Critical Incident Rapid Response Team. Ahziya Osceola

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1 Critical Incident Rapid Response Team Ahziya Osceola April 27, 2015

2 Critical Incident Rapid Response Team Ahziya Osceola Southeast Region Circuit 17 Broward County, Florida Table of Contents Executive Summary.3 Introduction 5 Case Participants and Genogram 6 Child Welfare Summary System of Care Review Practice Assessment...13 Organizational Assessment Service Array Page

3 Executive Summary On March 20,, 2015, the Florida Abuse Hotline received a report alleging that 3-year-old Ahziya Osceola had been found deceased in his home the day prior,, following an exhaustive search by law enforcement, which began when he was reported as missing earlier the same day. d Ahziya s body was found inside two plastic bags, which had been placed inside a cardboard box, which was then concealed under piles of clothing in the home s laundry area. Subsequent to this discovery and additional investigation by law enforcement, Ahziya s A stepmother, Analiz Redezno-Osceola, was arrested and charged with Aggravated Manslaughter, Child Neglect and Giving False Information to Law Enforcement. Ahziya s father, Nelson Osceola, was also arrested and charged with Child Neglect. The remaining ng children residing in the household (one half-sibling and one step-sibling) sibling) were taken into custody a Because of these circumstances, Secretary Mike Carroll of the Department of Children and Families deployed a Critical Incident Rapid Response Team (CIRRT) to the Southeast Region, Circuit 17, in order to determine the nature and efficacy of the child welfare system involvement with Ahziya and his family, and to assess potential systemic issues within the local system of care. The review team consisted of representatives from DCF s Office of Child Welfare and Children s Legal Services, as well as the Department of Health s Office of Child Protection and Special Technology, the Northeast Region s Office of Substance Abuse and Mental Health, the Seminole County Sheriff s Office and Community Based Care of Central Florida. The CIRRT findings revealed an extremely complex family history of involvement with multiple agencies within Broward County s system of care, including: Broward Sheriff s Office division of Child Protective Investigations (BSO CPI), which conducts all child protective tive investigations in Broward County; ChildNet, Inc. (ChildNet), which is the contracted Community Based Care lead agency (CBC) which h provides ongoing case management for Broward county; Office of the Attorney General (OAG), which provides Children s Legal Services for the Department in Broward County; Child Protection Team (CPT), which is administered by the Community Partnerships Division of the Human Services Department of Broward County; and Seminole Family Services, the social services agency administered by the Seminole Tribe of Florida ( the Tribe ), of which Ahziya and several of his immediate and extended relatives are recognized members. 3 Page

4 The comprehensive review of these agencies records, as well as face-to-face contacts with involved staff, revealed a several years long pattern of substance misuse, generalized neglect and physical injury to Ahziya, which began while in the custody of his mother, Karen Cypress, and ended while in the custody of Mr. Osceola and the joint physical care of Mrs. Redezno- Osceola. During the investigation of multiple reports that were received during that time, as well as the resultant period of court-orderedordered supervision and services, there was a generalized failure to first recognize then fully assess an emerging and worsening pattern of insufficiently explained physical injuries to Ahziya. Given that the removal from his mother (due to substance misuse) is what resulted in Ahziya s placement in his father s custody, the primary focus of the ongoing court-ordered services was the mother s completion and/or progress on case plan goals aimed toward reunification, rather than Ahziya s safety and well-being while in his father s and (eventually) stepmother s care. This report presents the CIRRT s findings, including the child welfare history, the family composition, a summary of the local child welfare services provided d and a comprehensive analysis of the system of care. The findings are reported in the key categories of Practice Assessment, Organizational Assessment and Service Array. 4 Page

