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. On March 26, 1998, the Panel began to review the circumstances surrounding the death of Andrew M., a child who was legally committed to the care and custody of the Department of Children and Families (DCF) when he died at a psychiatric inpatient facility on March 22, 1998. After its preliminary review, the Panel decided to issue its report in two parts.

On May 7, 1998, "Part I: The immediate circumstances" was released as a public report. In that report, the Panel reviewed the immediate circumstances of Andrew’s death, isolated those factors playing a prominent role in the death of this child, and made recommendations aimed at protecting other children who may be subject to "physical restraint" or behavior management programs in Connecticut.

In Part II of its report, "Child Welfare Case Management," the Panel reviews Andrew’s social, psychological, educational and medical history, his history with DCF, and the therapeutic, medical and social work management of his case. In conducting its review, Panel members took the sworn testimony of DCF employees, service providers and medical doctors, invited them to provide information and make recommendations, and reviewed all documents pertinent to this case including: DCF child protection records, Department of Social Services (DSS) records, Judicial Department records, hospital and physician records, social service provider records, and educational records. Suzanne M. Sgroi, M.D., Executive Director of New England Clinical Associates, provided consultation services to the Panel regarding psychotherapeutic case management.

After this review, Panel members shared their findings with one another and drafted this report. The report focuses on Andrew and his family’s involvement with the child protection system beginning in 1986 (and earlier) until his admission at the Facility where he died. Throughout this period, there were extensive revisions to the Connecticut child protection system’s policies and practices, most notably galvanized by the circumstances brought to light in the Emily Report issued in 1995. The Panel believes that the recommendations made in this report endorse and extend these revisions toward the end of better protecting children who receive services from state agencies.

As with Part I, with the exception of the child’s first name, all names of individuals, service providers, agencies and hospitals have been omitted from this report. Again, the Panel received complete cooperation from all state agencies involved which was instrumental in allowing the Panel to thoroughly conduct its investigation. The Panel has made every effort to provide a reasonably accurate account of the events in this case. The facts as set forth below represent the Panel’s best efforts to piece together the history of this case from the notes, recollections and memories of numerous individuals.

Andrew M. was born on December 6, 1986 to a thirteen-year-old mother from a family well-known to DCF. He came to the attention of DCF periodically between 1986 and 1988 after the agency received referrals regarding the mother’s out-of-control behavior during his infancy. Then, in October 1989, just a few months before his third birthday, DCF received a neglect referral from Hospital A because Andrew had suffered a serious injury to his left eye and his mother had not followed through with treatment. Subsequently, the child suffered a series of additional injuries and illnesses resulting in child abuse and neglect referrals being made to DCF by family members and professionals.

On March 13, 1991, neglect petitions were filed on behalf of Andrew and his siblings. On July 17, 1991, guardianship of Andrew was transferred to his grandmother. From 1991 to 1992, multiple reports of neglect were made to DCF regarding the care of Andrew and his four younger siblings in their grandmother’s and mother’s homes, including a repeated failure to keep medical appointments. DCF Worker #1 closed her case on March 10, 1993, and supported a petition to return Andrew’s guardianship to his mother.

From 1993 to 1995, numerous referrals were made to DCF regarding Andrew and his siblings. A child protective services case was reopened and closed on several occasions, neglect was confirmed, and the family was unreceptive to services, but no court action was taken.

In December 1995 and January 1996, suspected drug activity by the mother and physical and emotional abuse of the children were observed by DCF Worker #2. On January 4, 1996, the mother was arrested after allegedly selling drugs in her home with the children present. Andrew and his two brothers were placed with Foster Mother #1 pursuant to an Order of Temporary Custody (OTC). On January 29, 1996, the mother began an Alternative Incarceration Center (AIC) program designed for first-time drug offenders, after completion of which the case was dismissed.

On March 20, 1996, an adjudication of neglect was made by the court and all five siblings were committed to the care and custody of DCF. In April 1996, a court-ordered evaluation was conducted by Psychologist #2 and she concluded that reunification was a dubious pursuit and not in the children’s best interests. Despite that recommendation, DCF continued to focus on reunification. Service agreements between DCF and the mother were made with little or no compliance by the mother throughout 1996. Despite the mother’s failure to comply with voluntary service agreements, court-ordered expectations were not set until November 20, 1996.

Between January and July of 1996, Andrew received a medical diagnosis of exposure to tuberculosis, which required that he take medication continuously for nine months. He also had violent episodes of acting out in the foster home and was hospitalized three times in psychiatric inpatient facilities. He was placed with Foster Mother #2 on August 5, 1996. After additional psychiatric hospitalizations, Andrew was placed in the therapeutic foster home of Foster Mother #3 on October 28, 1996. This foster mother was trained, licensed and monitored by Agency #1, a child services agency. Andrew attended public school, as well as a therapeutic extended day program at Agency #1. On February 13, 1997, the commitments of Andrew and his siblings to the care and custody of DCF were extended for an additional period of twelve months.

Throughout Andrew’s placement with Foster Mother #3, concerns were expressed about the quality of care he was receiving in that therapeutic foster home, including a lack of supervision, numerous episodes of running away and multiple incidents of out-of-control behavior that resulted in school suspension and physical restraint by school personnel. Nonetheless, Andrew remained in this foster home for over one year until December 12, 1997 when he was transferred to a regular foster home in the same city.

On June 9, 1997, Andrew began to attend a specialized school for exceptional children. Between August and December of 1997, Agency #1, on three separate occasions, requested that DCF remove Andrew from the therapeutic foster home of Foster Mother #3 due to his need for a higher level of care. There were also reports that Andrew had shared, in full detail, a plan to kill Foster Mother #3 and her son.

On July 24, 1997, the mother filed a Petition to Revoke the Commitment of all five children. As a result, the court ordered an updated psychological evaluation and on October 21, 1997, Psychologist #2 concluded that Andrew should return to his mother after the return of his younger sisters. In November 1997, DCF placed the sisters with the mother, with a plan to reunite Andrew at the end of the school year.

After repeated requests by Agency #1, Andrew was moved on December 12, 1997 from the home of Foster Mother #3 to Foster Mother #4, a regular foster home. He continued to attend the same school and day treatment with Agency #1. In February 1998, Andrew was hospitalized on two occasions for out-of-control behavior after threatening to kill himself and others, and for running away. He was subsequently suspended from school. By his own reports, over a three-week period, he placed cleaning chemicals on a younger foster sibling’s toothbrush in a purported attempt to "kill" him, a plan not discovered by the foster mother until March 17, 1998. (Footnote 1)* He also stated to his school counselor that he wished his foster brother dead and repeated this statement to his mother in a telephone call. His mother appropriately relayed this information to the foster family which resulted in Andrew’s admission to the where he later died.

On March 20, 1998, two days prior to Andrew’s death, his commitment was extended for an additional twelve months, and the mother regained full custody and guardianship of Andrew’s sisters.