Executive Summary

Role of the Ombudsman

The Citizens’ Aide/Ombudsman is an independent, nonpartisan, impartial agency of the Iowa Legislature. The Ombudsman is responsible to receive and investigate the administrative actions of most Iowa state and local governmental agencies. The Ombudsman’s powers and duties are defined in Iowa Code Chapter 2C.

The Ombudsman may conduct an investigation based on a complaint or on the Ombudsman’s own motion. The Ombudsman is responsible for investigating agency actions that may be contrary to law, regulation, or policy, or that may be unreasonable, unfair, oppressive, inconsistent, mistaken, arbitrary, improper, irrelevant, or otherwise objectionable. The Ombudsman may also review agency procedures and practices and recommend how to strengthen or improve them.

After completion of an investigation, the Ombudsman may issue a report of the Ombudsman’s findings, conclusions, and recommendations.

Shelby Duis Investigation

At the request of three members of the Iowa Senate, the Ombudsman undertook an investigation into the policies and practices of the Iowa Department of Human Services (DHS) in the handling of child abuse allegations regarding Shelby Duis. The Ombudsman issued notice of the investigation on February 10, 2000, approximately five weeks after Shelby died.

In conducting the investigation, the Ombudsman researched Iowa law and DHS regulations (administrative rules), examined DHS policy and procedures, interviewed and took sworn testimony from DHS staff and other witnesses, reviewed relevant documents, reports, and trial testimony, made inquiries to several other states regarding their system for receiving child abuse reports, and consulted with a child abuse medical expert.

Findings and Conclusions

Given the Ombudsman’s statutory role and responsibility and the extensive review involved in the investigation, this report focuses on those polices, procedures, or practices the Ombudsman found to be questionable or inappropriate, and could be improved or strengthened. It should be noted the Ombudsman found many actions or decisions by DHS workers to be appropriate. There were also some actions or decisions about which the Ombudsman could not make any findings or reach any conclusions, given the evidence that was obtained or was available.

The Ombudsman found a number of instances when DHS staff did not respond appropriately or could have responded differently to concerns raised about Shelby. These instances relate to the way reports and intakes were handled and the way assessments were completed. However, the Ombudsman did not draw any conclusions whether and to what extent Shelby could have been protected from the abuse that ended her life.

The Ombudsman believes many of these instances are indicative of the need for certain policy and practice changes or improvements within DHS and in the way DHS interacts with components of the child protection system in Iowa. They may also be indicative of larger, more system-wide problems within Iowa’s child protection system.

While many of the problems identified in this report can be characterized as practice problems and addressed by training and supervision, the Ombudsman believes those problems can also be reduced by modifications or clarifications of policy and by a systemic change to the reporting and intake process. Streamlining how reporters interact with the DHS child abuse system and dedicating a centralized unit of uniformly trained intake workers would go a long way toward resolving individual differences and regional variances found in the current decentralized intake system. It could ensure consistent, accurate, and appropriate responses to the initial reports of child abuse or neglect. Structural reorganization coupled with certain policy changes could reduce the instances of policy and practice shortcomings identified in this investigation.

Reporting Process Problems

The Ombudsman reviewed the process reporters go through in making child abuse reports to DHS. Challenges during the process include ensuring reporters can quickly and effortlessly communicate with DHS employees who are responsible for gathering report information and making decisions whether to accept, reject, or refer the report for services.

With respect to Shelby’s case, the Ombudsman found:

In one instance, DHS identified the “reporter” of child abuse as the person who relayed the allegation of abuse to DHS. The person who initially made the allegation and had first-hand information about the abuse was not considered the reporter. There were two other instances involving relayed reports in which it was not clear to the Ombudsman whom DHS considered to be the reporter.

In one instance, a mandatory reporter did not make a report of suspected abuse to DHS; and as a result DHS did not have knowledge of important information concerning Shelby’s care and condition.

In four instances, mandatory reporters who made oral reports of abuse did not follow-up with written reports, as required by Iowa law.

In two instances, DHS employees, who were not intake workers, considered calls from persons who suspected abuse as calls “expressing concerns” only, not as calls “reporting abuse.” As a result, neither call was referred to an intake worker for an intake decision. [DHS has since issued a written clarification to all employees that any information that raises concerns about the care of a child is to be referred immediately to the appropriate child protection staff as a report of child abuse.]

In two instances, intake workers did not promptly return calls from persons whom they knew wanted to make reports of child abuse.

In several instances, reporters had difficulty reaching intake workers. Most of the time their difficulty stemmed from not understanding how the reporting system works, especially since it varies depending on where and when the call is made and where the child lives. When calling the local DHS office, reporters often had to leave messages with clerical staff and await return calls. Some reporters believed they had to call the same intake worker every time and, if the worker was not available, leave messages on the worker’s voice mail. Most reporters had to talk with more than one DHS employee before making contact with an intake worker.

