Critical Incident Response Team (CIRT) Initial Report

Date: 2010-06-07
Source: Oregon DHS

Critical Incident Response Team (CIRT) Initial Report
June 7, 2010

Executive Summary

On March 26, 2010, the Department of Human Services (DHS) received a report from
law enforcement officials that 9-year-old R.H. had been hospitalized with serious
physical injuries. At the time he was injured, R.H. was in the care of his adoptive
parents who had previously been certified foster parents. DHS had received referrals
concerning this child and this family prior to this incident.

Just before the release of this Critical Incident Response Team (CIRT) report, R.H.’s
adoptive parents were arrested and charged with causing his injuries.
On April 7, DHS Director Dr. Bruce Goldberg declared that a CIRT be convened. This
is a discretionary CIRT, not mandated by the Oregon Statute known as Karly’s Law.
This is the initial report of the CIRT team and is issued as an activity report and status
update. Because of the expanded review and analysis involved in this specific case,
which is underway at this time, more information will be made available as the team
continues and completes its work.

Activity Report and Status Update

In addition to launching a CIRT, the Department has taken the following actions:
· Sent a Rapid Response Team to Lane County. This was the second CIRT Lane
County has experienced within a four-month period. Accordingly, when this incident
occurred, the Department immediately deployed a team of experts to Lane County
child welfare offices to review files, observe branch processes and engage staff and
community partners around the following issues:
a) Is child welfare practice of high quality and consistent with policy, particularly
around child abuse screening/assessments and foster care certification;
b) Do the management structure and business processes support solid practice and
c) Are internal communication channels adequate, particularly those designed to
respond to and address issues that arise with foster parents; and
d) How is the community engaged in partnership with district child welfare officials?
· Conducted a personnel review specific to this case.

CIRT Process Update

Because this is a discretionary CIRT and the injuries were to a child who had previously
been in foster care, the Department’s approach to this Critical Incident Response Team
is different than others done in the past in the following ways:
1) The team’s review will encompass both a review of the R.H.’s history and the entire
certification history of the adoptive/foster home, including the review of files of
other children served in the home.
2) The team will specifically examine this case keeping in mind the Foster Care Safety
Team report and recommendations, published on March 8, 2010. Given the extensive
systems review the Foster Care Safety Team conducted of the foster care system, the
CIRT team is committed to ensuring that any recommendations resulting from its
review support and, where appropriate, enhance the recommendations of the Foster
Care Safety Team.
3) In addition to the regular CIRT members set forth in Department protocol, the
review team will include two members of the Foster Care Safety Team to ensure that
the evaluation of the policy and practice issues in this case include their perspectives.
4) Like the case that gave rise to the J.M. CIRT (reports released on January 12, 2010
and April 15, 2010), this case appears to involve a family that went to great lengths
to conceal the targeted abuse of a particular child. While overall, the Oregon child
welfare system’s safety decisions are getting stronger (statewide, Oregon’s re-abuse
rate has declined from 7.5% to 4.6%, and its foster care re-entry rate has also
declined from 9.6% to 7.7%), a systemic issue appears to be emerging regarding the
Department’s ability to investigate families where serious abuse is occurring and
where the family dynamic is such that the Department is unable to uncover the
abuse. To address that concern, the CIRT team has engaged a mental health
professional to review the files in this case, as well as the J.M. case, in order to make
recommendations for improvements in child welfare practice in this area.
Since the CIRT was called, the team has met twice to discuss the circumstances
surrounding this critical incident. As of the date this report:
· The CIRT team has completed the initial reviews of the Child Protective Services
(CPS) records and the certification file;
· The Department obtained orders to unseal certain historical records involving the
family, and DHS is now engaged in securing those records in order to review the
Department’s actions; and
· The team is in the process of conducting in-depth reviews of CPS records, electronic
and paper case notes and certification files.

Systemic Issues

The CIRT members have initially identified these systemic issues regarding the
Department’s work in this case:
· There may have been incidents where there was not clear guidance to foster family
certifiers regarding when to offer services to assist foster families and prospective
adoptive homes vs. when to intervene with measures to discontinue foster care,
including closing the home to additional foster placements, voluntary withdrawal,
non-renewal of certification, or revocation of the foster home certification; and
· Information from other professionals, including health care and mental health
providers, may have influenced the decisions and actions of caseworkers, either
positively or negatively.


Because of the active and ongoing criminal investigation this initial report does not
provide the CPS history in this case. In subsequent reports, the full chronology of the
Department’s history will be included. The CIRT team in this case will meet again
during the week of June 28.

Purpose of Critical Incident Response Team Reports

Critical incident reports are to be used as tools for determining whether there are
systemic issues which need to be addressed when there are incidents of serious injury or
death involving a child who has had contact with DHS. The reviews are launched by the
Department Director to quickly analyze DHS actions in relation to each child. Results of
the reviews are posted on the DHS website. Actions are implemented based on the
recommendations of the CIRT team. The ultimate purpose is to review department
practices and recommend improvements.


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