Investigation into the Death of Tabatha B




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State of Connecticut Child Fatality Review Panel’s
Investigation into the Death of Tabatha B.
released: November 30, 1998

Part I: Child Welfare Management
Part II: Long Lane School




Child Fatality Review Panel Members

Linda Pearce Prestley, Esq., Chairperson, Child Advocate

John Bailey, Esq., Chief State's Attorney

H. Wayne Carver II, M.D., Chief Medical Examiner

Betty S. Spivack, M.D., Pediatrician

Gary Fitzherbert, Executive Director, The Glenholme School

Leticia Lacomba, M.S.W., Regional Administrator, Department of Children and Families

Dr. Henry Lee, Commissioner, Department of Public Safety


Consultants

Suzanne Sgroi, M.D.

Maureen Regula, J.D.
Staff:

Barbara J. Claire, Esq., Associate Child Advocate

Desiree Fernandez, MSW, Assistant Child Advocate

Mickey Kramer, MS, RN-C, Assistant Child Advocate



Denise Scruggs, Administrative Assistant
SUMMARY OF FINDINGS



  • Although the Panel understands that progress has been made since the Juan F. Consent Decree was implemented, DCF’s failure to provide Tabatha with adequate intervention and protection during her first five years set the stage for an ominous pattern of deterioration in her mental health

  • Over the course of her life, Tabatha did not receive the proper care and treatment necessary to address her need for permanence and her mental health issues.

  • After a long series of failed placements in foster homes, shelters, and a residential facility, Tabatha was ultimately placed in Connecticut’s only juvenile correctional facility, an institution that is overcrowded, lacks resources, is understaffed and does not provide the therapeutic milieu necessary to treat a diverse population of emotionally disturbed children.

  • Because Connecticut lacks appropriate treatment resources for emotionally disturbed children, Tabatha moved from one end of a continuum where she once had been regarded as a deserving victim to the opposite end where she was viewed as an undeserving delinquent.

  • DCF’s Long Lane staff failed to recognize the significance of Tabatha’s multiple suicidal behaviors exhibited prior to her death, and failed to conduct a comprehensive assessment of her mental health issues.

  • The State of Connecticut does not have a secure in-patient residential setting to treat those children who are not serious offenders but who are at risk of flight.

  • Long Lane School is a DCF correctional facility that operates without outside oversight, without accreditation and without licensing.

  • Staffing at Long Lane School is grossly inadequate to meet the needs of its diverse population.

  • Long Lane School is failing to meet the mental health needs of many of Connecticut’s most troubled children. There is no comprehensive approach to mental health treatment, nor does Long Lane provide the intensive psychiatric care that many of the children require.

  • The environmental conditions at Long Lane School contribute to substandard living conditions and, in some respects, serve to jeopardize the safety of the children in residence.

  • Reports of abuse and neglect against children by staff and agency police officers are investigated by DCF Hotline, another branch of the same agency, without independent oversight of those investigations. The Panel believes that this practice presents a conflict of interest.

  • Use of force incidents involving DCF Long Lane police officers are not subject to an internal administrative review process within the police division of the institution.

  • Children at Long Lane School are routinely mechanically and physically restrained, often under circumstances which violates DCF’s policy.

  • Record keeping at Long Lane School is seriously deficient, to the extent that critical information regarding the children and their care is not being recorded.

  • Each department at Long Lane School operates as a separate entity with little or no sharing of information pertaining to each child’s condition or care.

