6.7 Conducting Special Investigations of a Child Death, Near Fatality, or Serious Injury

Georgia State Seal

Georgia Division of Family and Children Services
Child Welfare Policy Manual

Chapter:

(6) Special Investigations

Policy Title:

Conducting Special Investigations of a Child Death, Near Fatality, or Serious Injury

Policy Number:

6.7

Previous Policy Number(s):

N/A

Effective Date:

December 2020

Manual Transmittal:

2020-10

Codes/References

O.C.G.A. § 15-11-30 Rights and Duties of Legal Custodian
O.C.G.A. § 15-11-125 Venue
O.C.G.A. § 15-11-133 Removal of Child from the Home; Protective Custody
O.C.G.A. § 15-11-150 Authority to File Petition
O.C.G.A. § 15-11-202 Reasonable Efforts by DFCS to Preserve or Reunify Families
O.C.G.A. §16-12-100 Sexual Exploitation of Children; Reporting Violation; Forfeiture; Penalties
O.C.G.A. § 19-7-5 Reporting of Child Abuse (e)(f)
O .C.G.A. § 49-5-8 Powers and Duties of Department of Human Services
O.C.G.A. § 49-5-40 Definitions; Confidentiality of Records; Restricted Access to Records
O.C.G.A. § 49-5-41 Persons and Agencies Permitted to Access Records
45 CFR Parts 1355.38(a) (5), 1356.21(b) (3) (i), 1356.21(k), and 1356.67
Title IV-E of the Social Security Act Sections 471(a) (15) (D) and (a) (9) (c), and 475 (9)
Child Abuse Prevention and Treatment Act (CAPTA)
Adoption and Safe Families Act (ASFA) P.L. 105-89
Health Insurance Portability and Accountability Act (HIPAA) of 1996: P.L. 104-191
Indian Child Welfare Act of 1978 Final Rule (25 CFR Part 23)
Preventing Sex Trafficking and Strengthening Families Act

Requirements

The Division of Family and Children Services (DFCS) will:

  1. Complete the Child Death, Near Fatality, Serious Injury (CD/NF/SI) report for special investigations involving a CD/NF/SI.

  2. Conduct a joint investigation with law enforcement in accordance with the local Child Abuse Protocol.

  3. In addition to the provisions outlined in this policy also adhere to the following corresponding policy sections based on the legal status and/or the placement setting of the child or where the incident occurred:

    1. Policy 5.1 Investigations: Conducting an Investigation when the special investigation involves a CD/NF/SI of a child that is not in DFCS custody and the incident did not occur in a foster/adoptive home, foster care kinship placement, residential/non-residential facility or a public/private school.

    2. Policy 6.3 Special Investigations: Conducting Special Investigations on DFCS or Child Placing Agency Foster or Adoptive Homes when the special investigation involves a CD/NF/SI in a foster or adoptive home.

    3. Policy 6.4 Special Investigations: Conducting Special Investigations on Foster Care Kinship Placements when the special investigation involves a CD/NF/SI in a foster care kinship placement.

    4. Policy 6.5 Special Investigations: Conducting Special Investigations on Residential or Non-Residential Facilities when the special investigation involves a CD/NF/SI in a residential or non-residential facility.

    5. Policy 6.6 Special Investigations: Conducting Special Investigations on Public or Private Non-Residential Schools when the special investigation involves a CD/NF/SI in a public or private non-residential school.

    When a special investigation involves a child death, in lieu of observing the deceased child within the immediate-24-hour response time the investigator may contact any professional (e.g., coroner, medical examiner, law enforcement) who observed the child during the timeframe that could provide pertinent information.

  4. Determine whether there are other children in the home are safe and any actions needed to ensure their safety if they are determined to be unsafe.

  5. Engage healthcare professionals who provided direct emergency and/or ongoing care to the alleged victim child(ren) and obtain medical records.

  6. Refer a child involved in a CD/NF/SI case to have a forensic interview by a trained professional (i.e. Child Advocacy Center (CAC), Children Health of Atlanta (CHOA) or law enforcement), as applicable, based on the local child abuse protocol.

