Investigation into the Death of Aquan S.
released September 13, 1999
conducted by Connecticut's Child Fatality Review Panel

Key elements of the report:

Executive Summary
Summary of Findings

The full, 28-page investigative report, is available for download in Microsoft Word format by using the following link: Aquan S.

Executive Summary

Aquan S. was born to Donnette and Selvyn Maurice S. on July 24, 1984. He was the fifth of six siblings born to mother. Both the mother and father, Aquan, and four of his six siblings had police records.

The DSS and educational records reflect that the family moved many times and that the children experienced multiple caretakers. This pattern of transience continued over the course of Aquan’s life and was noted by school officials. At the onset of Aquan’s school years, he presented with both emotional and behavioral problems. With each new school year his emotional and behavioral problems escalated, and directly impacted upon his academic functioning. Special education services were offered as early as 2nd grade to address his behaviors and learning difficulties. While the school system appeared to be aware, early on, of the familial and environmental factors affecting Aquan’s emotional and behavioral problems, no formal referral was made to DCF requesting child welfare intervention until his 5th grade school year.

There were a total of three referrals regarding Aquan made to DCF during his life which resulted in varying degrees of agency involvement with Aquan and his family. The last referral was made by the Hartford Police in June 1996 when Aquan and his brother D. were found in their mother’s home, where she was harboring her adult son and his friend, both wanted on murder charges. Police also found a large amount of marijuana in the home and arrested the mother. As a result, DCF took a "96 hour hold" on the children, the criminal court issued Orders of Temporary Custody (OTCs) to DCF, and DCF filed neglect petitions on Aquan, D., and a third sibling in Superior Court for Juvenile Matters. In December 1996, Aquan and his brothers were adjudicated neglected and uncared for and Aquan and D. were subsequently committed to DCF.

In July 1998, Aquan became involved with the juvenile justice system; this involvement continued to the time of his death. During this period, he committed a series of delinquent acts resulting in a number of delinquency petitions being filed. Consequently, he was adjudicated delinquent and ordered to cooperate with and participate in a variety of services and sanctions. These services included probation and different forms of monitoring.

Months prior to Aquan’s death, it was clear to agencies involved that his behavior was beyond the control of his relative caregiver and that he needed the structure of a residential placement. As a result, several pre-placement interviews were set up. Residential placement never materialized, however, because Aquan was reported missing on March 30, 1999. Despite some attempts by local and state officials to locate him, and the fact that he was seen by family and community members within his neighborhood during this period, Aquan could not be located. He died on April 13, 1999 after being shot by a police officer.

  • Earlier, more aggressive interventions by the local school system would have been instrumental in identifying the neglect that Aquan was experiencing in his family’s care and in identifying his need for out-of-home placement sooner.
  • Child welfare interventions which occurred prior to major child welfare reform in 1995 may have contributed to Aquan’s problems over time. Child welfare interventions which occurred in this case after 1995 were much improved over the earlier interventions.
  • Aquan S. was under the jurisdiction of the Judicial Department and the Department of Children and Families at the time of his death. He was mandated by the Court to wear an electronic monitor to verify his times of arrival and departure from his relative foster placement. This device was operational and found intact on his ankle at the time of his death.
  • Out-of-control children under the age of 16 present a danger to themselves and local communities. The present legal system does not empower DCF to mandate a child’s cooperation.
  • In the weeks preceding his death, Aquan S. violated the terms of his probation, giving probable cause for the Judicial Department to seek a "take into custody" order. Such a request would have set in motion a more intensive search for Aquan. Instead, agency officials filed another delinquency petition, which was not scheduled to be heard until one month later.
  • Neither the Judicial Department nor DCF currently have collaborative policies that require ongoing and regular communication between caseworkers and probation officers when jurisdiction of both agencies is involved.
  • Case review reflects a disturbing lack of coordinated resources dedicated to finding a missing, out-of-control, fourteen-year-old child who had documented mental health issues.
  • Communities must begin to take more responsibility for the plight of their youth. Family members and members of the community who knew of but did not report Aquan’s whereabouts contributed to the state’s inability to locate and protect this youngster.
  • As highlighted in past fatality reviews, the child welfare case record contained few diagnostic impressions or assessments, limiting the DCF’s ability to conduct prospective case management.
  • Agencies and systems involved with Aquan did not identify his need for a higher level of therapeutic and placement services in a timely fashion.
  • Aquan’s case highlights that inner city youth are at greater risk of being lost in the system because there are insufficient resources and little coordination of existing resources to adequately meet the needs of these adolescents.
  • Focused dialogue between the community leadership and state agencies must be developed to facilitate better communication, understanding and cooperation to address the needs of inner city youth.
  • The filing of neglect petitions should simultaneously provide for mandates that children cooperate with child welfare agency services and should provide for sanctions, in the event that cooperation is absent.
  • A task force should be established to identify problems and examine the adequacy of resources to meet the needs of troubled adolescents in the inner-city.
  • A pilot program should be established in the city of Hartford to provide mentoring services to at-risk adolescents.
  • The child welfare agency must stress to its supervisors and social workers the need for compliance with agency policy which has established benchmarks for social worker visitation with children and families.
  • Child welfare agency supervisors should randomly conduct reviews of case narrative notes to ensure that social workers are performing periodic global assessments in their cases and are appropriately documenting those assessments.
  • When therapeutic services are identified as necessary for a child, both the school system and involved agencies must ensure that these services are made available and procured in a timely manner.
  • The child welfare agency should continue to focus on streamlining the Child Placement Team Process to allow for more timely access to residential placements for troubled children.
  • More stringent efforts must be made by authorities to locate missing or runaway, out-of-control adolescents who are in the legal custody of the state.
  • Local school systems should establish a protocol with local service providers and the child welfare agency to collaborate on and better coordinate the provision of services to children.
  • Each school should take a more global view of assessing children identified with behavioral and educational problems in order to determine if a higher level of services or a referral to DCF is warranted.
  • The Judicial Department and the child welfare agency should develop a protocol to share information on a regular basis in those cases where children are involved with both agencies.