Report: State let Haleigh Poutre down
Report: State let Haleigh Poutre down
BOSTON - In a scathing review of how the state cares for children in its custody, a special commission yesterday found that Haleigh Poutre was let down by "a systemic failure" on the part of the state and private health providers.
Haleigh, 12, was admitted to a Springfield hospital in September in a comatose state after being abused.
The state Department of Social Services has acknowledged overlooking signs of past abuse, largely because medical professionals and staff believed it was self-inflicted.
A three-member commission, appointed by Gov. W. Mitt Romney on Jan. 27, reported its findings yesterday on the state agency's involvement with Poutre during the past seven years.
"What happened to Haleigh Poutre ... should not have happened and did not have to happen," the commission's report said. "There are unquestionably things that the Department of Social Services can do and needs to do to improve its ability to identify and protect high-risk children. At the same time, this case represents a systemic failure on all levels, public and private, to provide ... the safety net that our children deserve."
The panel called for new coordination and sharing of medical information among the state and private health care institutions. The panel said the state social services department needs better access to medical, psychiatric and child abuse experts.
In findings that point to the state's failure to provide proper funding for human services in Western Massachusetts, the panel said expertise in child abuse "is seriously lacking" in the region.
"Western Massachusetts in particular suffers from an absence of child abuse resources," the commission's report said. "Most major pediatric hospitals in the eastern part of the commonwealth have special abuse teams to consult in reviewing suspicious injuries or providing guidance about reporting to DSS, but Western Massachusetts has none."
The report said the offices of the state Department of Social Services in Western Massachusetts receive about 1,000 reports of abuse or neglect every month, almost twice the number of reports received in Boston. Yet, there "are not appreciably more case workers" in Western Massachusetts than in Boston, the report said.
Also, mental health services for children "are strikingly lacking" in Western Massachusetts, with only one mental-health clinic to serve Westfield and surrounding small towns, the report said.
Christine C. Ferguson, former commissioner of the state Department of Public Health, who led the commission, said Haleigh's case "highlights a frightening confluence of a health care system ignorant of abuse and a child protective system ignorant of medicine."
Ferguson said the commission did not find carelessness or a failure to make best attempts to meet the girl's needs. "Instead, we found health, mental health, child welfare systems that ... were unable to penetrate the proffered explanation for Haleigh's injuries ... and were ill-equipped to provide her with the care ... any of us would want for our children."
The commission recommended that before seeking a court order to remove life-sustaining equipment from a patient, the state seek a second medical opinion from a doctor outside the person's hospital.
Right now, only the opinion of the patient's attending physician is needed for the state to ask for a court order to end life support.
The commission also urged that the state obtain the opinion from an ethics committee at the patient's hospital.
Romney said the panel made no finding of mistaken work, negligence or culpability on the part of state agencies or private health providers.
However, Betsy Clague, a Brocton lawyer who represents Avrett, said the report didn't go far enough and the commission committed "a glaring oversight" by failing to speak with her client.
The executive director of a nonprofit group that advocates for foster children blasted the panel's recommendations, saying they pose a far too complex solution to a very simple problem - the failure of frontline social workers.
"I don't see any teeth in this," Susan Molina, executive director of the Whitman-based Yellow Ribbon Kids Club said of the report and recommendations.
The Department of Social Services, which first became involved with Haleigh in 1998, received at least 12 reports of abuse or neglect of the girl between 2001 and 2005.
After Haleigh was hospitalized in Springfield, her adoptive mother, Holli A. Strickland, and stepfather, auto mechanic Jason D. Strickland were arrested and charged with assault and battery with substantial injury. Holli Strickland died on Sept. 22 in West Springfield, shot and killed by her grandmother, who then shot herself in a murder-suicide, police have said.
The 12-year-old girl was placed in pediatric intensive care at Baystate Medical Center in Springfield on Sept. 11 in a vegetative state, prompting police to charge her adoptive mother and stepfather with abuse.
Harry Spence, commissioner of the state Department of Social Services, has said he now believes that some of Haleigh's injuries stemmed from beatings by her adoptive mother and stepfather.
Romney said many of the commission's recommendations can be put in place by the state.
"As the Haleigh Poutre case demonstrates, errors in human judgment occur," Romney said in a statement. "What is unusual is how many people involved in Haleigh's care ... made errors. I welcome new systems and processes that will identify and guard against circumstances where human error may have severe consequences."
The commission also said the state agency's procedures are "substantially insufficient" to decide whether to seek removal of life support from children in its custody.
The state social services department moved to end Haleigh's life support eight days after she was hospitalized and six days after obtaining temporary custody of her.
The agency, supported by Haleigh's lawyer and court-appointed guardian, received permission from the state Supreme Judicial Court on Jan. 17 to take away a ventilator and feeding tube from the girl.
The day after that ruling, the state agency said the girl was breathing on her own and responding to commands. The girl, moved to the Franciscan Hospital for Children on Jan. 26, has since shown further signs of improvement, according to her biological mother, Allison Avrett of Agawam.