  7. Participate in the CAC Multi-Disciplinary Team (MDT) meeting to coordinate and discuss the case information with other child welfare professionals involved with the case, when applicable.

  8. Engage the coroner to obtain information about the cause, time, and manner of death, when the special investigation involves a child death.

  9. Engage the medical examiner (ME) and obtain the autopsy report, when the special investigation involves a child death.

    Autopsy reports may not be available prior to closure of the investigation. Efforts to secure the autopsy report must continue regardless of case closure.

  10. Substantiate neglect when evidence confirms that unsafe sleep practices were the cause or a contributing factor to the death of an infant (under the age of one) and case documentation supports that DFCS staff previously educated the caregiver(s) of the dangers of an unsafe sleep environment to child safety.

  11. Notify the Regional Director and DHS Office of Communications of any media request concerning the CD/NF/SI in accordance with policy 2.7 Information Management: Contacts with Media, Legislators, County Officials.

  12. Document case activities in Georgia SHINES within 72 hours of the occurrence.

Procedures

Social Services Case Manager

  1. Complete the Child Death, Near Fatality, Serious Injury report in accordance with policy 6.10 Special Investigations: Reporting a Child Death, Near Fatality or Serious Injury.

  2. Conduct a joint investigation with law enforcement as outlined by the local Child Abuse Protocol.

  3. In addition to the provisions outlined in this policy also adhere to the following corresponding policy sections based on the legal status and/or the placement setting of the child or where the incident occurred:

    1. 5.1 Investigations: Conducting an Investigation

    2. 6.3 Special Investigations: Conducting Special Investigations on DFCS or Child Placing Agency Foster or Adoptive Homes

    3. 6.4 Special Investigations: Conducting Special Investigations on Foster Care Kinship Placements

    4. 6.5 Special Investigations: Conducting Special Investigations on Residential or Non-Residential Facilities

    5. 6.6 Special Investigations: Conducting Special Investigations on Public or Private Non-Residential Schools

  4. Respond to the site of the CD/NF/SI with law enforcement, when possible, to:

    1. Gain firsthand information concerning the events leading up to the CD/NF/SI; and

    2. Observe the scene where the CD/NF/SI occurred. Document observations and take pictures of the scene.

  5. Interview everyone who had access to, and/or was acting as a caregiver for the child during the window of time the CD/NF/SI is believed to have occurred. Gather information about the condition and behaviors of the child and the caregivers during the time the child was with the caregiver (ex: child was lethargic, sick; caregiver was intoxicated, sleeping etc.).

  6. Engage law enforcement and emergency medical services (EMS) to gather information about:

    1. The child’s injuries;

    2. The parent, caregiver, or legal guardians’ explanation at time of arrival; and

    3. Obtain a copy of EMS run report.

  7. Engage healthcare providers who provided emergency medical care to the alleged victim child and obtain medical certification as to whether the child’s injuries meet the criteria for a near fatality (see Practice Guidance: Near Fatality).

  8. Refer a child involved in a CD/NF/SI case to have a forensic interview, as applicable, based on the local child abuse protocol:

    1. Attend or review the recorded forensic interview of the child(ren).

    2. Obtain a copy of the forensic interview.

  9. Participate in the CAC MDT meeting to coordinate and discuss the findings with other child welfare professionals.

  10. Engage the following collateral contacts in accordance with policy 19.16 Case Management: Collateral Contacts:

    1. The coroner to obtain information about the cause, time, and manner of death, when the special investigation involves a child death.

    2. The ME to obtain information about the cause, time, and manner of death, when the special investigation involves a child death.

      1. Request a copy of the autopsy report;

      2. When the autopsy report is not available, request the preliminary cause of death; and

      3. Provide any pertinent information about the child including DFCS history.

    3. The alleged victim child’s primary healthcare provider(s) to gather information about the child’s general well-being.

  11. Review the findings of the autopsy report to gather information about the cause, time, and manner of death. Determine additional action steps based on the results.