5 Introduction On March 20, 2015, the Florida Abuse Hotline (Hotline) received a report alleging that 3-year-old 3 Ahziya Osceola had been found deceased in his home the day prior, following an exhaustive search by law enforcement, which began when he was reported as missing earlier the same day. Ahziya s body was found inside two plastic bags, which had been placed inside a cardboard box, which was then concealed under piles of clothing in the home s laundry area. Subsequent to this discovery and additional investigation by law enforcement, Ahziya s stepmother, Analiz Redezno-Osceola, was arrested and charged with Aggravated Manslaughter, Child Neglect and Giving False Information to Law Enforcement. Ahziya s father, Nelson Osceola, was also arrested and charged with Child Neglect. The remaining children in the household (one half-sibling and one step-sibling) sibling) were taken into custody a Prior to his death, Ahziya and his immediate family (which includes a total of four half-siblings and one step-sibling) sibling) had been the subject of multiple reports alleging abuse or neglect dating back to April Ahziya was the subject of four (4) investigations received between August 2013 and December 2014, with the last of these being completed in early February One of these reports, received in January 2014, resulted in the removal of Ahziya and his three half-siblings from their mother, Karen Cypress, when it was determined they had been the victims of verified Medical Neglect he Inadequate Supervision and Substance Misuse. The children were adjudicated dependent, and each was subsequently placed with his/her respective father. Ahziya was (at the time) the only child fathered by Nelson Osceola, so he was the only child placed in Mr. Osceola s care. Ahziya and his half-siblings then received approximately nine (9) months of court-ordered ordered services and supervision - in their respective placements - from ChildNet, Inc. (ChildNet). In addition, the e family received services and family advocacy from the Seminole Tribe of Florida ( the Tribe ), which continued even after closure of the court-ordered ordered services case, which was terminated by the court for Ahziya in September During the Critical Incident Rapid Response Team s (CIRRT) review, face-to-face interviews were conducted with staff from Broward Sheriff s Office division of Child Protective Investigations (BSO CPI), ChildNet, Office of the Attorney General (OAG) and the Child Protection Team (CPT).. In addition, several phone contacts were made with the Tribe,, of which Ahziya and the majority of his immediate family are recognized members. While Tribe representatives were amenable to discussing general case management practices as well as their collaboration with both BSO CPI and ChildNet staff, they ultimately declined to provide their written case records specific to the Osceola family or to discuss this information verbally. 5 Page

6 Case Participants Name Age at Time of Incident Relationship Ahziya Osceola 3 years 7 months Decedent Half-Sibling to Ahziya 2 years Half-Sibling to Ahziya ). 2 years 7 years 5 years Half-Sibling to Ahziya ( Half-Sibling to Ahziya Step-Sibling to Ahziya, Half-Sibling to ) Karen Cypress 26 years Mother to Ahziya, Nelson Osceola 24 years Father to Ahziya and Analiz Redezno-Osceola 24 years 25 years Mother to Father to Stepmother to Ahziya. 23 years 27 years Father to twins Father to. Genogram (Child) Karen Cypress Nelson Osceola Analiz Redezno- Osceola Ahziya (Decedent) 6 Page

7 Child Welfare Summary In August 2013, the first report was received involving then 2-year-old Ahziya and his three half- siblings by their mother, Karen Cypress. The initial reporting sequence alleged that approximately three days prior, Ms. Cypress had been observed in a highly intoxicated state (e.g. falling out of a parked car door, vomiting) with the children in her care. Although law enforcement had been notified of these circumstances at the time this allegedly occurred, Ms. Cypress was reported to have left the scene prior to law enforcement s arrival. In addition, the report alleged a physical injury to Ahziya s face, for which Ms. Cypress had no reasonable explanation. The day following receipt of this initial report, an additional report was received by the Hotline, which alleged that Ahziya would return from visits with Mr. Osceola having unexplained bruises and smelling like marijuana. Despite this call containing additional allegations involving a different Alleged Perpetrator (Mr. Osceola), the call was coded by the Hotline as only containing supplemental information regarding the initial allegations rather than additional allegations, which would require a separate response and additional assessment regarding those allegations; neither did the BSO CPI initiate such a response on his/her own accord. However, Ahziya was examined by a CPT physician during this investigation,, who determined that a bruise to Ahziya s left cheek was consistent with Ms. Cypress s explanation that he had fallen and struck his face on the wooden frame of a bunk bed.. As such, there were no findings (by CPT) of an inflicted injury. Although Ms. Cypress denied any substance abuse problems and there was no substantive evidence gathered to the contrary, CPT recommended that she complete a substance abuse evaluation and follow through with any resultant recommendations. CPT further recommended that Ahziya complete an evaluation to determine whether there was the presence of any developmental disabilities. Given that Karen Cypress is of Native American (Seminole Indian) descent (and by virtue of their parentage, all four of her children), a Family Preservation Counselor with Seminole Family Services served as a family advocate for the duration of the investigation. Prior to investigative closure, the family had been referred and was voluntarily engaged in ongoing services with Seminole Family Services; ; Ms. Cypress had begun substance abuse counseling and had followed up with Ahziya s pediatrician, and he was already receiving speech therapy. This August 2013 report was closed with Not Substantiated findings of Substance Misuse and No Indicators of Physical Injury to Ahziya, and No indicators of Substance Misuse to the other three children ). In January 2014, the second report was received involving Ahziya (then 2 ½-year-old) and his three half-siblings, and this report resulted in all four children being taken into custody and eventually being placed with their respective fathers. 7 Page

