The Problem Is The System

During the intense coverage related to the death of Christopher Thomas, I kept iterating that the problem with child welfare in Milwaukee County was systematic, and that cases like Christopher's was only a symptom of the bigger underlying problem.

More tragic stories of babies dying because of the Bureau of Milwaukee Child Welfare have recently surfaced that strengthen my position on this issue.

One is the story of Vera Morehouse, who allowed her infant son to starve to death. The BMCW had received previous referrals on this family, but did not take any action. And this is despite having earlier charges filed against her. Didn't the worker think of checking CCAP first? That used to be standard procedure. While not to be used as a basis for removing children, the history used to be considered while making decisions based on the current referral and conditions. And that was a state worker handling that case.

Even more outrageous is the story of Melody Cole, who starved her 7 month old daughter, Layunnia Lewis , to death. What makes this story so outrageous is the way it was handled (emphasis mine):

According to the complaint, investigative reports and a 16-page report by the panel:

The Aurora Visiting Nurse Association made at least 12 attempts to see Layunnia after she was sent home. A visiting nurse saw the baby once, on Aug. 14. On Sept. 12, because of the parents' lack of cooperation, the association discharged the child from its services.

On April 5, while Layunnia was still in the hospital, the parents agreed to a voluntary in-home safety program run by the Bureau of Milwaukee Child Welfare.

Although the hospital workers reported to child welfare authorities that Cole was heard threatening to beat her other children, and that both parents showed up at the hospital drunk, the safety services were terminated at the parents' request about two weeks after Layunnia was released from the hospital.

Meanwhile, in the months leading up to Layunnia's death, child welfare caseworkers and a therapist made regular visits to her home to check on her 9-year-old brother, who was being monitored under a court order.

The brother's caseworker last visited the home Oct. 30. One month later, Layunnia was dead.

"For reasons not clear to the panel," the independent review panel wrote, "for some portion of time that the safety services case was open, neither the ongoing worker nor the safety service worker knew of their co-worker's involvement with the family."

There was clearly a lack of communication between all of these agencies, and no one wanted to step up and do the right thing. As a result, another baby had to suffer a painful death that was entirely avoidable. There was sufficient cause to detain the baby when the parents refused safety services, but they did not do anything about it. I can't help but wonder if the intake worker that referred the case to safety services was even notified that they dropped out of the family's life.

Then there was this pdf which was released last week. It is a report by BMCW that involves a baby that also was allowed to starve to death. This was even while a case was open with the BMCW, who was supposed to be doing an active investigation at the time.

If you take these three cases, plus the case of Christopher Thomas, you will find only one commonality. The different cases involved different agencies, both public and private. They also involved different levels of involvement with the system, from initial investigation to having an active ongoing caseworker involved.

The only commonality is the system in general. I remember, when the new system was being installed, arguing with the instructors on the effectiveness of the system. It would try to overgeneralize the people involved, trying to put people into convenient categories that never covered all of the intricacies and variables that are involved whenever you are dealing with people. No one person can ever be neatly fitted into a box, and any system that tries to do so is inherently going to fail.

I remember cases in which the worker's experience and knowledge said that a child should be removed due to unsafe conditions, but the systems format said otherwise and the child was not removed. That is until two months later when the kid showed up at the hospital due to being abused. Then the system finally agreed with what the worker said two months earlier. Fortunately, she had noted her concerns at the time and was not in trouble for the failure of the system.

However, this is the system that Denise Revels Robinson and Susan Dreyfus chose, and this is what we are stuck with until it gets changed to a more effective system. That is where the state legislature and Governor Doyle can help. They can order the system be properly staffed and that an effective program be put into place. It will mean another transition period for an already tumultuous program, but to do otherwise is just to allow more children to die needlessly.