    1. Consult with the Social Services Supervisor (SSS), if the ME refuses to release an autopsy report to DFCS.

    2. When an autopsy report is received after case closure:

      1. Immediately make a new report to the CPS Intake Communications Center (CICC) in accordance with policy 3.24 Intake: Mandated Reporters if the autopsy report indicates a different cause of death than initially predicted and it is attributed to child abuse; and

      2. Upload to Georgia SHINES External Documentation and denote in the comments section any additional steps taken.

    The autopsy report may not be available prior to closure of the investigation, the case disposition will be made based on the available information. Efforts to secure the autopsy report must continue regardless of case closure.

  12. Upload to Georgia SHINES External Documentation, prior to closure:

    1. Forensic interviews (including a video when available)

    2. Police reports (responding officer and detective)

    3. EMS run reports

    4. Medical records

    5. Autopsy report (if applicable and available)

  13. Complete additional reporting requirements in accordance with policy 6.10 Special Investigations: Reporting of a Child Death, Near Fatality or Serious Injury.

  14. Document case activities in Georgia SHINES within 72 hours of the occurrence.

Social Services Supervisor

  1. Ensure the Child Death, Near Fatality, Serious Injury report is completed and submitted in accordance with policy 6.10 Special Investigations: Reporting of a Child Death, Near Fatality or Serious Injury.

  2. Also adhere to the appropriate investigations or special investigations policy based on the legal status of the victim child and/or where the incident occurred when supervising a special investigation involving a CD/NF/SI.

  3. Ensure healthcare providers are contacted as collateral contacts on a special investigation involving a CD/NF/SI.

  4. Consult with subject matter experts (SME) as necessary to assist in making an investigation determination.

  5. Ensure an autopsy report is obtained on cases involving a child death, or efforts continue beyond case closure to obtain an autopsy report. Consult with the SAAG when the ME denies access to the autopsy report.

  6. Assess the findings of the autopsy report, verify the cause of death is consistent with the preliminary findings obtained during the special investigation and determine if further action is required.

Child Death Due to Unsafe Sleeping Environments

The SSCM will:

  1. Interview the caregiver(s):

    1. Develop a timeline of events including the days and hours leading up to the death of the child:

      1. Determine when, where, and how the caregiver placed the infant to sleep, e.g. was the infant put to sleep on the stomach, side, or back, etc., was the caregiver co-sleeping with the infant? Was the mother planning to breastfeed or was breastfeeding at the time of death;

      2. How often did the caregiver check on the infant? At what time did the caregiver last check on the infant and how long following that period was the infant found unresponsive.

      3. Who found the child and what was the child’s position when they were found unresponsive (e.g. on the back, stomach, under a blanket, etc.); and

      4. Who provided care for the children within the previous three days (daycare, grandparents, etc.).

    2. Gather information about the infant’s health, including but not limited to:

      1. Was the child full term and of a normal birth weight;

      2. Was the infant diagnosed with any medical conditions such as colic or reflux;

      3. Any recent illness such as a cold or fever; and

      4. Were immunizations up to date (if applicable).

    3. Gather information about the caregiver and other household members, including but not limited to:

      1. The caregiver’s emotional, behavioral, and/or cognitive protective capacities based on interviews and observations;

      2. The caregiver(s) condition at the time of the child’s death, e.g. was the caregiver under the influence of alcohol or drugs at the time of the child’s death (prescription or non-prescription); and

      3. Do the household members smoke tobacco in the home or are there other possible contributing factors (see Forms and Tools: Infant Safe to Sleep Guidelines and Protocol in Forms and Tools).

    4. Determine the level of understanding the caregiver(s) has of safe sleep environments:

      1. Has DFCS staff previously discussed and addressed the dangers of unsafe sleeping environments with the caregiver(s);

      2. Has the caregiver(s) received education from the birthing hospital about safe sleeping environments and the dangers to the infant; and

      3. Has the caregiver(s) received information from other sources (e.g. hospital, lactation specialists, and pediatrician) who recommended co-sleeping or sleeping practices for purposes of breastfeeding, bonding, soothing, historical sleeping practices, etc. If so, who and what were the specific recommendations.

