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Social services failures in death of Rockbridge infant underline larger, long-term problems in Virginia

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Social services failures in death of Rockbridge infant underline larger, long-term problems in Virginia

Picture of Alison Graham

This story was produced as a project for the 2019 National Fellowship.

Charlee Marie Ford lived in this home on Alone Mill Road outside Lexington.
HEATHER ROUSSEAU | The Roanoke Times
The Roanoke Times
Saturday, November 16, 2019

Charlee Marie Faith Ford came into the world struggling to live.

After an emergency C-section at 37 weeks, her lungs failed for nine minutes before doctors revived her.

She was born with opioids and marijuana in her system. Doctors diagnosed her with cerebral palsy and she suffered from severe seizures. Her mother was a drug addict, her father a convicted felon.

Doctors at the Charlottesville hospital where Charlee was born called the Rockbridge Area Department of Social Services because of the drugs in Charlee’s system. Physicians are required by law to make a report of child abuse or neglect when drugs are found in newborns.

 

A child protective services worker classified Charlee as low-risk, meaning she was unlikely to be a victim of further abuse or neglect. The worker completed a family assessment and put a safety plan in place that required Charlee’s father, Charles Ford, to accept primary responsibility for Charlee’s care. Her mother, Diana Nicole Hazelwood, was not allowed to be left alone with Charlee at any time.

In the months after her birth, Ford left Charlee’s mother alone with the child multiple times, according to testimony in Ford’s criminal case. The social services department received another complaint about the Fords and visited their home on Alone Mill Road. The same child protective services worker labeled the family as high risk for abuse and neglect. That would normally open a child protective services ongoing case and the department would provide needed services to the family.

But there were no services. There were no follow-ups. And after a few weeks, Charlee died.

Charlee spent her short life in Virginia's deliberately decentralized social services system, which gives the state little authority to oversee its 120 independent local departments. That lack of control leads to devastating consequences for Virginia’s children and families.

Charlee’s half-sister, Ashley Ford, said before Charlee’s death, her dad sent her ultrasound pictures and video called her about the baby nearly every day.

After Charlee died, he called sobbing.

“He kept saying, ‘She’s gone, she’s gone. I couldn’t save her,’” Ashley said.

Ashley, 26, lives in Maryland. She went to therapy when she had relentless nightmares about the baby. She saw Charlee every time she closed her eyes.

Ashley’s father told her the baby’s cause of death was undetermined. She knew Charlee had seizures and was born early, but when Hazelwood told Ashley the police were asking questions and requesting an autopsy, Ashley grew suspicious. She eventually learned about the drug abuse and the social service department’s involvement.

Then her dad was charged with murder.

Now Ashley blames the caseworker for Charlee’s death. Ashley said she would have taken the baby if social services had called for a family placement. She gave birth to her own daughter just weeks after Charlee was born.

“They had two chances and they failed her both times,” Ashley said. “That home was the cause of her death.”

Although the Rockbridge County social services department became infamous for its rampant dysfunction — a supervisor shredding child abuse complaints, screening out cases that should have been investigated, never performing background checks — it’s far from the only department consistently experiencing problems.

The state beefed up its reviews and oversight of the local departments after the failures in Rockbridge County. In 2017, state officials began reviewing departments annually through agency case reviews, where regional office employees select a handful of CPS, foster care and adoption cases to determine if the agency is following state policy.

An analysis of these reviews and quality management reports on departments across the state shows a failure to meet standards year after year. And Virginia has no formal process to ensure they come into compliance.

Rockbridge County’s department had improperly screened out child abuse and neglect complaints for at least four years, before and after Charlee's death in April 2016. The agency had a history of responding to a report, learning additional information and then screening out the report without an investigation or family assessment.

“Making initial contact on a CPS report and then screening out the referral is against CPS guidance and does not allow for the due process afforded to every citizen,” the agency’s 2017 review read.

The next year, the department’s review pointed out the same problem and copied and pasted the same recommendation. Eight out of 10 recommendations related to child protective services in Rockbridge’s 2017 agency case review appear, nearly verbatim, in the 2018 review.

It wasn't just in Rockbridge County. In 2015, a quality management report from the Orange County Department of Social Services found employees were not correctly maintaining the statewide database. The agency’s database includes vital information related to CPS and foster care cases. If the database is not maintained, the state cannot determine whether the department is acting within state policy.

The report said the integrity of the data had been addressed with the previous director and services supervisor on multiple occasions and a corrective action plan was created, but never implemented.

“It was difficult to determine if frequent visitation between parents and their children, as well as visitation among sibling groups to maintain relationships occurred,” the report read. “Other forms of communication, such as regular phone calls, were not noted.”