8 This report was received when Ahziya was found unsupervised in the first floor lobby of a hotel/motel where Ms. Cypress and her children had been staying in a fifth floor room. When law enforcement arrived and determined Ahziya s identity and Ms. Cypress s location, she was found to be passed out from intoxicationion with at least one partial bottle of liquor in the room accessible to the children. She was unaware Ahziya had exited the room and had been unattended for approximately 30 minutes. She was, therefore, arrested on charges of Child Neglect. During the arrest, Ms. Cypress incurred additional charges of Resisting Arrest and Battery on a Law Enforcement Officer. By the time this report was received and the BSO CPI responded to the location of this event, all four children had already been released by law enforcement to the care of the father,., with whom Ms. Cypress and the children had been residing until one to two weeks prior to her arrest. Ahziya, who was the only child fathered by Mr. Osceola at the time (as was not born until August 2014), was eventually placed by the court in Mr. Osceola s care based on the recommendation of Seminole Family Services. This was with the condition that Mr. Osceola continued to reside with his own paternal grandmother. The reason for this stipulation, as documented on the Home Study completed by Seminole Family Services, was that Mr. Osceola s drug screen results were pending at the time of placement, as were outstanding criminal charges the nature of which was not documented on the Home Study. The T were placed with their father,, and was placed with his father, (Note: Following his placement with, there have been no additional reports involving as an Alleged Victim or as an Alleged Perpetrator regarding any child.) The January 2014 investigation was closed with Verified findings of Medical Neglect and Not Substantiated Findings of Failure to Thrive to then 13-month- old. (who had been medically evaluated following their removal due to obvious and severe growth deficiencies), as well as Verified findings of Inadequate Supervision and Substance Misuse to all four children. The dependency case against Mr. Osceola was later dismissed by the court, which considered him to be a non-offending offending parent as to the circumstance that brought Ahziya into care. As such, and aside from the same standard requirements being listed in the Case Plan for the Father (of which there were three), there were no Case Plan tasks assigned to Mr. Osceola. The children were later adjudicated dependent and continued to receive services from ChildNet and Seminole Family Services in their respective placements. The third report, received in April 2014, involved Ahziya only and alleged he had multiple bruises on his body, including what appeared to be fingerprints and a bruise on the lower portion of each side of his jaw line. He was additionally alleged to have scratches on both sides of his neck, a large bruise and bump on the right side of his forehead, a knot above one ear and bruises over 8 Page