Table of Contents




INTRODUCTION

page 4

SUMMARY OF FACTS

page 4







PART I: Child Welfare Management of Tabatha

page 5

A. Child Welfare Management of Tabatha B. Prior to Long Lane

page 5

1. Pre-Consent Decree Case Management

page 5

Analysis

page 7

2. Post-Consent Decree Case Management Prior to Long Lane

page 8

B. Child Welfare Management at Long Lane

page 12

Analysis

page 15







Part II: Long Lane School – Introduction

page 18

A. Children in the Juvenile Justice System

page 19

1. Treatment vs. Correction Models

page 19

Recommendation

page 21

2. Adolescent Suicide

page 21

3. Standards for addressing the needs of incarcerated children

page 22

Recommendations

page 23

B. Overview of the Juvenile Justice System in Connecticut

page 24

C. Long Lane School

page 25

1. Overview of Long Lane School

page 25

2. Current Conditions at Long Lane School

page 26

a. The Population

page 26

Recommendations

page 28

b. Staffing

page 28

Recommendations

page 29

c. Mental Health Treatment

page 30

Recommendations

page 31

d. Physical Environment of Long Lane School

page 31

Recommendations

page 32

e. Reports of Internal Abuse and Neglect

page 32

Recommendations

page 33

f. Agency Police Officers

page 33

Recommendations

page 35

g. Use of Physical and Mechanical Restraints

page 35

Recommendations

page 36

h. Record Keeping

page 36

Recommendations

page 36

i. Lack of Communication

page 36

Recommendations

page 37

j. The Children’s Perspective

page 38

k. Other Concerns

page 38

APPENDIX

page 39


INTRODUCTION
Pursuant to Connecticut General Statutes sections 46a-13l(b) and (c), the Connecticut Child Fatality Review Panel is mandated to review the circumstances of the death of any child who has received services from a state department or agency addressing child welfare, social or human services or juvenile justice. After a preliminary examination of the facts in this case, the Child Advocate, as Chairperson of the Panel, began an investigation into the circumstances of the death of Tabatha B., whose death resulted from suicide while committed to the Department of Children and Families (DCF) at Long Lane School.
In conducting a review of this case, the Office of the Child Advocate (OCA) interviewed DCF employees, including staff of Long Lane School, and other social services providers who provided relevant information and suggestions for the Panel's consideration. Additionally, she reviewed records and documents pertinent to this case, including the records of DCF, the Department of Social Services (DSS), Tabatha’s clinical records from private agencies, documentation from other social service providers, Judicial Branch records, and reports from the Department of Public Safety and other law enforcement personnel. In the interest of maximizing resources and time, the OCA conducted its initial interviews in conjunction with DCF’s internal investigators in order to limit repetition and hardship to the individual witnesses. She also conducted more in-depth independent interviews where deemed necessary and appropriate. Additionally, she and other Panel members toured every building of the Long Lane facility that is used by children. They requested an up to date fire inspection of the institution as well. Finally, the OCA met with a group of children currently in residence at Long Lane School.
After intake of the above-described body of material, and after extended discussion, it was determined that it was necessary to focus both on the child welfare management of Tabatha’s case and on the state’s care of children at Long Lane School. As a consequence, this report was prepared by the OCA, with input from consultants and other Panel members. The full Panel then reviewed the report and voted to accept it for public release. The names of specific individuals have been omitted for reasons of confidentiality. Although the reliability and content of accounts and records may vary to some degree, it is believed that the following is a reasonably accurate account of Tabatha’s life.
The Panel wishes to publicly note the complete cooperation of Long Lane School administration, the Department of Children and Families, the Department of Public Safety’s Fire Marshal’s Office, the Judicial Branch, the Department of Social Services and private service providers. These agencies responded quickly and graciously to numerous requests for information and access to records. Finally, the Office of the Attorney General and the Department of Correction’s assistance in providing information to the Panel on the issues surrounding the state’s treatment of its correctional population and the training of corrections officers was invaluable.
SUMMARY OF FACTS
Tabatha B., a bi-racial child, was born on August 17, 1983 to a mother suffering from significant physical and mental health problems. No father was listed on the birth certificate, although paternity was later identified. Records indicate that her mother parented seven children, lost custody of five, and two other offspring died in a house fire.
The records reflect that Tabatha was the victim of physical abuse as early as two weeks of age and on numerous subsequent occasions. From infancy until her placement at Long Lane School, she was the subject of many referrals of sexual abuse and chronic neglect. She attempted suicide at the age of five and throughout her youth experienced numerous foster care placements and disruptions as well as psychiatric hospitalizations.

A number of psychological and psychiatric evaluations were conducted over the course of Tabatha’s lifetime and the termination of the mother’s parental rights was recommended by professionals as far back as 1988. No action was taken to follow through on this recommendation. Tabatha was the subject of neglect petitions, a family with service needs petition and a delinquency petition. The courts had involvement with Tabatha and her family, including her younger sister and her mother, over the majority of her lifetime.


It was not until 1996 that, at the mother’s request, a petition to terminate her parental rights to Tabatha was filed by DCF. This petition was granted by the court on August 9, 1996. After this, Tabatha’s foster placement disrupted and she experienced additional placements in both foster homes and residential facilities. By the age of fifteen, Tabatha had periodically threatened suicide, had been the victim of physical assault, had been the victim of rape and had an established pattern of running away from placements. She experienced court intervention as both a neglected child and as a delinquent child which resulted in her dual commitment to DCF. After being committed as a delinquent, Tabatha was placed at a residential facility where she assaulted a staff member. She was then transferred to Long Lane School.
Tabatha’s stay at Long Lane School was fraught with minor behavioral infractions. She experienced a series of setbacks and disappointments over events that occurred during that period and over relationships with family and former caretakers. She made statements about suicide and, on one occasion, unsuccessfully attempted suicide. She was placed on safety/suicide watches on numerous occasions during this period. On September 26, 1998, a series of events occurred that led to administrative charges of assault, disciplinary action against her, and a planned suicide attempt on that day. She was found hanging in her room, was transported to a local hospital and placed on life supports. Those supports were terminated two days later, by agreement of medical personnel, DCF and Tabatha’s biological family. Tabatha died on September 28, 1998, at the age of fifteen.

PART I: CHILD WELFARE MANAGEMENT OF TABATHA B.
A. Child Welfare Management Prior to Long Lane School
Panel finding:
Although the Panel understands that progress has been made since the Juan F. Consent Decree was implemented, DCF’s failure to provide Tabatha with adequate intervention and protection during her first five years set the stage for an ominous pattern of deterioration in her mental health.
1. Pre-Consent Decree Case Management1[1]
During the first two and one-half years of her life, Tabatha’s family was the subject of seven referrals to DCF for suspected abuse and neglect, including two involving the sexual abuse of Tabatha. Tabatha was allegedly the victim of attempted suffocation at the age of two weeks and the victim of sexual molestation in early and later infancy. On January 31, 1984, Tabatha was placed in the care of her godparents. Seven months later, the godfather was observed "french kissing" the one-year-old child in a doctor’s office. At the age of two, Tabatha was sexually abused by a seventeen-year-old boy. None of these referrals resulted in DCF opening a protective services case.

In January 1986, after additional referrals were made to DCF, Tabatha was evaluated for nightmares that she was experiencing as a result of sexual abuse. The psychologist recommended that a parent aide be provided to the family to teach appropriate skills and to monitor the godparent’s home environment. On January 21, 1986, DCF entered into a service agreement with the mother, designed to facilitate Tabatha’s return to her from the care of the godparents. This plan was carried out despite the fact that Tabatha’s stepfather, who was living in the home, had a history of alcohol and substance abuse, a chronic history of domestic violence, and had allegedly tried to rape his own mother and had sexual intercourse with his sisters.


