Investigation into the Death of Shanice M.
released March 12, 2001
conducted by Connecticut's Child Fatality Review Panel
Key elements of the report:
Shanice M. was born on August 23, 1993 to a working single mother. She received medical care at the pediatric clinic of Hospital A, a moderate-sized city hospital. Her mother kept Shanice’s well-child care visits and immunizations on schedule.
At age ten months, Shanice had her first asthma attack and her first hospitalization. The follow-up for that admission was at the pediatric care clinic she normally attended. Between August 1994 and January 1996, she visited the Emergency Department (ED) fourteen times for asthma-related reasons and was hospitalized on five of those occasions. There were eight missed follow-up appointments during this same interval. Multiple asthma triggers were noted in Shanice’s home environment, including smoking by caregivers.
On February 28, 1996, Shanice had her first Pediatric Intensive Care Unit (PICU) admission. She required a respirator to assist her breathing for three days. During this hospitalization, Shanice came under the care of Pediatric Pulmonary Specialist #1 for the first time. Pediatric Pulmonary Specialist #1 is a lung specialist who is the director of the PICU and the pediatric asthma clinic at Hospital A. He warned Shanice’s mother that the child was at high risk of dying from asthma. Pediatric Pulmonary Specialist #1 set up an educational program for Shanice’s family in cooperation with a visiting nurse agency, under the supervision of Nurse #1, the pediatric coordinator. The educational program involved most of Shanice’s family caretakers and their progress was felt to be good. Shanice had a brief PICU admission at the end of March 1996. During that hospitalization, her mother related that Shanice had no exposure to smoke, animals or soft toys. Over the next several months Shanice was described in pediatric clinic records as “an asthmatic in good control.”
Between June 24 and November 24, 1996, Shanice visited the Emergency Department (ED) of Hospital A six times, was admitted twice, and missed four follow-up appointments. On the morning of November 24, 1996 she was seen in the ED, treated and released. That evening she presented in a near-death state to the ED and was transferred to the PICU at Hospital B, a large, academic, tertiary-care facility in another city. This event and the prior multiple missed appointments led Hospital B, in conjunction with Pediatric Pulmonary Specialist #1, to initiate the first DCF referral, which was investigated by DCF Worker #1. In the aftermath of this investigation, Shanice’s mother agreed to weekly visits at Hospital A’s asthma clinic with care provided by Pediatric Pulmonary Specialist #1 and Nurse #2, the asthma nurse specialist. Because of the severity of the child’s condition, a letter was written by Pediatric Pulmonary Specialist #1 to all medical providers, to the Hospital A Emergency Department and to Shanice’s mother, stating that Shanice was to be admitted to the hospital if she presented with wheezing, even if she improved with treatment in the ED. Visiting nurse services supervised by Nurse #1 were instituted again. After substantiating medical neglect, DCF closed the case, concluding that appropriate services were in place.
After approximately one month of close follow-up care in the asthma clinic, Shanice’s appointments with physicians and visiting nurses were increasingly missed; two hospitalizations followed. According to hospital records, Shanice was brought to the ED on April 18, 1997 by her grandmother, who reported that she did not know the child’s medicine regimen, even though she was a daily caregiver for the child. She reported that multiple asthma triggers were still present in Shanice’s environment. During this admission, a second DCF referral was made by Pediatric Pulmonary Specialist #1; it was investigated again by DCF Worker #1. Medical neglect was again substantiated, and the case was transferred to DCF Worker #2, a treatment worker.
In May 1997, Shanice’s mother first expressed her wish to change physicians from Pediatric Pulmonary Specialist #1 to a private physician. One physician, Pediatrician #1, refused the case because he was not a provider for the insurance carrier. Throughout early May, Shanice was not seen at the asthma clinic or at any other physician’s office. On May 23, 1997, Shanice was brought wheezing to the ED of Hospital A by an aunt who was not aware of the process of automatic admission for the child, and she was mistakenly sent home. The following day she was seen again at the ED, this time requiring a PICU admission, leading to a DCF referral, again initiated by Pediatric Pulmonary Specialist #1. DCF Worker #2 continued to be the treatment worker on the case.