  2. Observe the sleep environment of the infant and document the following:

    1. Where the child was located when found deceased (e.g. swing, bassinet, adult bed, etc.);

    2. Any pillows, soft bedding, blankets, or any other objects that were found near or on the infant at the time of death;

    3. How was the infant clothed or swaddled;

    4. If co-sleeping was involved; and

    5. The condition and temperature of the home and the room where the child was found deceased.

  3. Take pictures of the sleep environment;

  4. Engage collateral contacts including individuals who can provide relevant information on the education the caregiver(s) has received regarding safe sleeping arrangements and verify recommendations made to the caregiver by other agencies or professionals (see policy 19.16 Case Management: Collateral Contacts).

  5. Request copies of any reports, interviews, photos, or video evidence that was obtained by law enforcement independent of DFCS.

  6. Review and analyze DFCS history (see policy 19.10 Case Management: Analyzing DFCS History).

    1. Does the documentation support that DFCS provided education and addressed safe sleeping environments with the caregiver(s) including whether the caregiver(s) agreed to utilize safe sleep practices;

    2. Is there a pattern of behavior showing that the caregiver allowed the infant to remain in an unsafe sleeping environment, or continued unsafe sleep practices after receiving education by DFCS; and

    3. Was a safety plan implemented addressing unsafe sleep practices in the current DFCS case, and whether the caregiver(s) adhered to the safety plan.

  7. During the supervisory staffing to make a special investigation determination, establish if the evidence supports that DFCS staff provided education and addressed safe sleep environments with the caregiver(s) (see policy 6.8 Special Investigation: Making a Special Investigation Determination).

  8. Substantiate neglect when evidence confirms that an unsafe sleep practice was the cause or contributing factor to an infant (under the age of one) death and documentation supports that DFCS staff previously educated the caregiver(s) of the dangers of an unsafe sleep environment to child safety.

Practice Guidance

Serious Injury

Serious Injury means bodily injury that involves substantial risk of death, extreme physical pain, prolonged and obvious disfigurement, or prolonged loss or impairment of the function of a body part, organ, or mental capability. Examples include burns, head trauma, blunt trauma, internal bleeding, multiple bruising and contusions, lacerations of organs, broken bones and amputation.

Near Fatality

Near fatality means as an act that, as certified by a physician, places the child in serious or critical condition. Once the child meets this criterion then the allegation of “near fatality” should be marked along with any other type(s) of maltreatment.

How to determine a near fatality:

  • Hospital records reflect that the child’s condition is serious or critical.

  • Ask the treating physician is the child’s condition serious or critical.

The Nature of Child Fatality Cases

Awareness of some basic dynamics and issues is critical to effective investigations of child fatalities.[1] Research has shown that children are most at risk of dying of maltreatment during the first 4 years of life. In fact, 40 percent of children who are victims of fatal maltreatment are infants (younger than 1-year-old) and 75 percent are younger than 5 years old. The Center for Disease Control and Prevention has reported that the chances of being murdered are greater on the day of birth than at any other point in a person’s life.

Caring for children during their preschool years can be very stressful for parents and other caretakers. Faced with a young child’s persistent problems with sleeping, feeding, and/or toilet training a caretaker may lose control and assault the child in anger or may cause injury while punishing the child. Some inexperienced caretakers have unrealistic expectations about what is appropriate child behavior and what children can do in the early stages of development. Some caretakers become angry because they view a child’s crying or bedwetting as an act of defiance rather than as normal behavior for a young child. The deadly combination of an angry adult and a physically vulnerable child can result in fatal or life-threatening injuries. When discussing child deaths related to maltreatment, the majority of child fatalities can be categorized as a variation of either acute or chronic maltreatment:

  1. Acute Maltreatment - the child’s death is directly related to injuries suffered as a result of a specific incident of abuse. Often in such cases, the child has not been previously abused.

    1. In cases involving acute physical abuse, the caretaker may have fatally assaulted the child in either an inappropriate response to the child’s behavior or a conscious act to hurt the child. Offenders in cases of Shaken Baby Syndrome (SBS), in which a child’s brain is injured from violent shaking, often cite the child’s crying as the “triggering event”.

    2. In cases of acute neglect, a caretaker’s one-time failure to properly supervise the child may result in a fatal injury. A common example is a fatal drowning that occurs when a parent leaves an infant briefly unsupervised in a bathtub or when children sustain fatal gunshot wounds when caretakers fail to properly secure loaded firearms.