Agency case reviews completed in 2017 and 2018 noted the same problem: documentation was still lacking for family engagement efforts, medications for foster care kids, safety and well-being.

The state has documented the same database problem at the Culpeper County Department of Social Services. Supporting case documentation cannot be found in the database, which “made it difficult to determine the quality of the casework that was being completed,” according to the department’s 2016 quality management review. The same problem was pointed out the following year in the department’s agency case review.

The lack of follow-through by the state department was discussed in a 2018 report by the Joint Legislative Audit and Review Committee. Commissioner Duke Storen, the head of the state social services department, called it a “well-founded” criticism at the state board’s meeting in December.

But JLARC reports have documented this problem for nearly 40 years. A 1981 review of the state social services department said, “There is no state-level follow-up for compliance with recommended changes” and “agencies can continue to operate for years with severe inadequacies.”

Another JLARC report in 2005 said the state department of social services had supervision and support weaknesses — that no one was monitoring the local departments and the state agency had only limited knowledge of whether local departments were complying with federal and state requirements.

The 1981, 2005 and 2018 JLARC reports all mentioned the state’s limited ability to intervene and its lack of authority spelled out in Virginia law.

The 2018 report said, “VDSS staff and leadership have historically perceived that their authority is limited to simply asking local department of social services to address identified problems, with no recourse if local department leadership ignores their request.”

Charlee’s death wasn’t the first indication something was wrong in the Rockbridge Area Department of Social Services in 2016, and she wasn’t the first infant who died. After Charlee’s death, three investigations — a quality management report, a special grand jury and a state board investigation — revealed a pattern of dysfunction directly affecting families.

In 2013, dispatchers received a 911 call that an infant wasn’t breathing. When they arrived at the mobile home, the baby’s mother was outside performing resuscitation on her 7-month-old son, Jake Wesley Slagle.

Trash, roaches, feces and fleas covered the walls and floors. Children in the home were partially unclothed and at least one child was covered in feces.

The Rockbridge County social services department received reports about the family’s inadequate shelter and supervision in 2010 and 2012, according to a child fatality review report from the Virginia Department of Social Services.

Before 2006, local agencies only reported when a child who died from abuse or neglect had been part of a previous child protective services investigation. Since then, local departments have reported any prior involvement with the family, including with parents and siblings. Both child deaths and the number of those families already known to social services has been rising in recent years. Data provided by the Virginia Department of Social Services. 

In a separate case, deputies arrested Robert Eugene Clark in 2016 for sexually abusing two girls, ages 3 and 8. He held their shoulders and forced them to watch pornographic movies. He raped and molested them on a regular basis and whipped them with a belt while they were naked.

The Rockbridge County Sheriff’s Office investigation also found that Clark’s sister, Samantha Simmons, performed oral sex on two boys, ages 12 and 15, in a van parked near the Clarks’ trailer. Both adults were convicted of sex crimes and sentenced to a combined 108 years in prison.

Sheriff's office Capt. Tony McFaddin said social services had been called about at least two of the four children in 2014 and 2015, but the complaints were never investigated.

The grand jury report revealed that initial reports to child protective services about the Clarks were not entered into the statewide database and were not followed up with an investigation. The CPS worker, Peggy Sigler, asked the child protective services supervisor why state policy was not being followed, and the supervisor replied that was the way she wanted it.

Sigler went to the agency director, who said she did not want to confront the supervisor about it. So Sigler bypassed the supervisor and opened an investigation three days after a request from the sheriff’s office.

According to the special grand jury report, only the supervisor or the director could authorize the children to be removed from the home, but neither did. The supervisor said, “They’re used to living that way so what’s the big deal.”

Sigler filed a protective order with the court and was able to remove the children against the supervisor’s wishes.

The regional office, which is made up of state employees based in Roanoke, conducted a quality management review of the department and finished its report in May 2016, one month after Charlee’s death.

The report, which delves into every unit of the department, revealed that the child protective services supervisor had been shredding child abuse and neglect complaints before they could be entered into the statewide database and investigated. The supervisor changed the dates on some reports to meet state response deadlines and told employees not to take emergency child abuse calls after regular business hours.

The supervisor created her own intake system where she alone determined whether a child abuse or neglect call should be investigated. The grand jury found that almost 50% of the reports where no action was taken should have been investigated.

“Workers stated that sometimes they are so concerned about some cases, they offer services in secret,” the report read.