According to records, from May 1986 through December 1988, DCF received twelve additional referrals concerning Tabatha's family. On October 28, 1987, her mother reported that Tabatha was sexually abused by her godparent’s teenage son. This incident allegedly involved oral sex, digital penetration, and attempted anal penetration. Four-year-old Tabatha’s ribs were allegedly broken and she was further physically assaulted in an attempt to prevent her from disclosing the abuse. The perpetrator of these offenses was convicted and incarcerated.
In June 1988, five-year-old Tabatha was admitted to a hospital after attempting suicide by smashing her face into a wall of exposed nails. In July 1988, she was transferred to a children's hospital, but was then removed against medical advice by her mother five days later. That same month, a psychiatric social worker reported to DCF that Tabatha was at risk of further emotional and sexual abuse. In August 1988, a psychiatrist issued a similar report and described her as having significant, severe emotional symptoms. The report was not investigated by DCF until one month after the referral, and resulted in recommendations for long-term outpatient treatment or, in the alternative, psychiatric hospitalization for Tabatha.2[2]
In October 1988, the mother twice advised the DCF social worker that Tabatha was continuing to have nightmares and difficulty sleeping and DCF advised her to take the child to the hospital. Tabatha was admitted with self-destructive behavior, uncontrollable anxiety, reported amnesia and behavioral problems. A psychologist conducted an emergency evaluation of Tabatha and her mother and strongly recommended that Tabatha have an inpatient psychiatric evaluation, and be committed to DCF, concluding that she would be at risk if she remained in the care of her mother. Tabatha was placed in a psychiatric hospital on a fifteen-day physician’s emergency certificate.
In November 1988, the mother agreed to voluntarily place Tabatha with DCF. Tabatha was discharged from the hospital to a foster home in December 1988. Later that month, a subsequent report from the psychiatric hospital concluded the termination of parental rights was essential for Tabatha’s future well-being because the mother would never follow through on promises to change her behavior. The team opined that:
by the time proof of her mother’s inability to care for her is again confirmed, critical periods in the child’s emotional development which would facilitate bonding with family will have been lost. Thus Tabatha would become a child further traumatized by the failure of reunification, prolonged reinstitutionalizations and the destruction of her expectations for nurturance and stability. Future permanency planning would be even more difficult.
The team deemed reunification with her mother unrealistic and contrary to Tabatha’s best interests.

During a supervised visit with Tabatha on December 14, 1988, the mother told Tabatha for the second time that she would kill the perpetrator of the child’s abuse. Five-year-old Tabatha then told her mother that she did not want to live with her. The mother reacted by screaming and crying and blamed Tabatha for not loving her. Throughout that month, Tabatha refused to visit her mother. On December 22, 1988, the mother filed a motion with the juvenile court requesting the immediate return of Tabatha to her care. Almost two weeks later, the court noted that, since Tabatha was on a voluntary placement, it could not prevent the return of Tabatha to her mother. DCF filed a last- minute request for an order of temporary custody, which was denied because it lacked the requisite affidavit alleging imminent danger to the child. Neither the court nor DCF records reflect any additional effort by DCF to secure the necessary legal support for Tabatha’s custody. As a consequence, despite the recommendation from the experts and the child’s strong preferences, she was returned to her mother’s care on January 4, 1989.


In March 1989, a court psychiatric evaluator concluded that the mother’s chaotic, impulsive and self-centered lifestyle was exceedingly unlikely to change, and that the mother was suffering from a serious emotional disorder. On March 15, 1989, the court adjudicated Tabatha as an “uncared for” child and ordered a six-month period of protective supervision.3[3] The mother was expected to participate in counseling at a clinic, cooperate with the Visiting Nurse Association (VNA) and a parent aide, inform DCF as to who was living in her home, and only use babysitters approved by DCF. In April and May 1989, the VNA made five home visits and the parent aide made four. Both agencies closed their cases. A status report filed with the court on June 13, 1989 indicated that the mother and Tabatha had been attending weekly family therapy for the previous five months. The mother, however, refused to participate in individual counseling. DCF recommended that the court end the protective supervision on September 15, 1989.
From 1989 to 1991, five additional referrals concerning the neglect or abuse of Tabatha were received by DCF. These referrals did not result in DCF opening a protective services case.
Analysis
The Panel is cognizant of the fact that, prior to the Juan F. Consent Decree, there existed a strong emphasis on family preservation. Therefore, the Panel does not intend to belabor the deficiencies in the management of Tabatha’s case by conducting an in-depth analysis of DCF’s handling of each referral during this period. Nevertheless, the child welfare lapses highlighted demonstrate a striking lack of proactivity that should have been taken to insure the wellbeing of this severely abused, emotionally disturbed and high-risk child. The handling of Tabatha’s case during this period is a good example of the kinds of child welfare management issues that the Consent Decree was invoked to remedy.
Without question, DCF did not afford adequate intervention, protection and care to Tabatha in her first five years of life. Indicators that the family could not care for her safely were overlooked or ignored. Striking evidence in 1988 that Tabatha was severely emotionally disturbed and that her mother was contributing to her mental health issues was discounted as was repeated evidence that Tabatha had been physically and sexually abused while in the care and custody of her mother. DCF did not meet the statutory standards required in the juvenile court for requests for orders of temporary custody and failed to utilize the expertise of the multiple psychological and psychiatric experts who had evaluated the mother and child in 1988 and early 1989 and who concluded that termination of parental rights was essential for Tabatha’s welfare.
2. Post-Consent Decree Case Management Prior to Long Lane
Panel Findings:

Tabatha did not receive the proper care and treatment necessary to address her need for permanence and her mental health issues.



Connecticut lacks appropriate treatment resources for emotionally disturbed children. As a consequence, Tabatha moved from one end of a continuum where she once had been regarded as a deserving victim to the opposite end where she was viewed as an undeserving delinquent.