  2. Chronic Maltreatment - in chronic maltreatment cases, the child’s death is directly related to injuries caused by abuse occurring over an extended period. Battered Child Syndrome is an example of chronic physical abuse. Although the direct cause of death in a battering case is usually a single specific injury (often brain trauma), numerous indications of previous maltreatment—old and new injuries and possible signs of neglect—are usually present. Depriving a child of food for a significant period of time is a common form of chronic neglect. In cases of chronic abuse, a history of the child’s previous maltreatment often will appear in either CPS or medical records.

Child Deaths and Joint Investigations with Law Enforcement and DFCS

Law enforcement is the criminal investigative agency in the community and often must investigate the same incident as DFCS.[2] Conducting a parallel investigation where CPS and law enforcement collaborate and work as a team allows both law enforcement and CPS to avoid potential conflict and to improve investigative outcomes.[3] These joint investigations should be conducted as outlined by the local Child Abuse Protocol and may include:

  1. Developing a plan to complete the investigation.

  2. Responding with law enforcement.

  3. Frequent and open communication to discuss the status of the case.

  4. Obtaining and sharing information in a timely manner, particularly at the following critical communication points:

    1. Completion of interviews

    2. Filing a dependency petition

    3. Prior to the return of the child victim to the home at any time during the life of a case

    4. Prior to the return of an alleged maltreater to the home at any time during the life of a case

    5. Reassessment of safety including changes to the safety plan or changes in placement

    6. Disclosure of information about criminal conduct

  5. Refraining or delaying an interview with the alleged maltreater due to a criminal case.

DFCS’ role is different from law enforcement. The role of DFCS is to determine whether maltreatment was involved in the child’s death or serious injury, identify the responsible party, and then take appropriate action to protect any surviving siblings. The role of the law enforcement is to determine whether a crime has been committed and who is responsible. To be successful, law enforcement and DFCS need to coordinate their efforts and use their respective resources and skills collaboratively. Thus, it is imperative that law enforcement assumes the leadership role in the investigation. This is necessary because of the legal and practical issues involved in obtaining evidence and confessions. Only a law enforcement investigator has the training, expertise, and legal mandate to execute search warrants, collect and evaluate evidence, interrogate suspects, and file criminal charges. If a SSCM prematurely confronts an individual suspected of fatally abusing a child, law enforcement may find it more difficult, if not impossible, to successfully interrogate that same individual later.

Requests by Law Enforcement to Refrain or Delay Interviewing Alleged Maltreaters

Law enforcement may request DFCS refrain or delay interviewing the alleged maltreater due to a criminal case. The SSCM still has a primary obligation to ensure child safety. In this situation open and clear communication with law enforcement is necessary so that each agency understands what is required.

When the alleged maltreater has access to the alleged victim child(ren) and a safety determination cannot be made without conducting an interview, communicate directly with law enforcement to coordinate the interview or to obtain a transcript of the interview conducted by law enforcement. When it is determined that the SSCM will not be conducting a separate interview with the alleged maltreater, a list of questions or information that is needed from the individual(s) can be provided to law enforcement to ask the during the interview.

Children’s Advocacy Centers (CAC)

Child advocacy centers (CACs)[4] are community-based, child-friendly, multidisciplinary services for children and families affected by sexual abuse or severe physical abuse. CACs bring together, often in one location, child protective services investigators, law enforcement, prosecutors, and medical and mental health professionals to provide a coordinated, comprehensive response to victims and their caregivers. This is called the MDT response and is a core part of the work of CACs. CACs offer therapy and medical exams, plus courtroom preparation, victim advocacy, case management, and other services.

Forensic Interviews

The forensic interview is generally conducted at the local CAC by a professional specially trained in conducting forensic interviews with children.[5] In addition to yielding the information needed to make a determination about whether abuse has occurred, this approach produces evidence that will stand up in court if the investigation leads to criminal prosecution. Properly conducted forensic interviews are legally sound in part because they ensure the interviewer’s objectivity, employ non-leading techniques, and emphasize careful documentation of the interview.

