Criminal Negligence or Accident Child Fatality Severe Trauma

Criminal, Negligence, or Accident: Child Fatality & Severe Trauma Cases A Multidisciplinary Response Lisa Bender, LMSW Child Abuse Prevention and Treatment Program Manager—Iowa Department of Human Services

Manner of Death for Children in Iowa 2008 % 2009 % Total % Natural 234 60. 6% 202 65. 0% 436 62. 6% Accident 87 22. 5% 62 19. 9% 149 21. 4% Suicide 10 2. 6% 8 2. 6% 18 2. 6% Homicide 19 4. 9% 6 1. 9% 25 3. 6% Undetermined 36 9. 3% 33 10. 6% 69 9. 9% Total 386 311 Source: Iowa's Child Death Review Team, Annual Report for 2008 and 2009 697

Child Fatalities in Iowa Series 1 4% 3% 10% 21% 62% Natural Accident Suicide Homicide Undetermined Source: Iowa's Child Death Review Team, Annual Report for 2008 and 2009

How Do We Prevent Child Deaths? By improving our ability to determine the true cause and manner of fatalities and near-fatalities. To do this takes a collaborative, multidisciplinary response to child death and severe trauma cases.

Who Do We Need at the Table? Emergency Medical Services • First Responders, Paramedics, Fire Department Law Enforcement • Local, County, State Medical Providers (Physicians, Nurses, etc. ) • ED providers, Family Practitioners, Child Abuse Experts, Mental Health/Substance Abuse Treatment Providers

Social Workers • Child Protective Services, DHS • Other (i. e. hospital, private practice, etc. ) Medical Examiners • Forensic Pathologists, State/Local MEs and Medical Examiner Investigators Criminal/Juvenile Justice • County Attorneys, Attorney’s General, Judges, Court Appointed Special Advocates

Emergency Medical Services

EMS in Iowa Code § 147 A § Establishes Iowa Department of Public Health (IDPH) as the lead agency designated for coordinating & implementing the provision of emergency medical services in the state. § Functions under Medical Director.

IDPH - Credentials Personnel § Basic Level EMS § EMR – Emergency Medical Responder § EMT – Emergency Medical Technician § Advanced Level EMS § § EMT-I – EMT Intermediate EMT-P – EMT Paramedic PS – Paramedic Specialist AEMT – Advanced Emergency Medical Technician § Endorsements § CCP – Critical Care Paramedic Source: Iowa Emergency Medical Care Provider Scope of Practice April 2012

EMS Personnel Responsibilities § “Duty to Act” § Rooted in the “Good Samaritan Law” § “Star of Life” represents six primary EMS functions: 1. Detection 2. Reporting 3. Response 4. On-Scene Care 5. Care in Transit 6. Transfer to Definitive Care

EMS at Arrival § § Scene safety Appearance of environment Law enforcement present Initial impression § Life threatening § “Stay and Play” or “Load and Go” Source: Reylon Meeks, RN, Ph. Dc -- Fire Chief, City of Pleasant Hill

EMS On Scene § Stabilize the patient § Provide life-saving interventions § History from caretaker/s § Determine hospital § Transport patient Source: Reylon Meeks, RN, Ph. Dc -- Fire Chief, City of Pleasant Hill

Arrival to Hospital § Give report § Overview of call and treatments § Hand off to a higher level of care § Anything transported is left § Clothing § Bottles § Diapers § Document the call § Make a CPS and/or LE report if there is reasonable belief that abuse/neglect may have contributed to death or injury Source: Reylon Meeks, RN, Ph. Dc -- Fire Chief, City of Pleasant Hill

What information may EMS have? Observations: § Who called 9 -1 -1 § Who was present at the scene § What environmental conditions were present, i. e. temperature, health/safety hazards, indications of drug/alcohol abuse, etc. § Where was the injured/deceased located upon arrival § What was the emotional reaction of the caretaker(s) and any other individuals present, including other children § What information did the caretaker(s) provide about the child’s condition

Law Enforcement

Various Jurisdictions State Agencies: § Iowa Department of Corrections § Iowa Department of Natural Resources Enforcement § Iowa Department of Transportation Motor Vehicle Enforcement Agency § Iowa Department of Public Safety, 7 divisions, including: Ø Iowa State Division of Criminal Investigation Ø Iowa State Division of Narcotics Enforcement Ø Iowa State Fire Marshal Ø Iowa State Patrol

County Agencies: § 99 counties in Iowa § Sheriff’s office in each (duties outlined in Iowa Code § 331. 65) § Provide law enforcement outside of urban municipalities Local/Municipal Agencies: § Several hundred local/municipal law enforcement agencies in cities and towns across Iowa Colleges and Universities

Roles/Responsibilities of Law Enforcement Public Safety § Prevent crime and keep peace Enforce the Law § Iowa Code § Local/Municipal Code Investigation/Prosecution § Gather evidence to meet burden of proof

Roles/Responsibilities Related to CPS § Law Enforcement (LE) are Mandatory Reporters of child abuse/neglect. § LE works jointly with CPS when there allegations of both child maltreatment and a criminal act. § A peace officer has the authority to remove a child from the home, without a court order, when a child is believed to be in imminent danger.