Most of the employees reported the supervisor created an atmosphere of bullying, harassment and intimidation at the agency. Criminal background checks on applicants, employees and volunteers had not been completed in 15 years. Child protective services workers had not completed mandated training because the supervisor did not allow them to attend.

The report detailed the worst case of corruption, malfeasance and negligence seen in any one department. 

A special grand jury investigation, the first one in the county since the 1980s, was opened to determine whether criminal charges could be found against the department’s workers.

The grand jury report released in 2016 confirmed much of what was found in the first report, but the probe did not turn up sufficient evidence to bring forth any criminal charges against department employees or the supervisor.

Citizens and legislators contacted the Office of the State Inspector General to investigate, but the office said it could not because the department received less than half its funding from the state. That law was changed in 2017 as a result of the situation in Rockbridge County.

After the special grand jury, the state board of social services opened an investigation into the local board, a group of seven citizens appointed by the local governments to provide oversight to the department.

It was the first time the state board had ever investigated a local board, a power that is outlined in Virginia law. The board investigated for 10 months, saying it wanted to create a process it could follow in any subsequent investigations.

In August 2018, the board voted unanimously not to suspend or remove any members of the social services board. The state board found the Rockbridge board had acted passively, but the members didn’t know how to act as a board because they hadn’t received proper training from the state.

The investigation focused on whether the local board knew of problems within the agency before the quality management report was released. State board members said they found no such evidence.

Every local board member involved during that time has since resigned. Turnover on the board is still high — two members have resigned this year.

The department itself is still working to recover.

The child protective services supervisor who shredded reports no longer works for the department, but whether she was fired or resigned was never disclosed. Before the quality management report was released, the agency’s director announced her decision to retire. The local department named a permanent replacement just months later, but she stayed in the position for less than two years before taking a job outside of social services. The department hired a new director from within, Dinah Clark, earlier this year after nearly 15 months of searching.

Staff turnover, especially with CPS and foster care caseworkers, is especially high and vacancies only exacerbate problems with meeting state policies. This fall, the department was left with just one CPS caseworker to handle more than 70 cases. Nationally, about 15 cases per worker is the accepted standard. 

The Virginia Department of Social Services measures its local departments in percentages.

A key indicator is how quickly CPS caseworkers contact a family or a child after the department receives a valid child abuse or neglect call. The state requires contact between 24 hours and five working days depending on the seriousness of the allegations. To be counted as timely, the caseworkers have to either complete, or attempt to complete, the contacts face-to-face, by email or by telephone.

The state wants the departments to complete timely contacts in 95% of cases.

From June 2018 to June 2019, the most recent data available from the state, more than 30% of local departments fell short of the state’s target in seven months or more. Eight departments never made the state’s target during that period.

In those months, Rockbridge County achieved timely contact between 39% to 87% of the time. Montgomery County ranged from 33% to 83%. Alleghany County ranged from 58% to 100%. Giles County ranged from 45% to 100%.

In its agency case reviews, the state looks at a number of measures. The review team selects 10 child protective services cases that were screened out to determine whether the agency followed state policy in deciding whether to investigate the report.

Agencies vary. One year, Rockbridge County screened out reports correctly 50% of the time, Highland County was correct in 40% of cases and Carroll County was 80%.

The state also reviews cases to determine whether agencies are conducting monthly visits with families, whether foster care children are receiving sufficient visits with their parents and siblings, and whether the child’s permanency goal — reunification, kinship care or adoption — is appropriate for the family’s circumstances. No more than 10 cases are reviewed in any instance.

Every case gets a number, and every one of those numbers is another Virginia child, parent and family.

Those percentages could mean another foster child who hasn’t seen his caseworker in months, another parent who doesn’t know where his or her child is living, or another teacher who sees the same kid come to school with more and more bruises.

Charlee was one of those numbers: a case that fell through the cracks and a child left in a dangerous home.

Her parents, who needed services, were imprisoned. Her father, Charles Ford, pleaded guilty to child endangerment and was sentenced in August to three years. Her mother served almost two years before she was given a suspended sentence in September.

A $17 million wrongful death lawsuit, brought by Ashley Ford, has been filed in Rockbridge County Circuit Court. The lawsuit names Charlee’s parents, the Rockbridge County social services department, its board, the former director, the former child protective services supervisor and the CPS caseworker as jointly responsible for Charlee’s death.

The case is still awaiting its first hearing.

This ongoing reporting project is supported by the Fund for Journalism on Child Well-being, a program of the University of Southern California Center for Health Journalism. If you or someone you know would like to relate a story about social services, from any locality, please contact reporter Alison Graham at 540-981-3324 or alison.graham@roanoke.com.

[This article was originally published by The Roanoke Times.]