exposing the dark side of adoption
Register Log in

Review Of Connecticut Foster Child's Death Cites System Failures

public

By ARIELLE LEVIN BECKER

The Hartford Courant

May 7, 2009

The system meant to protect 7-month-old Michael Brown Jr., who died last year while in the foster care of a state Department of Children and Families worker, failed him in numerous ways, according to a review of the child's death released Wednesday.

Although his foster mother, Suzanne Listro, had twice been the subject of DCF investigations into allegations that she abused her adopted son, the DCF workers responsible for determining if Listro was qualified to be a foster parent were not aware of them because of a department practice.

Listro was a DCF employee, so cases involving her were kept out of the agency's computer system. The allegations against Listro were not substantiated.

The review, conducted by DCF representatives, the Child Welfare League of America and the Office of the Child Advocate, found that investigations into abuse and neglect by DCF employees fell below standards. DCF Commissioner Susan I. Hamilton last July offered a similar assessment of the investigations of Listro, calling them "substandard and unacceptable."

But state Child Advocate Jeanne Milstein said the problems in investigations extend beyond Listro's case or those of DCF employees.

"It took this tragedy and the commissioner herself reviewing this case to understand that it wasn't just this case where investigations were substandard," she said. "There were many other cases as well."

The review also found that the licensing process for the foster home failed to assess "powerful indicators" for a successful placement, such as support networks and the potential foster parent's ability to maintain enduring friendships. DCF released a summary of the report, but declined to make public the entire document.

Listro was charged with first-degree manslaughter and risk of injury to a minor in connection with Michael's death last May, just a week after he was placed in her care. She has pleaded not guilty and has been fired from DCF. Her lawyer could not be reached for comment.

Listro, 43, told police that Michael fell off a bed in her Mansfield home while she was ejecting a video and turning off her television. When she turned around, she said, she saw him lying on his back on the floor, and when she picked him up, he cried for a moment, then went limp, according to her arrest warrant affidavit.

But the prosecutor in the case, Matthew C. Gedansky, said in court last July that Listro's story was not consistent with Michael's head injuries. Michael was taken to Windham Community Memorial Hospital, then transferred by Life Star helicopter to Hartford Hospital, where he was pronounced dead.

Michael's death prompted changes at the agency, including some recommended by the review. Reports and investigations into DCF employees, which for a decade were maintained in paper files separate from the department's electronic database, are now entered into the database. Gary Kleeblatt, a DCF spokesman, said Wednesday that he did not know why the employee files had been kept separate.

The specialized unit that conducted the investigations involving Listro was placed under new management and overhauled, and the staff was retrained.

And DCF now hires an outside agency to handle the licensing of DCF employees seeking to become foster parents to avoid conflicts of interest.

"The death of Michael badly shook the department and me personally," Hamilton said in a written statement. "While several notable reforms have been implemented, I am determined that we learn everything we can so we can continue to improve the safety and well-being of children in foster care."

The review also found that "safe foster placements of infants and children are hampered by a shortage of homes equipped to accommodate them." It recommended that DCF examine the capacity for accommodating infants and children and also develop protocol for collecting and providing caregiving information to foster parents.

Milstein praised the review's recommendations, but noted that some of them — including putting reports about DCF workers into the electronic database used by investigators — had been recommended by her office years ago.

"It took a tragedy to get that implemented," she said.

And Milstein said there is more to be done.

Milstein said that DCF must better monitor the quality of investigations and suggested that the department's quality improvement division should review cases randomly on a daily basis to see if they are meeting the standards.

"It was just a substandard investigation," she said. "But we see that more often than we'd like to see in other cases as well."

Milstein said the problems do not reflect a lack of money or staffing in the agency, which has a budget of nearly $900 million and investigators with what Milstein said are among the lowest caseloads in the country. Instead, she said, it's a matter of leadership committing the department to "vigorous quality improvement" and holding workers to quality practices and standards.

2009 May 7