On October 22, 1993, the mother contacted DCF and reported that ten-year-old Tabatha had sexually molested a one-year-old child and that, in response, she had hit Tabatha with a belt, causing two welts on her arm.4[4] A DCF social worker interviewed the mother and Tabatha. Three days later, the mother contacted DCF and stated that Tabatha no longer loved her and demanded that Tabatha be "placed for good." On that day, Tabatha was voluntarily placed in a foster home. Within a month, the foster mother requested Tabatha's removal due to her crying, screaming, fighting with other children, banging into walls and sleep difficulties. On December 3, 1993, Tabatha was hospitalized in a psychiatric unit for seven days with no visit from her mother. She was discharged to another foster home with diagnoses of post traumatic stress disorder and dysthymia. Residential treatment was recommended. The court granted an order of temporary custody to DCF on the same day.
Tabatha was again admitted to a psychiatric unit on January 1, 1994 with suicidal ideation, oppositional behavior and temper outbursts. Given Tabatha's failure in two foster homes, her unresolved issues with her mother, and her behavioral problems, a longer-term inpatient evaluation was recommended. Consequently, Tabatha was transferred to another hospital where she stayed from January 6, 1994 through February 25, 1994. Her discharge diagnoses were dysthymia, oppositional defiant disorder, post traumatic stress disorder and parent-child problems, with a recommendation for placement in an experienced, therapeutic foster home in conjunction with a day treatment program, or, in the alternative, a residential placement. Despite these specific recommendations, Tabatha was placed with newly-licensed foster parents who, the record reflects, the DCF worker suspected would be overwhelmed by Tabatha's behaviors. To augment this placement, Tabatha entered an extended day treatment program in March 1994.
In April 1994, Tabatha’s mother first voiced her intention to terminate her parental rights to Tabatha. On April 6, 1994, Tabatha was adjudicated as a "neglected" and "uncared for" child and committed to DCF.5[5] The court expectations required that visitation between Tabatha and her mother occur in a supervised family therapy setting. According to a treatment plan dated April 27, 1994, DCF’s goal for the family was "reunification." In June 1994, the mother began visiting Tabatha for the first time since the fall of 1993. Once again, Tabatha began exhibiting suicidal, destructive and aggressive behaviors. In August, a new social worker was assigned to her case. In September 1994, the foster parents requested Tabatha's immediate removal because of stealing and self-abusive behaviors. She was placed in a new foster home on September 7, 1994.
A court-ordered psychiatric evaluation dated October 15, 1994, described the mother’s lifestyle as dissolute, impulsive, dangerous and antisocial. She was living with two men at the same time, sharing her bed with both of them. She stated that it was good for Tabatha to have "two daddies." The report, filed in court on October 31, 1994, also reflected that the mother had been married five times and had maintained relationships with dangerous people, including the arsonist who set the fire that killed two of her other children. The evaluator summarized:
In spite of repeated recommendation[s] not to return Tabatha to the care of her mother and in spite of no apparent change in [mother's] functioning, Tabatha continues to be considered for return to her mother's care under which circumstance she had been repeatedly abused, neglected and placed at risk of harm by herself as well as by a succession of male abusers who have been given access to Tabatha as a result of her mother's actions.
The evaluator concluded that the mother would never be able to protect or supervise any child at any time in the future. He cautioned that any hope that the mother and child could be reunited was absurd, regardless of the intensity or nature of therapeutic contacts.
On November 2, 1994, an administrative review of Tabatha’s case was held and, despite the above-mentioned findings of the evaluator, DCF concluded that "some progress [had] been made" and that the goal was reunification within a year. In January 1995, Tabatha’s foster mother reported constant behavior problems at home and in school, and both DCF and Tabatha's therapist expressed concerns about Tabatha not eating well and not taking her medication. Nonetheless, DCF, in concert with the therapist, decided to begin supervised visitation in the mother's home. The therapist attributed Tabatha's recent behaviors to "anxiety about returning home." From January through April 1995, at the therapist’s urging, DCF began supervised, and then unsupervised, visits. Visitation was briefly suspended in May 1995 when the mother's therapist reported that the mother was refusing treatment and required medication. Tabatha's behavior greatly improved during this period of no visitation but Tabatha's therapist remained firm in her belief that extended visits with the mother should resume, and DCF agreed. Tabatha and her mother consistently reported that the visits were going well until August 4, 1995, when the mother indicated that she wanted to terminate her parental rights to Tabatha, reporting that, during the last visit, she had given Tabatha a knife and told her to kill her (the mother). On another occasion, Tabatha reportedly asked her younger sister to jump out of a window.
In September 1995, Tabatha’s foster mother indicated her willingness to adopt Tabatha. The following month, the mother stated that she wanted the foster family to adopt Tabatha, but also voiced her interest in visiting with Tabatha again. DCF instructed Tabatha's therapist that the mother and child were to have no contact.
In February 1996, Tabatha expressed her ambivalence about remaining in the foster home. Nonetheless, DCF filed termination of parental rights petitions. By the end of that month, Tabatha was expressing her desire to resume contact with her mother and blaming DCF for all of her problems. She was formally discharged from her day treatment program in April 1996, but did not begin with the recommended outpatient treatment until October 1996. After vacillating several times, Tabatha’s mother voluntarily terminated her parental rights on August 7, 1996.
Tabatha asked to be removed from her foster home in September 1996, claiming that she was the victim of physical and verbal abuse. The foster mother admitted to "bopping" Tabatha and a service agreement was signed. In October 1996, Tabatha again alleged that she was being verbally abused in the foster home. She was placed in two different foster homes over the next three days.
During this period of time, Tabatha continued to have intermittent contact with her mother despite her new therapist’s recommendation against it in January 1997. The therapist expressed concerns to DCF again in March and April 1997. Tabatha began skipping school, receiving detentions and missing therapy appointments. In June, Tabatha was evaluated at a hospital emergency room for suicidal threats and discharged after a "safety contract" was signed. In July 1997, the foster mother requested Tabatha’s removal. Tabatha was placed at a shelter, and her former foster mother began visiting.
On August 10, 1997, Tabatha fled the shelter and was sexually assaulted. She was returned to the shelter, where she subsequently made a number of allegations regarding substandard care. Tabatha continued to have telephone contact with her mother, although she was expressing her anger at her mother to the social worker. She was upset that, among other things, her mother "always chose her sister over her." Tabatha continued to skip school.