A document containing critical information regarding a report of child abuse, completed by a DHS employee taking after-hours calls to the child abuse hotline, was not provided to the intake worker, nor included in the official intake record. [DHS has since addressed this problem by providing written report information from the hotline to intake workers.]

Intake Process Problems

A reoccurring problem discovered by the Ombudsman was that intake workers did not always document every contact concerning a child as an intake (e.g., if they did not consider the caller’s information to be an allegation of abuse). [Again, DHS has since issued a written clarification that any information that raises concerns about the care of a child shall be treated as a report of child abuse.]

The Ombudsman also identified problems related to insufficient documentation of intake information, inappropriate decisions to reject reports, and inconsistencies with intake decisions. It is noteworthy that a consultant’s report produced for the Ombudsman in early 1999 found wide variation around the state regarding the “thoroughness of case record rejection verification.” The same consultant’s report noted the level of actual supervisory oversight and involvement was unclear. Policy clarification, along with additional training and supervisory guidance, may help to address these problems. The Ombudsman believes these problems can be reduced by having a centralized unit of specially trained workers whose primary responsibility is to receive and document reports and to make intake decisions.

With respect to Shelby’s case, the Ombudsman found:

Two reports of child abuse were not handled and documented as intakes.

In each of three instances involving alleged physical abuse, the intake information did not sufficiently describe the reported injuries.

Three reports of child abuse that were rejected should have been accepted for investigation or assessment. The last rejected report occurred three weeks before Shelby died.

One report of child abuse should not have been rejected without first conducting an in-depth intake (i.e., contacting mandatory reporters who may have relevant information).

Assessment Process Problems

The Ombudsman identified a number of policy and practice problems concerning how the investigations and assessments concerning Shelby were conducted and documented. The majority were practice issues – actions the Ombudsman believes the Child Protection Worker (CPW) reasonably should have taken under DHS policy. Additional training and supervisory consultation and review may help to ensure that CPWs identify and interview all relevant witnesses and collateral sources to ensure a thorough understanding of the situation and development of the relevant facts, including verification of the explanation or history given for an injury. Training and supervision are also important components to assist CPWs in identifying signs of abuse (including the appearances and patterns of injuries, and the mechanisms for injuries), and in developing their assessment skills (including photographic documentation, use of measurement tools, and other investigative means to gather information).

Other problems with certain assessment actions may require policy promulgation, modification or clarification. For example, the Ombudsman believes a CPW should be required to attempt to contact the doctor before an examination and share information about the alleged abuse and the explanation given for the injury or condition. Policy should be clarified to assure that service referrals are acted upon and in a timely manner.

With respect to Shelby’s case, the Ombudsman found:

In several instances, the CPW did not contact and interview persons who may have had relevant information regarding the allegations of abuse. In other instances the CPW did not observe, inspect, collect or consider evidence to the fullest extent possible.

In several instances, the CPW noted concerns about the caretaker’s behavior, but did not specify the nature of those concerns nor follow up on verifying or assessing those concerns.

Three weeks before Shelby’s death, the CPW received additional information about Shelby while an assessment was still open and had sufficient concerns to repeatedly refer Shelby to a doctor, but did not take any further assessment actions, including observation of Shelby, to ensure that she was not being abused and was safe.

Recommendations

The Ombudsman recommends:

1. The Department of Human Services (DHS) redesign the child abuse reporting system so that:

a. Reporters have a single point of contact which they can be instructed to call, regardless of where they live, the time of day, or the county, cluster or region having responsibility to evaluate the report.

b. Reporters are able to speak with an intake worker during their initial call.

c. All report information, regardless of who initially receives the report, be promptly documented and retained, timely routed, and appropriately evaluated.

[The Ombudsman believes DHS would gain valuable insight, perspective, and assistance in responding to this recommendation by consulting with appropriate social service staff in states that have a state-wide centralized child abuse hotline system for reports and intakes (such as Arizona, Florida, and Texas), regarding their rationale for and experience in implementation of such a system.]

2. DHS review its definition of who is a “reporter,” and, if possible without statutory change, modify it to also include an individual who has been identified by a reporter (i.e. person calling DHS) as the source of the allegation and as the individual wanting to make a report of child abuse.

3. DHS increase efforts to instruct and remind mandatory reporters about the importance and need to report suspected abuse directly to DHS.

4. DHS increase emphasis on training, encouraging, and reminding mandatory reporters to file written reports and should consider ways to facilitate the filing of written reports.

5. DHS review the 48-hour time frame for filing of written reports by mandatory reporters and determine if it should be enforced and/or extended.

6. DHS modify policy to clearly provide that written reports that are received will be reviewed before a final decision or approval is made to reject the report. In the event a written report is received after a rejection decision is made, a supervisor should review and determine if the rejection decision should be reconsidered.