Despite Pediatric Pulmonary Specialist #1’s strong misgivings, a transition plan was made for transfer of Shanice’s medical care to Pediatrician #2. Pediatric Pulmonary Specialist #1 expressed a firm belief that Shanice required the care of an asthma specialist in addition to a general pediatrician and provided a list of alternative providers of this specialty care. Visiting nurse services were again initiated. There was an agreement that the asthma clinic would continue to provide care until other physician services were available. Pediatric Pulmonary Specialist #1 again wrote a letter concerning the process of automatic admission to the hospital if Shanice presented to the ED with wheezing. This letter was sent to all family care providers, the ED and to Pediatrician #1. Because of confusion over which physician was providing care for Shanice, Pediatrician #2 never received a copy of the letter.
The visiting nurses reported a repeated disregard by the mother for their schedule of visits. The first visit with Pediatrician #2, scheduled for June 18, 1997 was not kept. On July 7, 1997 Shanice was seen for the first time by Pediatrician #2; she was wheezing badly enough that she was sent immediately to the ED and required a PICU admission at Hospital A. Pediatric Pulmonary Specialist #1, who happened to be the attending physician in the PICU, again submitted a referral to DCF. An investigation was conducted by DCF Worker #3, an investigations worker. The medical neglect allegation was substantiated and the case transferred back to the treatment unit with DCF Worker #2. At the time of discharge from the hospital on July 12, 1997, a service agreement was signed by Shanice’s mother and DCF Worker #2. The service agreement indicated that failure to comply with its requirements would lead to action to place Shanice in foster care. The requirements included weekly medical care for Shanice, cooperation with intensive family preservation and cooperation with visiting nurse services. This agreement was subsequently renewed on July 30, 1997.
Shanice was seen by Pediatrician #2 on July 22, 1997 and was not seen again by her or any other provider until October 13, 1997, almost three months later. Visiting nurse visits were sporadic due to the mother’s inaccessibility. On multiple occasions, the visiting nurse could not get in; when she could, Shanice was frequently found to be wheezing. On several occasions, the visiting nurse requested that Shanice be brought to the ED but there was no compliance with this request. No appointment was ever made to see an asthma specialist after the change in physicians from the pulmonary specialist to the regular pediatrician.
On September 4, 1997 the visiting nurse agency closed the case due to a continued lack of cooperation by Shanice’s mother. The records reflect that DCF was aware of the cessation of visiting nurse services and of the many concerns which the visiting nurses expressed about the case. In September 1997, DCF Worker #2 was promoted to a supervisor position, but continued to work her previous caseload, including Shanice, until new workers were assigned.
On November 7, 1997, Shanice was again admitted to the PICU at Hospital A, after being transported to the ED for an asthma attack. At that time, there had been no visits to Pediatrician #2 since October 13, 1997. A note was written on November 8, 1997 by Pediatrician #3 (head of pediatrics at Hospital A and covering the PICU at the time of admission) which indicated that Pediatrician #2 had only seen Shanice twice in July and once in October and that visiting nurse services had been discontinued due to a lack of cooperation by the mother. A report was made to DCF by a social worker at Hospital A who had no previous contact with this family. The investigation was conducted by DCF Worker #4, an investigations worker. After speaking with the hospital social worker and Pediatrician #2, DCF Worker #4 classified this referral as “not substantiated.”
On November 27, 1997, DCF Worker #5, a trainee, was assigned to the case as the treatment worker under the supervision of DCF Worker #2. On December 11, 1997, DCF Workers #5 and #2 met and agreed that Shanice’s mother was not neglecting the child and set an agenda for closure of the case. The next day a service agreement was made with Shanice’s mother. DCF did not inform Pediatrician #2 of the existence or requirements of the service agreement. The DCF case was closed on February 26, 1998.
Just six days later, in the early morning hours of March 4, 1998, Shanice was brought to the ED at Hospital A in critical condition. The medical record indicates that she was in severe respiratory failure and near death, although her mother stated that she was still conscious and speaking when she saw her after arrival at the ED. She was placed on a respirator and received medication to relieve her asthmatic attack, but within one-half hour she had a cardiac arrest. She was resuscitated and transferred to Hospital B where she died on March 8, 1998.