On September 17, 1997, Tabatha was admitted to a short-term intensive residential program but, by the end of October, she was constantly absent without leave from the program and from school. Despite concerns about adequate supervision, DCF allowed Tabatha to remain in this placement. On November 12, 1997, Tabatha’s probation officer filed a Family With Service Needs petition (FWSN),6[6] alleging that Tabatha was beyond the control of DCF, her statutory parent.
In November 1997, Tabatha was AWOL from her residential program at least seven times. On November 25, 1997, she was adjudicated as a FWSN, and specifically ordered by the judge not to run away. That same day, she left the facility and did not return. The court issued a "take into custody" order, and Tabatha’s probation officer filed a delinquency petition alleging violation of the court order. Tabatha was missing for two months. On January 23, 1998, she turned herself in to the police and was placed in detention.7[7] On January 27, 1998 the court ordered a psychological evaluation of Tabatha and remanded her to detention. She was appointed a guardian ad litem and insisted that she wanted to be placed at Long Lane School.
As a result of this latest evaluation, Tabatha was diagnosed with oppositional/defiant disorder, depressive features, cannabis abuse and alcohol abuse. Residential placement was again recommended. The psychologist requested that DCF consider highly-structured visitation with the mother, opining that the visits would assist in the child's compliance. At a detention hearing on March 10, 1998, the court also strongly encouraged DCF to allow contact between Tabatha and her mother during the period of detention. During this period a substance abuse evaluator concluded that Tabatha would benefit from substance abuse treatment.
On March 26,1998 the court adjudicated Tabatha as a delinquent child and committed her to DCF for a period not to exceed eighteen months. However, this was a direct placement through Long Lane School8[8] and, the following day, Tabatha was placed at a residential facility for adolescent girls with substance abuse problems, under the supervision of her Long Lane parole officer. On April 26, 1998, Tabatha was involved in a physical altercation with a staff member. She was arrested, temporarily placed at a shelter, and then transported to Long Lane School on April 27, 1998.
DCF received six more reports of suspected abuse or neglect involving Tabatha’s family between 1989 and 1993 before DCF again opened a protective services case. Tabatha’s mother contacted the agency on October 22, 1993 and reported that she had hit her daughter with a belt as punishment for sexually abusing a younger cousin. It is clear from the record that ten-year-old Tabatha was now seriously emotionally disturbed and that her mother felt unequal to the task of controlling her daughter’s behavior.
This period of state involvement with Tabatha is reflective, not of DCF inaction or failure to respond but, rather, the failure to secure for Tabatha the proper treatment that she desperately needed and the failure to make an appropriate permanency plan for her. The only positive factor in Tabatha’s life during this period was the assignment of a dedicated and committed DCF social worker who would remain on her case consistently almost until the time of her death.
Despite Tabatha’s two psychiatric hospitalizations and required placement in two more foster homes in 1993-1994, and continued expert opinion that the mother was unfit and unable to protect or supervise any child at any time in the future, DCF pursued the unrealistic and unsafe goal of reunification of the now eleven- year-old girl with her mother. The Panel can only conclude that the child welfare interventions made were contrary to Tabatha’s best interests.
In September 1995, when Tabatha’s third foster mother expressed an interest in adopting her, DCF finally suspended visitation with her birth mother and stopped pursuing family reunification. Tabatha was discharged from the extended day treatment program in April 1996, and DCF left the task of finding another psychotherapist for Tabatha to her foster mother. Tabatha received no psychotherapy for the next six months. As a result, her desperate need for skilled psychotherapy and consistent emotional support was not met. The deterioration of Tabatha’s mental health issues continued.
Only at the behest of the mother did DCF finally file a petition to terminate parental rights which was granted after the mother’s voluntary consent in August 1996. Not surprisingly, thirteen-year-old Tabatha now had tremendous ambivalence about a legal dissolution of her family relationships that was against her own hopes and wishes. The records do not reflect that she was given an opportunity to address her hurt, anger and feelings of rejection and abandonment, especially after she began to experience the reality of this legal proceeding and its consequences.9[9] This only exacerbated her already deteriorated emotional condition. Because Tabatha was old enough to act independently, DCF, her statutory parent, could not prevent Tabatha from initiating contacts with her birth mother, a person who continued to feel ambivalent about her decision to sign away her parental rights and who did not discourage the contact.
At that point, there was ample evidence that Tabatha’s needs could not be met in nonspecialized foster care and that she needed a therapeutic placement or residential care. The records do not reflect that either option was tried, was available or was even considered. Instead, over the next nine months, she experienced two additional placements in foster care and an emergency shelter, was hospitalized for suicidal threats and was sexually assaulted after running away. She was then placed a in a short-term residential treatment program that lacked the skilled psychiatric services and close supervision that she required and she began to be truant from school and absent from the program without leave. This was a clear indication that this placement was unsuitable for her. Rather than seeking a psychiatric facility that could meet the child’s needs, DCF petitioned the court to declare her a child whose "family" (DCF) could not control her. Based on her past behavior, it was not surprising that after the court "ordered" her to stay at the placement, Tabatha violated the court order later that day by, once again, running away.
A commonly-utilized legal maneuver had opened the door for a delinquency petition on a child who, up to that point, had only committed status offenses, behaviors such as running away or being truant from school. After being missing for two months, Tabatha was placed in detention on January 23, 1998 for two months and evaluated with the diagnoses of cannabis abuse and alcohol abuse and oppositional-defiant disorder with depressive features. She was then adjudicated a delinquent child and committed to DCF thereby enabling DCF to place her in a residential facility for adolescent girls with substance abuse problems. That decision was deficient in that the facility did not have the intensive psychiatric services to address her more serious underlying mental health issues that Tabatha now required. After further deterioration at this facility, she was arrested and charged with assault of a staff member and placed at Long Lane School on April 27, 1998.
Thus, at age fourteen and one-half, Tabatha went from being a victim of physical, sexual and emotional abuse and severe neglect to being a delinquent child. From the perspective of her caretakers, her status had changed from that of an abused and neglected child with severe emotional damage who desperately needed skilled parenting, a consistent caretaking environment and long-term skilled psychiatric treatment to that of a "bad" child who needed punishment and correction. Tabatha had slid from one end of a continuum where she once had been regarded as a deserving victim to the opposite end where she was viewed as an undeserving delinquent.