9 his left rib cage on his back. The report further alleged a series of injuries (pinch marks, bruises, scratches, and a busted lip ), which reportedly dated back to the end of March The Alleged Perpetrator was unknown. Ahziya (who was by then 3-years-old) was initially seen at his daycare by the assigned BSO CPI and Seminole Family Services. When asked about his injuries, he stated he had fallen in his room (he provided this answer twice). However, staff at the daycare indicated when they had asked him, he stated ted his father had hit him. Staff members were additionally concerned over the number of times Ahziya had arrived in the past several weeks with a number of assorted bruises/marks, some of which were reasonably explained by Mr. Osceola and some of which were not. In addition, Ahziya had recently missed several days of daycare and again was observed with bruises upon his return. When Mr. Osceola was interviewed, he indicated Ahziya had been with him at a family Easter gathering over the weekend (this report was received on a Monday) and that s where/when he had sustained the bruising on his face. He said all of the children at the gathering were running wild and Ahziya ran into one of them, causing him to fall. Ahziya continued to play afterward so he appeared ared to be OK. Mr. Osceola was unaware of the bump on Ahziya s head but did state he had fallen in his room as well as fallen off the toilet. Mr. Osceola expressly denied abusing Ahziya, characterizing him as a child who falls all the time, does not pay attention to where he is going, and as a result, runs into tables, countertops and other pieces of furniture which may cause injuries. Mr. Osceola also offered that Ahziya simply bruised easily due to a low immune system. Ahziya was seen again for a medical evaluation at CPT, which resulted in positive findings for physical abuse as the injuries on his face at the jaw line were consistent with fingertip marks from being grabbed. The other injuries were deemed consistent with accidental injuries typical of an active 3-year-old child. During a joint visit in mid-may 2014 with Ahziya by ChildNet and Seminole Family Services (while the April 2014 investigative was still open), Ahziya was noted to have a mark below one eye that Mr. Osceola stated occurred while Ahziya was playing around in the bathroom. Of note is that this is a similar explanation provided by Mr. Osceola when he was previously questioned about the origin of the suspicious lump on Ahziya s head. During a joint visit in early June 2014 by the BSO CPI and Seminole Family Services, there was discussion regarding the Tribe seeking medical testing to determine if there was a metabolic reason for Ahziya to bruise easily. At a later June 2014 home visit, ChildNet and Seminole Family Services observed what appeared to be a rash on Ahziya s buttocks. Ms. Cypress was the one to have taken note of and questioned this, so ChildNet suggested to Mr. Osceola that he begin keeping a log to document each time Ahziya was injured and/or experienced any medical problems. 9 Page

10 The April 2014 investigation was closed with Not Substantiated findings of Physical Injury to Ahziya, without a specific individual being found responsible for these injuries. Based on Mr. Osceola s explanation that some of the previous injuries observed by ChildNet, Seminole Family Services and daycare staff were accidental in nature (falling in his room and falling off the toilet), a Safety Plan was developed, which simply called for more direct supervision on Mr. Osceola s behalf to avoid such falls from occurring. This failed to address the CPT findings that at least some of the injuries observed during his medical evaluation were intentionally inflicted and/or indicative of abuse. Upon investigation closure, Ahziya continued under the previously initiated services being jointly provided by ChildNet and the Tribe. It was then determined during a monthly visit to Ahziya in July 2014 (conducted jointly by ChildNet and Seminole Family Services) that Mr. Osceola had apparently been involved with Analiz Redezno-Osceola for quite some time. Mr. Osceola expressly indicated he needed to finish up the visit as Mrs. Redezno-Osceola (whom he referred to as his wife at the time) was at the hospital about to give birth to their child, Despite this information becoming known, there is no indication that ChildNet addressed the addition of these new family members to the household, particularly as relates to Mrs. M Redeznoor not her ability and willingness to jointly provide safe and stable care for Ahziya. It is unclear from ChildNet notes whether this history was obtained and examined at any point prior to the closure of Ahziya s ChildNet case, which occurred two months later in September Osceola s history y with her own child and how this impacted During the CIRRT review, a background search regarding Mrs. Redezno-Osceola revealed that several prior reports had been received on her child, between April 2012 and April 2013, one of which resulted being placed under in-home-court-ordered ordered services with ChildNet as well. and Mrs. Redezno-Osceola s history is as follows: ). - f s,. nv 10 Page

11 . n- n, - c - n ( When ChildNet case was terminated in April 2014, remained in his mother s care and custody. No additional reports were received involving as an Alleged Victim or Mrs. Redezno-Osceola as an Alleged Perpetrator (regarding any child) until the March M 2015 report was received regarding Ahziya s death. During home visits to Ahziya in July and August 2014, ChildNet indicated the intent to recommend the case for closure at the next review hearing scheduled to occur in September 2014, and for the children to remain in the care of their respective fathers. This was in contrast (as also documented) to Seminole Family Service s desire to maintain the case as open to provide Ms. Cypress additional time to fully complete her Case Plan tasks,, with the goal continuing to be reunification. On September 9, 2014, the court terminated the ChildNet case involving Ahziya, per the motion filed by Mr. Osceola s attorney. The court further maintained Ahziya in the full custody of Mr. Osceola, and Ms. Cypress was granted unsupervised visitation each weekend. The final report involving Ahziya (prior to his death) was received on December 7, 2014, and again alleged Physical Injury by an unknown Alleged Perpetrator. The report (which contained essentially the same information in two reporting sequences made by the same party on the same date) specifically alleged that Ahziya had been seen at the hospital Emergency Room for bruising on his face as well as complaints of painful buttocks when he sat down. The injuries allegedly had occurred while Ahziya was in the care of Mr. Osceola and/or Mrs. Redezno- Osceola, and were noted by Ms. Cypress when she picked up Ahziya for an unsupervised visit. 11 Page