7. DHS provide public education and awareness to increase reporters’ and the community’s understanding of DHS’s role and how the child protection system functions, including the responsibilities and limitations of the various DHS workers.

8. DHS monitor and ensure compliance by employees with the September 18, 2000 policy directive that “information that raises concerns about the care of a child” be relayed to the “child protection unit” and treated as a report of child abuse.

9. DHS adopt a policy providing that intake workers (those responsible for gathering report information and making intake decisions) attempt to speak with every reporter as soon as possible after the reporter has contacted DHS to report child abuse, if that reporter was not able to speak with an intake worker during the initial contact.

10. DHS clarify policy that any report that is rejected, while there is an open assessment about the same child, should be documented as a rejected intake. If it is a duplicate of a report on which there is an open assessment, the duplicate report should also be documented in the Assessment Summary.

11. DHS emphasize, in policy and in the training of intake workers, the need not only to gather, but also to document information relevant to reported allegations of abuse as completely and accurately as possible.

12. DHS provide additional training to intake workers to better ensure appropriate and consistent decisions are made on intake. [The Ombudsman believes creation of a statewide centralized unit to receive reports and complete intakes (see Recommendation #1) will facilitate appropriate, consistent, and adequately documented decision-making.]

13. DHS ensure that any written notice advising a reporter that the report has been rejected state clearly the specific reason for the rejection. If a report is rejected solely because it is a duplicate of a prior report, the reporter should be informed of that reason, unless this would clearly violate confidentiality laws.

14. DHS accord reporters who are notified that their reports are rejected an opportunity to contact an appropriate designated DHS staff person, such as a supervisor or child protection specialist, if they disagree with the decision or have additional questions about the decision.

15. DHS provide additional training to workers involved in child protection about the signs and indicators of physical abuse, sexual abuse, and neglect, the distinguishing characteristics of accidental versus inflicted injuries, and the mechanisms of injuries; DHS also provide additional training for the identification of substance abuse, particularly the use of methamphetamine and how that impacts family dynamics and child safety.

16. DHS modify policy to require that, in the event DHS refers a child for examination by a physician, the CPW attempt to contact the physician in advance of the examination and inform the physician about the child’s injury or condition, any explanation given for the injury or condition, and other pertinent history concerning the child. If the CPW discovers during the assessment any additional relevant information regarding the cause or explanation for the child’s injury or condition, the CPW should contact and confer with the doctor again.

17. DHS adopt a policy encouraging the use of cameras, bruising color charts, and injury measurement instruments in conducting assessments, whenever possible, to document visible injuries and other evidence relevant to the assessment. All CPWs should be equipped with a camera, a bruising color chart, and injury measurement tools. DHS should also develop and provide an appropriate training curriculum for the use of cameras, color charts and injury measurement tools.

18. DHS clarify policy stating when it is essential or necessary to make a visit to the home in conducting an assessment of the child and the family, and when it may be appropriate to attempt unannounced home visits.

19. DHS and the Iowa General Assembly review the 20-business day time-frame for completion of assessments to determine if it allows adequate time to conduct thorough assessments and complete the written Assessment Summaries. Consideration should be given to allow supervisors and program staff to grant limited extensions in cases when extensions are clearly necessary.

[Although the Ombudsman did not find any evidence to indicate that the 20-business day time-frame for completion of an assessment impacted how Shelby Duis’case was handled, the Ombudsman believes that a rigid 20-day time-frame may be an artificial and potentially counterproductive requirement.]

20. DHS develop a standardized process for recommending and making referrals for DHS services, to assure that recommended services are properly and timely referred and acted upon; DHS develop a separate referral form or revise a current referral form to prominently document the specific services recommended, any priority or urgency in implementing them, and any subsequent actions taken on the recommendations (i.e., approval, assignment, referral, initiation).

DHS should review the process for recommending, referring and initiating services, including completion of necessary paperwork, to find ways to improve the initiation and delivery of services.

21. DHS increase the frequency and depth of supervisory and program staff review of completed intakes and assessments, and encourage consultation with supervisory and program staff; DHS adopt a policy requiring supervisors to review all relevant information in the assessment file, before approving the Assessment Summary; DHS evaluate whether it has staffing resources necessary to provide adequate review, oversight, and consultation, and if such resources are inadequate, make any required personnel and budgetary requests to the Governor and the General Assembly.

22 DHS review how effectively multi-disciplinary teams are functioning across the state and find ways to improve the development and utilization of all multi-disciplinary teams as a resource for CPWs.

23. DHS and other appropriate Iowa officials, such as the Attorney General, the Department of Public Health and the University of Iowa Health Care collaboratively study the accessibility to and the sufficiency of medical child abuse expertise available to DHS child protection staff. Based upon this evaluation, take the necessary steps to provide or obtain such expertise.