 

B. Child Welfare Management at Long Lane


Panel findings:
Tabatha was placed in a correctional facility that lacks sufficient resources and the treatment milieu necessary to meet the needs of a diverse population of emotionally disturbed children.
DCF’s Long Lane staff failed to recognize the significance of Tabatha’s multiple suicidal behaviors exhibited prior to her death, and failed to conduct a comprehensive assessment of her mental health issues.
The State of Connecticut does not have a secure in-patient residential setting to treat those children who have complex emotional needs but who are not serious offenders.
As a direct result of the assault on the staff person at the residential facility, Tabatha was placed at Long Lane School on April 27, 1998.10[10] Within days of her arrival she began to be written up for such offenses as engaging in back and forth conversations with her peers, poor group interaction behavior, provoking peers, poor attitude, use of profanity, cracking her knuckles. and poor cafeteria behavior. In May, she was written up on twenty-eight occasions. In response to her disruptive behavior on May 16, 1998, Tabatha was locked in her room.
Tabatha’s therapeutic program at Long Lane consisted of weekly meetings with an unlicensed, but experienced, clinician who had a Masters of Social Work degree and the title of Psychiatric Social Work Associate. Her only training in suicide assessment took place in 1992. This clinician was assigned to the girls’ cottage and met with Tabatha for the first time on April 28, 1998, the day after Tabatha arrived. A primary focus of the therapeutic intervention with Tabatha appears to have been her relationship with her mother, whom she had not seen in a year. The clinician sought and received permission from Tabatha’s DCF caseworker to engage Tabatha’s mother in therapeutic family sessions at Long Lane School. Tabatha’s mother attended a few scheduled sessions but canceled so many that the clinician stopped telling Tabatha about scheduled meetings in order to prevent her disappointment. The Panel’s review of the clinical records of these sessions revealed little of the content of the session. However, monthly clinical update notes reflect that the focus of these meetings was Tabatha’s relationships with others, anger management skills, and her perceived bulimic condition..
In June, Tabatha had a preplacement interview at an in-state residential facility and was rude to the interviewer. She reconsidered her behavior and wrote a letter of apology, requesting a second interview. After the second interview, she was not accepted into that program. During this month, Tabatha was written up for twenty-five incidents including poor circle behaviors, silliness, going back and forth with a peer, poor line norms, excessive noise, and a non-caring attitude. Twice in June, she was punished with seclusion.
Throughout her stay at Long Lane, Tabatha continued her pattern of exhibiting noncompliant behavior and complaining about medical problems. Her mother continued her pattern of disappointing her daughter by failing to keep scheduled visits. Tabatha was assessed for depression and was prescribed medication, although she often refused to take it. In August 1998, she celebrated her fifteenth birthday and marked the second anniversary of her mother’s voluntary termination of parental rights. On August 3, 1998, the Long Lane psychiatrist evaluated Tabatha for depression and bulimia.
Tabatha received a pass to visit her former foster family on August 15 and 16, 1998. The visit went well and Tabatha earned a pass for the weekend of August 22. On August 21, however, Tabatha’s parole officer revoked this pass as a consequence of Tabatha’s reluctance to consider an out-of-state placement in Pennsylvania. (Tabatha wished to remain at Long Lane since she had begun off-grounds visiting.) That day, an alert report was issued because Tabatha stated that she "wanted to kill herself." Tabatha's clinician ended the alert several hours later concluding that she was no longer considered a risk to herself or others. Tabatha was not seen by a psychiatrist or psychologist in response to this incident.
Seven days later, Tabatha was involved in a verbal and physical altercation with another child. She was physically restrained by staff and placed in seclusion for a brief period. On August 30, Tabatha threatened to injure herself if she was not permitted to talk to her mother. She was crying, highly anxious and agitated. She was placed on a ten-minute safety watch,11[11] with a safety suit and safety blanket, in a stripped room.12[12] Tabatha’s clinician removed all precautions the following day, and dismissed the incident as Tabatha’s anger. The clinician discussed anger management skills with her. Although this was Tabatha’s second suicide threat in nine days, no attempt was made to have her evaluated by a psychiatrist and her clinician apparently had sole responsibility for removing the safety watch.
Because of her behavior, Tabatha was placed on "pending transfer" status to the diagnostic unit. Unfortunately, the shortage of beds in the diagnostic unit meant that this status could last indefinitely.13[13] On August 31, she requested a grievance form as she wanted more free time out of her room. The Long Lane records indicate there was a shortage of staff on that day, and other than bathroom breaks, receiving her meals, and visiting the nurse for five minutes, Tabatha was confined to her room for most of the afternoon and evening of August 31. On September 2, during her free time, she began yelling and swearing and was again moved to isolation.
Tabatha's mother failed to appear for a scheduled family therapy session on September 8, 1998. On that same day, Tabatha was placed on "cottage probation" (confinement to the cottage) for ten to twelve days for a previous infraction. On September 11, 1998, Tabatha was advised that her interview at the out-of-state facility would take place the following week. She was also informed that her long-time DCF social worker, with whom she had a good rapport, was transferring Tabatha’s case to a new worker. Finally, Tabatha was told that she would have to testify in a sexual assault case in which she had been the victim.
On Saturday, September 12, Tabatha was involved in a verbal altercation with another child and was sent to her room for "awhile." At noon, Tabatha and the same child resumed their confrontation, and Tabatha was sent to her room for the remainder of the shift. At 1:50 p.m., staff heard a gagging noise coming from Tabatha's room and found her on the floor with a scarf triple-knotted around her neck. According to varying reports, Tabatha was found semi-conscious, she appeared "blue" and staff had difficulty untying the knot. By the time a nurse responded to the scene, Tabatha no longer appeared "blue," she insisted that she had not meant to harm herself and that the incident had been an accident. As the situation was being assessed, however, Tabatha wrapped her bathrobe around her neck, squeezing tightly, in full view of the nurse. Tabatha then bit a staff person who attempted to remove the robe. The agency police officers were called and Tabatha was restrained, placed in a safety suit, and placed on a one-to-one safety watch.14[14]
Tabatha was on "pending transfer" status from September 12 through September 18. She did not have contact with her clinician until Monday, September 14, two days after the incident. The clinician had received a short message on her answering machine about the incident and met with Tabatha to assess her. Tabatha claimed that her plan was to get attention, that her foot slipped, and that she was unable to call for staff. The clinician was unaware, at the time of the suicide assessment, of Tabatha’s second attempt to strangle herself in the presence of staff or that she appeared "blue" when found. Tabatha was removed from one-to-one observation and placed on a ten-minute safety watch, at which time she was described as depressed and withdrawn. The following morning, her clinician removed the safety watch entirely. Later that day, Tabatha had her first visit since her attempted suicide with the Long Lane psychiatrist.
On September 18, 1998, Tabatha was placed on cottage probation for five to seven days for biting during the suicide attempt. On September 22, 1998, Tabatha left a message with her stepfather for her mother to call and schedule a family therapy session with the clinician.15[15] On September 23, 1998, Tabatha received two positive written reports, the first since she had been at Long Lane. The next day, Tabatha visited an out-of-state facility with her clinician and her case manager, both of whom felt that she was in good spirits during the trip. During the interview process, however, Tabatha was advised that she would be placed at that facility in a "week or so" and that, based on her recent suicide attempt, her admission was conditioned on her initial placement in their forty-five day diagnostic unit. Tabatha was unhappy about this decision, and continued to be upset that she had to be placed so far away from home.
Two days later, on September 26, 1998, Tabatha threatened another child. Youth Services Officers (YSOs) restrained her and received minor injuries in the process. Tabatha was charged administratively with assault and returned to seclusion where she was checked every fifteen to thirty minutes by a staff person. At 11:05 a.m., she was summoned to an administrative hearing with the Duty Officer,16[16] and subsequently placed on a half-hour safety watch. Records reflect that she was checked by a YSO approximately every half-hour, the last check being at 3:50 p.m. when the YSO observed a blanket hanging over the window. Tabatha said "hi" and appeared to be trying to nap. At 4:15 p.m., the same YSO entered Tabatha’s room and found her hanging, unconscious, by her bathrobe tie from the window shade brackets. The YSO attempted to hold Tabatha up while screaming for assistance.
In response to the emergency call made from the girls’ cottage, agency police officers (APOs) were on the scene in a matter of minutes. One officer lifted Tabatha to alleviate pressure on her neck, while another officer ran to call 911. Tabatha had no pulse and the knot around her neck was very tight and difficult to remove.17[17] Cardiopulmonary resuscitation was begun. The nurses responded within seven to ten minutes and continued the CPR until relieved by paramedics. Tabatha was stabilized, a pulse was detected and she was transported to a local hospital. She was later transferred to a children’s hospital, where a joint decision between DCF, Tabatha’s mother and medical professionals, was made to terminate life support. Tabatha died on September 28, 1998.