Children’s Advocacy Centers (CAC) Multi-Disciplinary Team (MDT)

Multidisciplinary teams represent a variety of disciplines that interact and coordinate their efforts to diagnose, treat, and plan for children and families receiving child welfare services.[6] They may also be referred to as a "child protection team," "interdisciplinary team," or "case consultation team”. Due to the complex nature of child abuse investigations and family assessments, MDTs are often used to enhance and improve investigations and responses for children and families.

Children’s Healthcare of Atlanta - Stephanie V. Blank Center for Safe and Healthy Children

Stephanie V. Blank Center for Safe and Healthy Children provides forensic medical evaluations and interviews, behavioral health assessments and counseling, multidisciplinary team review and case tracking and research. In addition to clinical services, the Stephanie V. Blank Center for Safe and Healthy Children offers ongoing training, education, and consultation as well as collaborative partnerships within the community. Some of services the Center for Safe and Healthy Children provide, include:

  1. Personalized, age-appropriate exam education and preparation

  2. A comprehensive medical history and examination by a forensic physician or nurse practitioner

  3. Colposcopy exams using video camera equipment for detailed, high quality photographic documentation

  4. Recorded forensic interviews

  5. Second-opinion consultations

  6. Expert witness testimony

For more information or to schedule an appointment please call Scottish Rite (404-785-3820) or Hughes Spalding (404-785-9930).

Child Abuse Investigative Support Center

The Georgia Bureau of Investigation’s (GBI) Child Abuse Investigative Support Center[7] assists law enforcement, child protective services, and district attorneys with the investigation of physical and sexual abuse of children. The Child Abuse Investigative Support Center provides forensic medical consultations in which the child’s injuries are evaluated and medical records and the social/home environment are reviewed. An expert opinion is rendered and a letter detailing the accidental or inflicted nature of the injuries is provided. Expert testimony regarding the opinion is also available as needed. Services from the support center can be obtained by contacting:

Child Abuse Investigative Support Center
GBI Headquarters
3121 Panthersville Road
Decatur, Georgia 30034
404-270-8194
FAX 404-270-8183

Autopsy Reports

An autopsy determines the cause, manner, and underlying mechanism of death. This procedure also documents all the significant pathologic conditions present in the body at the time of death.

Child Fatality Review Committees (CFRC)

Each county shall participate as a member of the local multi-disciplinary CFRC that will review all deaths of children ages birth through age 17 years. County Departments must designate a representative to serve on the local CFRC based on the County’s Child Abuse Protocol and CFRC requirements. The SSCM may be contacted by the local county DFCS representative of the CFRC and/or asked to participate in the meetings. During the CFRC meetings, the SSCM/DFCS Designee may request an official copy of the death certificate or autopsy findings to include in the case record even after DFCS’ investigation has been completed. See policy 1.10 Administration: Child Fatality Review for additional information about the role of the CFRC.

Forms and Tools

Child Abuse Investigative Support Center (CAISC) - GBI
Frequently Asked Questions About Autopsies - GBI Medical Examiner’s Office

1. Investigating Child Fatalities, Lieutenant Bill Walsh (Retired); Crimes Against Children Unit, Special Investigation Division, Reserve Battalion, Dallas Police Department; Issued through the U.S. Department of Justice Office of Justice Programs and Office of Juvenile Delinquency Prevention, Portable Guides, August 2005
2. Investigating Child Fatalities, Lieutenant Bill Walsh (Retired); Crimes Against Children Unit, Special Investigation Division, Reserve Battalion, Dallas Police Department; Issued through the U.S. Department of Justice Office of Justice Programs and Office of Juvenile Delinquency Prevention, Portable Guides, August 2005
3. The Role of Law Enforcement in the Response to Child Abuse and Neglect, U.S. Department of Health, and Human Services, 1992
4. Copyright ©2014 National Children’s Alliance
5. Children’s Services Practice Notes for North Carolina’s Child Welfare Social Workers; From the Division of N.C. Division of Social Services and Family and Children’s Resource Program Vol. 8, No. 1, December 2002, © 2002 Jordan Institute for Families
6. U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau, Child Welfare Information Gateway
7. Georgia Bureau of Investigation, Medical Examiner’s Office, The Child Abuse Investigative Support System PDF; www.gbi.ga.gov