12 It should be noted this is the first investigation wherein Mrs. Redezno-Osceola was determined to be residing with Ahziya and Mr. Osceola; they had been married in June 2014 and Ahziya s youngest half-sibling, had been born in August During his exam at the ER, Ahziya was noted to have a circular bruise with an overlying abrasion on his cheek underneath his left eye. Ahziya was also noted to have some abrasions or tears in the anal area, which the reporting party specifically stated (as per Ahziya s medical evaluation) may be due to problems associated with severe constipation, but which had not yet been fully confirmed. There were concerns/allegations that each time Ahziya sustained any injuries or bruising while in the care of Mr. Osceola and/or Mrs. Redezno-Osceola, Mr. Osceola would state Ahziya had simply fallen.. However, when Ahziya was asked how he was injured, he said his mommy hurt my butt (referring to Mrs. Redezno-Osceola). The reporting party, who had seen Ahziya the day of the ER visit, described him as very happy, rambunctious and talkative. He bounces off the walls. The assigned BSO CPI initiated the investigation by calling to notify Seminole Family Services of the new report. After also speaking with medical staff and confirming that Ahziya s injuries were not severe, the BSO CPI and Seminole Family Services agreed that Mr. Osceola s paternal grandmother should take Ahziya home from the hospital with her, and the BSO CPI would see him the following day. (Note: This relative is the same individual with whom Mr. Osceola was required to live when he was initially given custody of Ahziya following the January 2014 removal from Ms. Cypress s care.) Ahziya s diagnoses upon discharge from the ER were constipation, facial contusion, initial encounter and abrasion. When interviewed by the BSO CPI, both Mr. Osceola and Mrs. Redezno-Osceola denied having abused or otherwise injured Ahziya intentionally.. Mr. Osceola said he was at work when the facial injury allegedly occurred, so his only knowledge of the events was secondhand from his wife,, who relayed to him that Ahziya was climbing on a wagon in his room, and despite being told several times to get off the wagon, eventually fell and struck his face. Mrs. Redezno-Osceola provided the same account of Ahziya having fallen in his playroom and injuring his face while climbing on a wagon. She further advised that due to his low immune system she was very careful with the foods she provided him to eat. Ahziya stated he had gotten a boo boo on his face when he had fallen n down. He denied he had been hurt by anyone, and stated his father, mother and stepmother were all very nice to him. He also stated he had to go to the hospital for a doctor to look at his boo boo. In addition to the ER visit, Ahziya was seen for a third medical evaluation at CPT, two days following commencement of the investigation. The written CPT report, which was documented on a Sexual Assault/Abuse Exam form, indicates positive findings for physical abuse with a specific description of the facial injuries as follows: 12 Page