 

Analysis


A review of Tabatha’s case during this period of time, and specifically of those events surrounding her death, leads the Panel to conclude that, although it appears that Long Lane staff correctly followed procedures established by the institution, those procedures did not comport with the standards of care necessary to safeguard the well-being of this severely disturbed child.
The severity of Tabatha’s psychiatric problems was never recognized by DCF, her statutory parent, before or after her commitment to Long Lane School in April 1998. Her records reflect that, by early 1997, she needed an extended placement in a secure residential treatment program that offered skilled psychiatric services and milieu therapy. Unfortunately, Connecticut lacks such facilities for the growing population of disturbed adolescents who need skilled and secure treatment beds. Even if DCF had recognized and attempted to meet the complex treatment needs of this abused, neglected, and severely disturbed child in a timely fashion, it would have been difficult to find a placement for her in this state.
Instead of being placed at a secure, residential treatment facility for severely disturbed adolescents, Tabatha was now placed in a correctional facility. By her behavior throughout her five-month stay at Long Lane School, she continued to demonstrate her need for a treatment model, rather than a correctional model of intervention. She received minimal psychotherapeutic services and she responded with defiance and received negative consequences for minor infractions of the rules, such as talking and being silly with other girls in a manner deemed inappropriate by the staff.
In addition to providing minimal psychiatric services to its severely disturbed population of delinquent adolescents, Long Lane School is understaffed with an unacceptably low ratio of staff to children (1:10) in the cottages where most of the population resides. In fact, the YSO who found Tabatha was responsible for the direct care of nineteen girls on the afternoon of Tabatha’s death. Understaffing makes it very difficult to monitor those children who are at risk for suicide. Theoretically, once identified as suicidal, children can be transferred to the diagnostic unit on the grounds for closer monitoring and treatment. However, the option of immediate transfer to the diagnostic unit rarely is possible, since there was and is a long waiting list for open beds.
Another deficiency pertinent to Tabatha’s case is that Long Lane School staff had not received the level of initial training or yearly updates in training that are recommended by the American Correctional Association.18[18] This means that most of the staff who have direct contact with children are not adequately trained to recognize suicide risk and also lack training in suicide prevention.19[19]
Although she had a successful visit with her former foster mother on the weekend of August 15, 1998, Tabatha began an ominous pattern of threats of self-injury and suicidal behavior on August 21, 1998. Precipitating factors included her disappointment over her mother’s failure to attend scheduled visits, learning of a plan for an unwanted transfer to an out-of-state facility, and having her pass for weekend visits revoked as punishment for refusing to consider this proposed transfer. Nevertheless, Tabatha’s initial suicide threats were not taken seriously and her clinician lifted the suicide alert several hours later.
Unfortunately, Tabatha’s suicidal behavior was viewed as defiance and manipulation, rather than as an indication of severe psychiatric illness. None of the staff at Long Lane School recognized the lethal nature of her extensive prior history of suicidal behaviors and the plethora of recent stressors that placed her at the highest level of risk for killing herself. When she again threatened to injure herself on August 30, 1998, she was physically restrained in a safety suit and safety blanket and placed in a stripped room with staff checks every ten minutes until the following day.