Local Police Department Des Moines PD is largest and most urban law enforcement agency in the state of Iowa. DMPD made up of nearly 500 personnel: § 379 sworn officers § 110 civilian support personnel Source: http: //www. dmgov. org/Departments/Police/Pages/About. aspx

DMPD divided into 2 Major Divisions: 1. Operations Division 2. Investigations Division, includes: • Detective Bureau, made up of: • Intelligence Section • Family Conflict Section • Crimes Against Persons Section • Crimes Against Property Section • Identification Section Source: http: //www. dmgov. org/Departments/Police/Pages/About. aspx

Family Conflict Section The Family Conflict Section consists of specially trained investigators responsible for the investigation of criminal behavior of a sexual nature and also cases serious child abuse or trauma. The section includes a Domestic Abuse Resource Team (DART), a Victim Advocate who works directly with the DART investigators to reach out to victims of domestic violence. Crimes relating to elderly abuse are investigated here as well. Source: http: //www. dmgov. org/Departments/Police/Pages/About. aspx

Types of trauma cases investigated by Family Conflict include: § § § § § sexual assaults and attempted sexual assaults intra-family sexual abuse attempts to entice children child exploitation obscene communications child in need of assistance proactive Internet cases child abuse / trauma cases infant deaths

Iowa Department of Public Safety Reduce preventable injuries and deaths Suppress criminal activity Minimize costs of compliance with government requirements Promote integrity & excellence in the workforce Source: http: //www. dps. state. ia. us/overview. shtml

Iowa Division of Criminal Investigation “The mission of the Iowa Division of Criminal Investigation is to provide law enforcement services to qualified city, county, state and federal agencies who request the expertise or resources of the division. ”

DCI—Major Crimes Division § Comprised of 28 Special Agents across the state § Called in to assist local enforcement with major crimes, such as: § Death investigations § Assault investigations § Sexual offense investigations

What is the Role of Law Enforcement? Observations made by responding officers: § Who called 9 -1 -1 and who was present § What was observed at the scene § What evidence was gathered Immediate actions: § Secure scene § Interview witnesses § Remove children (if believed to be in imminent danger) Ongoing investigation/prosecution: § Conduct joint interviews § Provide insight on family criminal history or involvement with LE § Gather other evidence which could impact CPS outcome

Child Protective Services

State of Iowa’s child abuse reporting and assessment law, Iowa Code sections 232. 67 through 232. 75, was initially enacted in 1978 and has been amended several times since then.

Criteria for CPS Assessment In Iowa, the Department of Human Services (DHS) has been given the responsibility and legal authority to conduct an assessment of child abuse when it is alleged that: § The victim is a child. § There is a caretaker. § The child is subjected to one or more of the ten types of child abuse defined in Iowa Code § 232. 68.

The Code of Iowa defines a child as being: § Any person under the age of eighteen years. The Code of Iowa (§ 232. 68) defines a caretaker or “person responsible for the care of a child”, as any of the following: § A parent, guardian, or foster parent. § A relative or any other person with whom the child resides and who assumes care or supervision of the child. § An employee or agent of any public or private facility providing care for a child. § Any person providing care for a child, but with whom the child does not reside, without reference to the duration of the care.

Categories of Abuse There are ten categories of child abuse identified in Iowa Code: § § § § § Physical Abuse Mental Injury Sexual Abuse Denial of Critical Care Child Prostitution Presence of Illegal Drugs Manufacturing or Possession of a Dangerous Substance Bestiality in the presence of a minor. Allows access by a Registered Sex Offender Allows access to Obscene Material

Physical Abuse Any nonaccidental physical injury, or injury which is at variance with the history given of it, suffered by a child as the result of the acts or omissions of a person responsible for the care of the child.

Mental Injury Any mental injury to a child's intellectual or psychological capacity as evidenced by an observable and substantial impairment in the child's ability to function within the child's normal range of performance and behavior as the result of the acts or omissions of a person responsible for the care of the child, if the impairment is diagnosed and confirmed by a licensed physician or qualified mental health professional.

Sexual Abuse The commission of a sexual offense with or to a child pursuant to chapter 709, section 726. 2, or section 728. 12, subsection 1, as a result of the acts or omissions of the person responsible for the care of the child.

Denial of Critical Care The failure on the part of a person responsible for the care of a child to provide for the adequate food, shelter, clothing, medical or mental health treatment, supervision, or other care necessary for the child's health and welfare when financially able to do so or when offered financial or other reasonable means to do so.

DCC Subcategories 1. Failure to provide adequate food and nutrition 2. Failure to provide adequate shelter 3. Failure to provide adequate clothing 4. Failure to provide adequate health care § For all of the four above failure must be to such an extent that there is danger of the child suffering injury or death. 5. Failure to provide the mental health care necessary to adequately treat an observable and substantial impairment in the child’s ability to function.