13 o Ms. Cypress was interviewed by telephone the same day of investigative closure and indicated that Mr. Osceola had not permitted her to see Ahziya since initiation of the investigation, approximately two months prior. She stated that while she was previously completing her Case Plan tasks and specifically when Ahziya was brought to visit her i he would often have some type of mark or bruise on his face. Ms. Cypress further stated that while Ahziya was somewhat clumsy, she was concerned that Mr. Osceola and Mrs. Redezno-Osceola were not providing proper supervision to prevent these injuries from happening. She intended to speak with her attorney and seek to have her visitation rights readdressed in court,, given Mr. Osceola s failure to comply with the previous order upon termination of ChildNet services.. She had continued to have weekend visitation with her other three children ) with no difficulties. Despite CPT s positive findings of abuse for Ahziya s facial injuries which were communicated to the BSO CPI prior to investigative closure - this investigation was closed with No Findings of Physical Injury and with no individual(s) being held responsible for the injuries. Mr. Osceola s paternal grandmother continued to be actively involved in Ahziya s life and care, and sometimes acted as a mediator between Ms. Cypress and Mr. Osceola regarding matters of visitation. The BSO CPI, in conjunction with Seminole Family Services (which remained involved with the family for the duration of the investigation), determined there was no need for a Safety Plan and no need to initiate any repeat services from ChildNet. System of Care Review This review is designed to provide a comprehensive assessment of the child welfare system s interactions with the Osceola family and to identify issues that may have influenced the system s response and quality of decision-making. Practice Assessment PURPOSE: This practice assessment examines whether the child welfare professionals assessments, actions and decision-making regarding the family were consistent with the Department s policies and protocols. FINDING A: There was insufficient assessment of Ahziya s safety while in his father s care. This occurred during individual investigations, over the period of time when yet more reports were received at the Hotline with similar allegations of abuse, as well as during ongoing court-ordered case management.. This included occurrences of new injuries being observed, a pattern of repeat injuries, and inconsistencies between parent/caregivers statements regarding the origin(s) of the injuries. 13 Page

14 Of significant concern was the failure to adequately assess the origin of and person responsible for the multiple injuries that were medically determined to have been inflicted, and which were mostly about the face, head and neck area of such a young child. All but one of the reports alleging physical injury to Ahziya occurred after he was placed in Mr. Osceola s care, and Mr. Osceola always provided a similar explanation of simple falls or accidents as the cause of these injuries. Although an active toddler can often incur typical childhood injuries during everyday play, these are more often on the exposed, boney prominences of a child s body, such as the shins, knees and elbows. Accidents during play can also result in the occasional abrasion, asion, bump or bruise to the chin or forehead area, but such injuries should be viewed with additional scrutiny - particularly when the same explanation is provided for repeat injuries and when a medical evaluation confirms the injury is consistent with being intentionally inflicted (e.g., the grab marks about Ahziya s chin and jaw line). In addition, Ahziya s cognitive and developmental capacity, relative to his young age, make it unlikely he was able to positively identify the cause and/or timeframes of the multiple injuries he sustained over time. He would likely be unable to correctly differentiate the outcome of two unrelated events that happened in close proximity to one another (e.g., being grabbed on the face within the same relative period of time that he ran into another child and fell down, or being struck by a caregiver within close proximity to him having fallen off a wagon in his room). His age and size also made him physically vulnerable and still almost entirely dependent upon his caregivers for his day-to-day care, and incapable of self-protection and/or self-reporting (i.e. spontaneously telling a teacher, family member or other responsible adult who would take the initiative to intervene in a protective manner). Furthermore, there was a pattern of over-reliance reliance on parent/caregiver statements and a failure to consistently utilize external (to the family) collateral sources to reconcile information and/or evidence during investigations and ongoing case management. The parties often relied on the statements of household members and/or the Tribe and did not seek out corroboration from highly evident sources (e.g., failure to contact others who were at the Easter gathering to corroborate the account of Ahziya having injured his head during a fall). Even in those circumstances when prudent collateral contacts were conducted, this information appears not to have been reconciled with information to the contrary, which was provided by the family. The most significant of these circumstances is the April 2014 investigation wherein CPT made positive findings of physical abuse (grab marks to Ahziya s face and jaw line), yet this investigation was closed as Not Substantiated tiated with the perpetrator having not been identified. Investigative documentation also does not indicate that additional family members (Mrs. Redezno-Osceola s mother and two adult brothers) residing with the family during the last investigation prior to Ahziya s death, were fully assessed in terms of their own histories (abuse/neglect and criminal), the extent of their caretaking roles, their capacity to provide safe and stable care, and whether or not their presence alone could pose a threat to Ahziya s physical or emotional well-being. 14 Page

