to the child or injury to others. Effective 7/24/20, MDHHS licensing consultants began making unannounced visits to Child Caring Institutions – quarterly to all Child Caring Institutions, monthly when a first provisional license is recommended, and weekly when a second provisional license is recommended. Additionally, the Department implemented weekly Child Caring Institution status meetings to identify concerns that impact child safety and require immediate action, such as caseworker verification of safety and wellbeing, implementation of safety plans, review of staffing sufficiency, additional investigation by Children’s Protective Services Maltreatment in Care unit or licensing, technical assistance by licensing and/or program offices, and temporary suspension of new referrals to the facility. Participation at the weekly meetings includes, among others, the Bureau of Out-of-Home Services director, the Juvenile Justice Programs director, the manager of the Regional Placement Unit and the respective managers of foster care and juvenile justice program offices. The Division of Child Welfare Licensing also hold conference calls with the caseworker in the local office after revery restraint of a child on their caseload. The Division of Child Welfare Licensing seriously considers issuing a provisional license to Child Caring Institutions that have more than one serious restraint violation. After the tragedy at Lakeside, MDHHS asked national experts to help guide reform of its use of residential services and improve safety for children receiving residential services. National experts issued a report containing recommendations to improve oversight of safety and quality of care to children receiving residential services and their families, including moving towards restraint-free programs. In September 2020, Michigan convened a 6-month steering committee to implement the recommendations in the report. The steering committee is set to conclude its work at the end of March 2021. Finally, MDHHS has implemented a series of trainings for Child Caring Institutions focused on implementation of best practices to prevent and safety reduce the use of restraints; additional technical assistance is planned in 2021.
Primary Agency of Focus: Children's Services Administration The OCO recommends that MDHHS amend R 400.4121 to require either A bachelor's degree in social sciences, human services, or a related field, or A minimum number of years of experience working with children before being employed in a CCI as a direct care worker. This would encourage persons who plan a career working with children to apply for such jobs, reorient the nature of the position toward effective interaction with traumatized children and away from physical management of such children, and bring staff qualifications in line with the required qualifications for staff in other child welfare program areas.	MDHHS recognizes the important role CCI direct care staff have in working with children who have experienced trauma and their families. Draft revisions to the licensing rules, that are expected to take effect in Fall 2021, enhance the amount and types of training newly hired and existing staff will receive when employed at a Child Caring Institution. Under the draft revised rules, staff are required to complete 50 hours of training in their first year of hire, and 25 hours annually thereafter. Staff will select from over 30 annual training topics as identified in Michigan Administrative Code R400.4128 and the Child Protection Law including, but not limited to, topics related to working as part of a team, understanding and defusing challenging behaviors, relationship building with the family, crisis intervention, suicide prevention, grief and loss for foster children, and other topics which will enhance staff skill and ability to deliver effective services and intervention with youth and their families.
Primary Agency of Focus: Children's Services Administration The OCO recommends that MDHHS identify jobs within the state civil service that are substantially similar to the position of direct care worker at a private non-secure CCI. MDHHS should require by contract that pay rates for direct care workers within private non-secure CCI's be commensurate with the department's pay rates for substantially similar positions within the state civil service and include pay differentials for employees with relevant child welfare experience.	Beginning in December 2020, MDHHS began working with Public Sector Consulting Group and residential service providers to identify comparable market rates for similar positions and identify salary benchmarks commensurate with job duties and expectations. The next meeting among MDHHS, Public Sector Consulting Group, and residential providers is scheduled for March 17, with additional meetings to occur in April and May. This work will be factored into actuarily sound rate recommendations for Child Caring Institutions.
Primary Agency of Focus: Children's Servies Administration The OCO recommends that MDHHS add a requirement to Michigan Administrative Rule 400.4128; Rule 128, to require all direct care workers in CCI's, similar to the first aid training requirement, to take Parent Resources for Information, Development, and Education (PRIDE) training as required for foster parents.	While Parent Resources for Information, Development, and Education (PRIDE) training is geared toward the placement of children with foster parents and relatives, Child Caring Institution contracts require orientation for all new staff that include topics identified in Michigan Administrative Code R400.4128 and the Child Protection Law. Current draft rule revisions will require additional annual training in over 30 areas related to staff providing effective treatment for children and families involved at Child Caring Institutions. Additionally, all staff will receive annual trauma-focused program training to maintain a trauma-informed milieu and treatment environment. In 2020 and 2021, all Child Caring Institutions were invited to participate in the Six Core Strategies training, delivered by national experts in congregate care system reform. The training included five three-hour training sessions on strategies they should take to reduce the use of restraints, seclusion, and other coercive practices. The training focused on ways that Child Caring Institutions can promote permanency, family-driven, youth-guided, and trauma-informed care, cultural and linguistic competence, strength/resiliency-based and individualized care. A workgroup has drafted rule revisions that will require all Child Caring Institutions to develop agency-based and child specific crisis prevention and intervention strategies that are strength-based and non-coercive. These plans will be used to support staff and assist children in self-regulation, social skills, and healing.
Primary Agency of Focus: Michigan Legislature The OCO recommends that the Michigan Legislature amend the Child Care Organizations Act, MCL 722.111 et seq., to limit the number of children that a CCI may house within a self-contained unit of a facility to 19 residents or less.	As part of the Child Caring Institution Steering Committee convened from September 2020 through March 2021, a workgroup analyzed and carefully considered modifying the Licensing Rules for Child Caring Institutions to limit residential program size to a capacity of 16 youth or less. The workgroup recommended updates be made to licensing rules, contracts, programs, and oversight focus on factors that improve safety and positive outcomes for children and their families such as engagement with families, reducing lengths of stay, prevention of restraint/seclusion use, workforce support and development, urgency toward permanency, use of data for program improvement, post-discharge supports, trauma-responsive interventions and organizational oversight. The workgroup recommended, and the Steering Committee agreed, not to modify the licensing rules, or contracts, for residential services to limit bed capacity. The decision was based on the following: 1) Insufficient data, research, or consistent approach in other locations, 2) current Michigan data does not support this recommendation and 3) evidence to establish a correlation between bed capacity and safety/outcomes research suggests that positive outcomes are linked to factors such as family engagement, staff training, and adherence to evidence-based practices. As MDHHS implements Qualified Residential Treatment Programs under the Family First Prevention Services Act, its contractual requirements and residential treatment programs will implement trauma-informed treatment models, staff professional competencies, licensed nursing, and intensive aftercare support to sustain each you and family success in the community.
Primary Agency of Focus: Michigan Legislature The OCO recommends that the Michigan Legislature appropriate sufficient funds to support the establishment, monitoring, and administrative costs of CCI’s with smaller resident populations as recommended in this document.	No response

PDF Version of Report:  Case No. 2020-0036