· Shanice M. died of asthma which is a chronic, life-threatening medical illness that requires acute care and ongoing preventive measures in order to be successfully managed.
· Asthma disproportionately affects the urban poor child. Patterns of health care in this population may not be conducive to optimal treatment of children with severe asthma.
· Children with complex and difficult-to-manage medical problems require a more sophisticated level of case management and monitoring. State agencies dealing with these children must develop criteria to identify such children and be given the authority and resources to obtain necessary expert medical consultation.
· DCF was informed by Shanice’s physician, a specialist in the field of pediatric pulmonology, that she was at high risk of dying if her illness was not properly managed. Referrals of such a serious nature should be reviewed and assessed at the upper management level in DCF’s organization.
· Service agreements between DCF and the mother were not enforced yet a neglect petition was never filed and DCF ultimately closed its case.
· Those service agreements were not shared with providers whose services were required by the agreement.
· DCF social workers did not have the necessary expertise to effectively provide the case management and safeguard this medically fragile child. Communication between DCF social workers assigned to Shanice’s case was insufficient to insure that each caseworker was fully apprised of the history and severity of the child’s condition.
· DCF currently does not have an adequate number of nursing or physician consultants to effectively meet the consultative demands of social work staff in their efforts to provide protection and services to medically fragile children.
· Despite the availability of Regional Resource Group nursing expertise in Shanice’s case, it was not adequately utilized. When presented with conflicting opinions between a pediatric pulmonary specialist familiar with the case and a general pediatrician, new to the case, a third expert opinion was not sought.
· The State of
· DCF should rapidly move to create working, multidisciplinary teams in those regions which do not yet have them, in compliance with Public Act 98-241. Such multidisciplinary teams should routinely review any cases with three or more substantiated neglect reports within a twelve-month interval, in which a child in the household is under six years of age.
· The Regional Resource Groups should be strengthened to provide adequate numbers of qualified nurses to meet the consultation needs of DCF staff. RRG nurses should be routinely consulted and involved in a continuing fashion in all cases involving medical neglect and children with special health care needs. They should be involved in (though not responsible for) decisions affecting legal action, closure of the case, or assignment of a new worker. They should routinely receive updates on the status of all medically fragile children in the region. Social work practice policy should include guidelines for referral to the RRG.
· All DCF investigative and treatment social workers should receive ongoing training regarding common, but serious, health care issues such as asthma. Such training should include a review of common childhood illnesses as well as illness management principles and effective communication and collaboration with community health providers. Additionally, consultation with the regional pediatric physician consultant should be routine in cases where there is conflict between treating physicians or between treating physicians and the family. Social workers and nurses should have ready access to general and specialist pediatricians for consultation on specific cases.
· Legal action (the filing of neglect petitions) is indicated when there is repeated noncompliance with service agreements, particularly when the parent has already been warned of this potential consequence. Social workers should request advice from the regional legal counsel or the Assistant Attorney General assigned to that Region if there are any questions regarding the criteria for legal action.
· The requirements of service agreements should be shared with professionals whose services are required by the agreement. Those agencies or individuals should provide periodic, written documentation concerning the degree of compliance with the terms of the service agreement.
· DCF narrative entries into the LINK computer system should be made in a timely fashion, no more than three days after the events described, as required by DCF policy . Each region should establish the practice of conferencing all new investigations on cases already active in on-going services.
· Difficult or complex cases, including cases of medical neglect and children with complex health problems, should not be given to social work trainees. Trainee case loads should be limited to permit individual attention during the training period.
· In complex cases such as the case of Shanice M., visiting nurse agencies (or other involved mandated reporters) should be requested to provide DCF with documentation of their findings and assessments regarding a family’s willingness and ability to safely and effectively manage a child’s potentially life-threatening chronic illness. This is especially important when such an agency makes the decision to discharge a family from their service based on noncompliance or lack of availability on the part of a parent or caretaker. They also need to comply with child abuse and neglect reporting laws and refer suspicions of abuse and/or neglect.
· DCF should include in its policy on case closure an expectation that cases involving mandated reporters will require written notification to the reporter when a decision is made to close the case.