15 On the one occasion that a Safety Plan was developed in reference to Ahziya, due to the repeat presence of multiple injuries to his head, face and neck area, the focus was simply that of providing more direct supervision; it was never determined who had inflicted the grab marks (per CPT s medical assessment) noted on Ahziya s chin and jaw line. Lastly, a review of the ChildNet case chronological documentation did not reflect that any direct services were provided by either ChildNet or the Tribe to Ahziya or Mr. Osceola, for the duration of Ahziya s placement. While there was mention during home visits of parenting classes (February 7 and March 19, 2014), a developmental evaluation by the Tribe for Ahziya (February 21, 2014) and a parenting coach (June 11, 2014), there was no subsequent documentation of these services ever having been initiated and/or engaged. A June 11, 2014 note specifically indicated that no services were being provided to the children. Some documentation by the BSO CPI during its investigations did indicate that Ahziya was in daycare for a portion of his placement. FINDING B: Collection and sharing of information and evidence occurred in silo fashion and was both inconsistent and insufficient among BSO, ChildNet, CPT, the OAG, the Tribe and the Court. Evident during the review was the absence of all parties coming together for any multiwhen the pattern of repeat injuries and/or successive reports began disciplinary staffings, even and then continued to emerge.. Ahziya and his three primary caretakers were the subjects of seven investigations received in less than three years (April 2012 to December 2014), which also resulted in two separate court-ordered ordered periods of services and supervision - one for Mrs. Redezno-Osceola with and one for Ms. Cypress with Ahziya and his three oldest half- siblings. Yet there was no indication these agencies ever recognized the need, either individually or collectively, to gather as a group to ensure that all parties had the benefit of the collective information each agency possessed. In addition, there was a lack of attachments and documentation with filed Judicial Review Social Study reports about the case status, case plan progress and/or medical updates, which led to a lack of detail available to the Court. This was significant particularly to additional investigations regarding Ahziya after he was placed in Mr. Osceola s care. Of note was the absence of any information regarding the April 2014 investigation (the first allegation of a physical injury to Ahziya after being placed with Mr. Osceola) in the review report that was completed in late April 2014; neither was there any mention of this (per the court records) during the hearing itself. Similarly, the CPT report regarding the positive findings for the grab marks on Ahziya s face was neither filed with the court nor mentioned in the legal file. There was also no documentation to support that the OAG was notified of this new investigation by either BSO CPI or ChildNet. Lastly, while CPT findings were typically verbally communicated to the BSO CPI shortly after CPT medical evaluations were conducted, the written reports were not provided in a timely fashion and sometimes were received after investigative closure. In fact, the last CPT case 15 Page

16 regarding Ahziya prior to his death, from December 2014, was found to remain open with CPT at the time this review occurred. FINDING C: There was an over-emphasis on completion and progress on Case Plan goals related to Ahziya s mother, Karen Cypress, with no noted emphasis on ensuring Ahziya s safety, health and well-being while in the care of his father, Nelson Osceola. While Ahziya was seen on an at-leasdetails of these contacts reflect very little evaluative component(s) when it came to assessing Ahziya s safety and well-being while in Mr. Osceola s care. Of the 11 documented visits to Ahziya in Mr. Osceola s home (10 of which were made jointly by ChildNet and Seminole Family Services; the 11 th visit was made solely by Seminole Family Services), the details of all but one monthly basis during ChildNet s service provision, the visit were documented using the same documentation template, most of which was simply blank and/or not applicable to Ahziya s circumstances. Organizational Assessment PURPOSE: This section examines the level of staffing, experience, caseload, training and performance as potential factors in the management of this case. FINDING A: There are diluted lines of responsibility, authority and actions that can be taken by both BSO CPI and ChildNet staff, due to Tribal rights and authority per the Indian Child Welfare Act of 1978 (ICWA). This includes matters relating to investigations, service provision, removal, placement and reunification. Of particular significance is information-sharing by the Tribe concerning its social services involvement over the years with the family via Seminole Family Services. While both BSO CPI and ChildNet reported very positive and collaborative relationships with the Tribe and Seminole Family Services, this was based primarily on factors such as availability to conduct joint visits, approval to access children and families residing on the reservation, and generalized support and advocacy provided to the families for the duration of investigations and court-ordered service provision. When children of Native American/Seminole Indian descent are determined to be unsafe and require removal from their parents/caretakers, the Tribe (via Seminole Family Services) independently has the authority pursuant to ICWA to determine where the children will be placed. A Home Study is completed by Seminole Family Services and presented to the court. BSO CPI routinely completes criminal and abuse history checks on potential placements offered by the Tribe (if the demographic information is available), and is permitted to present any safety concerns these checks reveal while at the shelter hearing. However, assigned Judges (who in this family s case, was most often a Magistrate) are generally supportive of the placement recommendations of the Tribe. 16 Page

