Investigation into the Death of Ezramicah
released May 2002
conducted by the Connecticut Child Fatality Review Panel

Key element of the report:

The full, 32-page investigative report, is available for download in Microsoft Word format by using the following link: Ezramicah H.

Executive Summary

On October 24, 2001, Ezramicah was brought to a hospital in critical condition.  The six and a half month old infant was placed on life support for three days and died on October 27, 2001.  The medical examiner ruled Exramicah's death a homicide.  The baby's father is currently awaiting trial for the death of his son.  Ezramicah was born on March 31, 2001.  One and a half months later, the Department of Children and Families (DCF) initiated an investigation of suspected child abuse/neglect because Exramicah had a broken leg.  The agency concluded that the infant's leg had been broken under suspicious circumstances.  The child was placed in the care of DCF.

DCF’s ensuing management of the case was incomplete and inconsistent.  The infant was removed from his home twice and placed in two foster homes and one shelter.  Ezramicah’s family was referred by court order to several services and supports, including parenting classes, therapy and in-home supports.  Some of the referrals were timely; others were not.  The parents participated in some services and not in others, without enforcement by DCF.  Less than five months later, while still under court ordered protective supervision, the child died at the hands of his father.  A highly publicized and contentious discussion between the DCF Commissioner and a judge of the superior court followed.

The fatality review investigation revealed that errors were made throughout the course of Ezramicah’s life.  The most significant mistakes include:

  • DCF failed to monitor of follow-up to ascertain whether Ezramicah's parents were complying with the court ordered services.
  • DCF did not coordinate or facilitate communication between DCF, service providers, medical experts, the Court, or the attorney representing DCF (assistant attorney general), resulting in decisions being made without a full understanding of all the issues and perspectives.
  • DCF did not keep accurate contemporaneous records including at least 22 narrative entries that were made after Exramicah died, resulitng in lack of inforiton being provided to those who were making decisions about his care and protection.
  • DCF had policy mechanisms in place that would have provided oversight of the parents’ compliance with court orders, yet the policies and procedures were not implemented.
  • DCF’s quality assurance measures and treatment planning failed to provide for appropriate case management and child protection.

Numerous past child fatality investigations have revealed that the child welfare system failed to provide sufficient resources to assist the family and protect the child.  In contrast, Ezramicah’s death was not due to a lack of resources.  This investigation revealed that, while resources were in place, there was inadequate oversight and supervision of case management, a lack of coordination and thoroughness in the provision of family services and supports, ineffective treatment planning, and poor communication.  

DCF and the Court identified and designed mechanisms and resources to help Ezramicah’s mother and father succeed as parents.  They included education, training and therapy.  Yet, to the extent that these services were recommended, they were not put in place in a timely manner, there was little monitoring to determine if the parents were active participants and there was no follow-up to determine whether the overall goals and objectives were being met.

DCF has a well-defined system of oversight in the agency’s policies and procedures.  Expectations of staff supervision are clearly defined.  Case practice is reviewed regularly through treatment planning and administrative case review processes.  In cases of court ordered protective supervision, case status reports describing a family’s cooperation and progress are required by the court.  These systems provide ample opportunity for the sharing of information and analysis of progress by a number of people to ensure that children are safe.  Unfortunately, in Ezramicah’s case, these systems of case oversight were ineffective.

 

The Court and the assistant attorney general (AAG) representing DCF were never fully informed about Ezramicah’s parents’ response to court orders.   The AAG and the Court rely on DCF’s reports regarding compliance with court-ordered services and progress towards goals.  Informed decisions cannot be made unless the information they receive is accurate and complete.   The lack of follow-up regarding the parents’ compliance with court -ordered services and the subsequent lack of information reported to the Court and the AAG placed Ezramicah at considerable risk of harm.

In an August 2001 court review, the AAG and the Court were unaware that Ezramicah’s parents were out of compliance with court-ordered services.  Without that knowledge, there was no evidence to support keeping the child in DCF custody.  Upon returning Ezramicah to his parents the Court ordered very specific steps for the parents and diligent supervision that went beyond standard requirements.  In addition, the Court ordered an in-court review in one month and not the usual four-month time period.  At that next review, on September 18th, DCF and Ezramicah’s parents reported to the Court that they were participating in all court-ordered services and that Ezramicah was thriving at home.

Finally, the heightened controversy over what happened in the August court proceedings generated considerable public attention, nearly overshadowing the underlying tragedy.  A dispassionate look at what occurred revealed that there was less in dispute than public statements implied.  The Commissioner of the Department of Children and Families issued a memorandum that stated, “Over our objection, the Juvenile Court ordered the child’s return home.”  Transcripts reveal that the AAG did not object on the record.  Instead, the AAG indicated in a closed chambers meeting that DCF “opposed the child’s return home” that day and preferred to return Ezramicah to his home in 2-4 weeks, once services to the parents were put in place.  However, the AAG and all present in the chambers acknowledged that the facts and evidence did not support continued DCF custody of Ezramicah and therefore there was no basis for objection to the court ruling.

The highly public conflict created a scenario of blame that has a potentially chilling impact on the legal process for protecting children.  Moreover, confidential proceedings were released to the public.  Statements were made and information was released before a full investigation had taken place.  Publicized arguments that involve the disclosure of confidential documents from closed court proceedings may impact the degree to which all court officers, families and providers are forthcoming. 

While the public discourse focused on the August hearing, there had been a second court review in September, ignored by the public arguments, at which Ezramicah’s DCF worker stated that Ezramicah was safe and his parents were in compliance with DCF.  But Ezramicah’s parents were not in compliance with court orders.  Unfortunately, no one was closely watching the case and monitoring the delivery of services.

DCF must address the agency’s persistent problems of lack of coordination, communication, effective supervision, oversight, and follow-up in order to better protect children.  These system issues have been raised in other fatality reviews conducted by the Office of the Child Advocate and the Child Fatality Review Panel including Alex B. and Ryan K.  Again, the recommendations include the following:

Investigations of families suspected of child abuse must include global family assessments that take into account all factors affecting parenting including social economic factors, history of abuse/neglect upon all members, connectedness to communities and family composition.  Delivery of services should be determined by the global assessment and adjusted over time as the assessment process identifies changes in the family situation.
  • The Department of Children and Families must comply with its own policies on administrative case review and case management.  ACRs must be attended by all involved persons as required by DCF policy and scheduling must be flexible to accommodate participation.  Social workers must be prepared to report on all services in place, compliance with those services, and progress or lack thereof towards treatment goals.
  • Communication must be clear and open.  Contractual agreements with providers must include expectations for reporting compliance and outcomes as well as participation in meetings.  At a minimum, case workers must communicate with all providers regarding family participation in court-ordered services before making recommendations in treatment planning and court proceedings.  Accurate, timely information will help keep children safe. 
  • DCF must establish and follow specific protocol for referrals to medical child abuse experts for evaluations of alleged victims of child abuse.  That protocol should include at a minimum, identification and communication of necessary data, response time, assignment of follow-up responsibilities, and alternative sources of expertise when an expert is not available to complete the investigation in a timely manner.
  • Complete and accurate information communicated to the AAG and the Court is critical.  Public discourse should be avoided until such time as all the relevant information is gathered, investigations are complete and the facts are fully known. 
  • Mechanisms must be in place to ensure attorneys representing children meet all obligations of their appointment and follow court orders as well. 
  • Expand the capacity of the existing multidisciplinary child abuse investigation teams to conduct collaborative investigations of suspected child abuse, particularly in cases where alleged victims are nonverbal and not visible in the community.