This typical aversive response to a child’s threat of suicide was necessitated by the low cottage staffing levels at the facility. With only two cottage staff to monitor twenty children, the only safe way to monitor a suicidal child who must be checked every ten minutes is to apply this level of physical restraint.


If the child is not a bona fide suicide risk, such an aversive response might prevent her or him from threatening self-injury in the future. However, for a seriously emotionally disturbed adolescent, an aversive response to a suicide threat can be very traumatizing, especially if the child does not also receive an intensive psychotherapeutic response or an alleviation of stressors. Tabatha received neither. In fact, after she convinced her clinician on August 31, 1998, that she was not a suicide risk, all suicide precautions were removed. Active psychotherapeutic intervention to prevent suicide was indicated at this time, but was not initiated.
Tabatha’s psychic stress was intensified in early September 1998, when she learned that she soon would lose a valued relationship with her DCF caseworker and that she would be required to testify in the upcoming criminal trial of the person who had sexually assaulted her in August 1997. At this point, she manifested all of the primary risk factors for suicide listed in the literature.20[20] On September 12, 1998, after being sent to her room as punishment for arguing with a peer, she tried to hang herself with a scarf. On this occasion, staff heard gagging noises and rescued her before she sustained serious injury.
Although Long Lane policy requires that a clinical assessment be conducted in cases of suicidal behaviors in order to determine the type of intervention necessary, Tabatha was assessed by a nurse with no clinical qualifications to make such an assessment. Tabatha denied that she had been trying to kill herself yet wrapped a bathrobe around her neck, squeezing it tightly in the presence of the nurse who was assessing her. Again, her behavior was treated as defiant and manipulative, rather than as a cry for help.
In retrospect, it is clear that, at that point, Tabatha should have been sent to a psychiatric facility for evaluation and admission. Instead, she again was put into a safety suit and placed on one-to-one supervision. Since her suicide attempt occurred on a weekend, she remained in the safety suit with one-to-one supervision for the next two days. Again, on September 14, 1998, Tabatha was able to convince her clinician that she was not at risk for further self-injury. By the time she saw the facility psychiatrist on September 15, 1998, all suicide precautions again had been removed.
It is important to note that critical information about Tabatha’s suicide attempt on September 12 was not communicated to the clinician. She was not made aware of the seriousness of the attempt, nor that Tabatha had made a second attempt to strangle herself while the nurse was evaluating her. Such information, critical to a complete assessment would have assisted the clinician in appreciating the seriousness of Tabatha’s suicide attempt. Nevertheless, on September 14, it was premature to remove all suicide precautions on this high-risk adolescent who had attempted to hang herself two days earlier.
Although the plan to move Tabatha to the diagnostic unit at Long Lane School, a setting where she could have been supervised more closely, remained in place, it was never implemented because there was no space available in that unit. Indeed, the Panel learned through interviews with staff that pending status is "a joke" since there are never beds available. Instead, Tabatha remained in the cottage where she had attempted suicide with no special precautions in place to safeguard her. In summary, Long Lane’s response to Tabatha’s suicide attempt can only be deemed punitive and not therapeutic. By placing Tabatha on cottage probation, the clear message was that she was being punished for bad behavior.
On September 24, 1998, Tabatha visited an out-of-state facility and was told that she would be moved there in approximately one week to begin a forty-five day stay on the diagnostic unit because of her recent suicide attempt. While she seemed in good spirits during the trip, she was clearly unhappy with the prospect of being transferred to a diagnostic unit in a new facility. Two days later, on September 26, 1998, she threatened and physically assaulted a peer, was forcibly restrained by YSOs, and was secluded in her room. Given Tabatha’s recent history of suicide attempts, the half-hour room checks instituted by the staff, while conforming to Long Lane policy, were insufficient for this high risk adolescent, and allowed her enough time to remove the belt stitched to her bathrobe, knot a noose and hang herself from the window shade brackets.
As the Panel has found in other fatality reviews, the decisions made in Tabatha’s case were deficient in the sense that each incident was treated as an isolated event rather than as part of a larger pattern. Tabatha needed service providers and caretakers who worked as a team, shared critical information with one another and assessed this complex and severely-disturbed child in a comprehensive fashion. Under such circumstances, a review of Tabatha’s history, her self-injurious behaviors, her self-destructive statements and the plethora of emotionally significant events in her life that occurred during August and September 1998 would have highlighted her extreme risk for completing a suicide attempt. There is no question that Tabatha was in need of intensive psychiatric treatment and that the counseling provided was simply insufficient to meet her needs.


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