17 FINDING B: Tribal representation, both in court proceedings as well as in the duration of services being provided by Seminole Family Services, focused on family advocacy rather than child advocacy. Staff from the Office of the Attorney General indicated that while Guardians ad Litem (GAL) are typically appointed to all removed children at the shelter hearing, they are also routinely and immediately discharged by the court for any child of Native American/Indian Descent. This is again pursuant to ICWA, which stipulates the Tribal representative(s) role is to support the family and advocate for the family s rights. Given that family advocacy can and often does differ from individual child advocacy, in some cases, this can create circumstances where family and/or parental needs may take precedence over individual child needs for safety, permanency and well-being. While it s apparent that (at the time) permanency for Ahziya was achieved with Mr. Osceola, it is not apparent that Ahziya s needs for safety and well-being were ensured as well (pursuant to the Findings in the Practice Assessment section, above). FINDING C: The number of investigative assignments for the involved BSO CPIs, and the level of their child welfare experience, were not deemed to be factors in the handling of prior child protective investigations. The four prior reports involving Ahziya were collectively investigated by a total of three BSO CPIs; one CPI handled two of the investigations (the January and December 2014 reports). The following table provides information regarding length of employment, caseloads (based on the number of investigations received per month) and any specific information regarding the CPIs employment status during the months they were assigned their respective investigations. 17 Page

18 BSO CPI Month Assigned to Investigation # of Investigations Received Experience to Date of Assignment Comments CPI A August ½ years Within recommended industry standards (12-15). CPI B January 2014, December and 6, respectively 7 ½ years and 8 years, respectively Within recommended industry standards for January 2014; well below recommended industry standards for December CPI C April years Well below recommended industry standards. In addition to handling these investigations, CPI C was serving as Acting CPI Supervisor for Squad 5 during this month, which had handled all Institutional investigations, as well as all investigations involving children of Seminole Indian descent since March Squad 5 employed a total of five CPIs during this time. Note: The number of investigations received does not include Supplemental Reports, Additional Reports, Out-of-Town Inquiries or Out-of-State Inquiries. Service Array PURPOSE: This section assesses the inventory of services within the Broward County child welfare system of care where the Osceola family s case originated. FINDING: Broward County has a comprehensive service array that includes Tribal-provided services, as well as domestic violence, substance abuse and mental health providers who are co-located and immediately available to both BSO and ChildNet staff. Other than the matter related to information-sharing and coming together as a collaborative team (which was discussed as Finding B under the Practice Assessment section), the service array and availability of these services were not determined to be a factor in the outcome for Ahziya. The Tribe has an impressive service array for matters related to substance misuse and mental health problems, and is also in the position to pay for private (outside of the Tribe) services when a need is identified that cannot be met by the services available from the Tribe itself. 18 Page

19 The independent taxing district, the Children s Services Council of Broward (the Council), provides a substantial investment in family support services and works closely with BSO CPIs and ChildNet leadership in identifying the need for these in-home family support services. The Council funds high-quality, evidence-based programs that serve a significant number of families identified by BSO CPIs in order to prevent them from crossing into the dependency system. Case-specific specific progress for families served by the Council s programs is funneled back to BSO CPIs, and those reports are then entered into the case record(s). However, given that the Council provides the majority of family support services as described, it is also the source for determining the quality and value of such interventions. Because ChildNet does not develop its own resources as a part of its prevention efforts, the organization may be disadvantaged at properly identifying the most effective resources for families such as Ahziya s. Another resource for investigators is a weekly roster of available referrals for families. This roster contains information such as service description and location, target population and wait- list issues. The only noted concern by BSO CPI staff regarding rding availability of a specific service was for education and/or parenting classes geared toward parents of children with developmental/behavioral disabilities and/or other special needs, as these services are often limited due to space availability. Lastly, given that Ahziya was a member of the Seminole Indian Tribe, ChildNet looked to the Tribe to link the family to any necessary services as the Tribe and DCF s State of Nation Tribal Agreement points to the Tribe providing these services. 19 Page

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