6. Gross failure to meet the emotional needs As necessary for normal development and evidenced by the presence of an observable and substantial impairment in the child’s ability to function within the normal range of performance and behavior. 7. Failure to provide proper supervision Which a reasonable and prudent person would exercise under similar facts and circumstances, to such an extent that the failure resulted in direct harm or created a risk of harm to the child or there is danger of the child suffering injury or death. 8. Failure to respond to the infant’s life-threatening conditions Failing to provide treatment which in the treating physician’s judgment will be most likely to be effective in ameliorating or correcting all conditions.

Child Prostitution Defined as the acts or omissions of a person responsible for the care of a child which allow, permit, or encourage the child to engage in acts prohibited pursuant to Iowa Code section 725. 1.

Presence of Illegal Drugs (PID) “Presence of illegal drugs” is defined as occurring when an illegal drug is present in a child’s body as a direct and foreseeable consequence of the acts or omissions of the person responsible for the care of the child.

Manufacturing or Possession of a Dangerous Substance “Manufacturing or possession of a dangerous substance” occurs when the person responsible for the care of a child: § Has manufactured a dangerous substance in the presence of the child, or § Knowingly allows the manufacture of a dangerous substance by another person in the presence of a child, or § Possesses a product containing ephedrine, its salts, optical isomers, salts of optical isomers, or pseudoephedrine, its salts, optical isomers, salts of optical isomers, with the intent to use the product as a precursor or an intermediary to a dangerous substance in the presence of the child.

Bestiality in the Presence of a Minor “Bestiality in the presence of a minor” is defined as the commission of a sex act with an animal in the presence of a minor as defined in Iowa Code section 717 C. 1 by a person who resides in a home with a child, as the result of the acts or omissions of a person responsible for the care of the child.

Allows Access to… A Registered Sex Offender § It is child abuse if a caretaker knowingly allows unsupervised access to a child by a registered sex offender or allows a registered sex offender to have custody or control of a child up to age 14 or a child up to age 18 if the child has a mental or physical disability. The exceptions are if the registered sex offender is the caretaker’ spouse or is a minor child of the caretaker. Obscene Material § This type of abuse is defined as a caretaker knowingly allowing a child access to obscene material, exhibiting obscene material to a child, or disseminating obscene material to a child, as defined in Iowa Code Section 728. 1.

Child Protective Assessment Outcomes Assess Child Safety/Risk Substantiate Abuse/Neglect Recommendation for Intervention

Assessing Safety The assessment worker will use safety constructs to evaluate the safety of the child with the caregivers in the home environment: § Threats of maltreatment that are present at this time (i. e. aggravating factors that combine to produce a potentially dangerous situation. ) § Child’s vulnerability to maltreatment (i. e. the degree to which a child cannot avoid, negate, or minimize the impact of present or impending danger. ) § The caretaker’s protective capacities (i. e. the family strengths or resources that reduce, control, or prevent threats of maltreatment from arising, as well as risk factors that have a negative impact on child safety. )

Safety Assessment Outcomes Child is either: § Safe § Conditionally Safe § Unsafe

Substantiation of Allegation Iowa Administrative Code (IAC) defines the burden of proof required for substantiation as a “preponderance of the evidence”: § “Preponderance of evidence” means evidence which is of greater weight or more convincing than the evidence which is offered in opposition to it. (IAC 441— 175)

Substantiation Outcomes Not Confirmed – There was not a preponderance of evidence to suggest abuse occurred and, therefore, the incident will not be placed on the Central Abuse Registry. Confirmed (Not Placed on Registry) – There was a preponderance of evidence to suggest Physical Abuse or Denial of Critical Care (lack of supervision or lack of adequate clothing) occurred and ALL the following conditions were met: * The injury was minor. * The injury was isolated. * The injury was unlikely to reoccur.

Founded (Confirmed AND Placed on Registry) – The was a preponderance of evidence indicating the alleged abuse occurred, the victim was a child, and the perpetrator was a caretaker. In addition, if the allegations were Physical Abuse or Denial of Critical Care (lack of supervision and lack of adequate clothing), the criteria of minor, isolated, and unlikely to reoccur were not met.

Recommendations for Intervention Following an assessment a Child Protection Worker (CPW) makes a recommendatio n for services by: • Analyzing the safety and risk factors affecting the child and family • Determining what available services are appropriate • Determining whether court involvement is needed

Service Provision Recommended interventions may include the following: § Information Only § Information and Referral § Community Care Services § DHS Case Management § Court Involvement § Juvenile Court Action § Criminal Court Action

What information may CPS have? Observations at scene and/or later visit to home: § Who was present § What was observed § Who was interviewed (including other children) Assessment Information: § § Social history Assessment of family strengths/needs Previous confirmed cases of abuse/neglect Collateral contact information