Date: 2006-10-06
Source: Oregon DHS

Review Completed
Report Completed 10-6-06

I. Introduction
Oregon Department of Human Services (DHS) adopted the Critical Incident Response Team (CIRT) protocol on November 1, 2004. This protocol was developed for the following purposes:
• To specify the Department of Human Services, Child Welfare procedures that will be used when a critical incident occurs;
• To increase the Department’s accountability to the public;
• To ensure timely responses by the Department with respect to any critical incident in Child Welfare; and
• To increase the Department’s ability to recommend necessary changes to statutes, administrative rules, policies and procedures, practices, training and personnel matters.

The following is a 30-day report as required by the protocol, which includes initial findings, preliminary recommendations and next steps. During the next 30-day period, DHS will continue a comprehensive review of these preliminary findings and assess the degree to which these findings have statewide implications. The CIRT team will then assign specific tasks, identify time frames and desired outcomes.

II. CIRT Reason:
On September 4, 2006, 2-year-old Keyana Bravo-Hamilton was brought to Mt. Hood Medical Center Emergency Department by her relative foster parents, Armondo and Dunia Moreno. The child was not breathing and medical staff were unable to resuscitate her.
Keyana and her 4-year-old half-sister, Jasmine Hamilton, had been placed with the Morenos, Jasmine’s paternal uncle and his wife, since June 9, 2006, after a home study and recent local adoption committee recommended placement of both children in the home. This relative foster care placement was intended to become the adoptive placement for both girls.
On September 9, 2006, Ms. Moreno was arrested and, on September 18, 2006, she was indicted on charges including, murder. On September 18, 2006, Mr. Moreno was also indicted on criminal mistreatment charges.

III. CIRT Response and Case Status Update:
a. Criminal Investigation and CPS Assessment:
Gresham Police Department is handling the criminal investigation. As noted above, on September 18, 2006, Ms. Moreno was indicted on four charges, including: one count of murder by abuse; one count of murder; one count of criminal mistreatment of Keyana’s sister, Jasmine; and one count of criminal mistreatment in the first degree for withholding medical treatment. On September 18, 2006, Mr. Moreno was also indicted on one count of criminal mistreatment in the first degree and the couple was charged with “intentionally and knowingly withholding necessary and adequate medical attention from Keyana.”
The Gresham child welfare office is coordinating with law enforcement on the child protective services assessment.
b. Media Response:
Pursuant to the protocol, the CIRT lead designated Gresham Police Department as the media lead. Patricia Feeny is the DHS media contact.

IV. CIRT Review Process:
a. Case Review Process:
To date, case file review has been conducted at the Beaverton Child Welfare office by technical staff from Central Office on 9-14 and 9-15-06 and 9-28 and 9-29-06. However, although many documents have been translated from Spanish to English, there are still some documents that have yet to be translated and, therefore have not yet been reviewed by the CIRT. It is anticipated these documents will be translated and the review team will complete their review by October 9, 2006.
The CIRT team has also developed a list of questions and areas of focus for this review related to the Agency’s relative search, casework contacts, substitute care placement reviews, children’s medical services, the adoption selection process, and
communication among Agency staff. Actions of DHS staff are being reviewed for compliance with administrative rule and policy as well as approved practice.
At this time, there are no recommendations or action steps since all critical information from the case has yet to be translated and reviewed by the review team. Staff interviews have been scheduled and the completion of those will be included in the 60-day report. The review process will be used to assist in the development of questions for subsequent staff interviews.
b. Staff Interview Process:
At the time of this report, staff interviews by DHS administration and human resources staff are not yet scheduled.

V. Initial Findings and Recommendations:
As noted above, there are no recommendations or action steps at this time.



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