Investigation into the Death of Falan F.
released December 19, 2001
conducted by Connecticut's Child Fatality Review Panel
Key elements of the report:

Executive Summary

The full, 17-page investigative report, is available for download in Microsoft Word format by using the following link:Falan F.
Executive Summary
Shortly after two and one half years of protective custody and court involvement, 16-year-old Falan F. ended her life by hanging herself while incarcerated in an isolated adult prison cell.

Falan was born to a family with a reported history of alcohol abuse, involvement with the police and poor coping with behavioral problems.  She was referred for mental health services as early as age eight for “out-of-control” behaviors.  Although therapy and medications were recommended, treatment was never followed through and she was not reintroduced to any support or protection services until the Department of Children and Families substantiated allegations of abuse upon Falan when she was 13.

In school, detention, and finally adult jail, systems repeatedly focused on controlling Falan’s behavior through punitive measures such as school expulsions and confinement.  Any therapeutic treatment she received was sporadic.  Her out-of-control behavior became the focus of response, without regard for family dysfunction, learning disability, or actual physical abuse.  The system repeatedly gave little attention to the root causes of her problems: physical abuse and mental illness. 

Despite multiple placements in foster homes, group homes, shelters, detention, a residential treatment center, and emergency hospitalizations for attempted suicide, Falan was ultimately sent home to a family that did not change its behavior to respond to her needs.  A pattern of abuse, punishment, sporadic treatment, expulsion and confinement formed her life’s experience.  Without consistent therapeutic follow-up, or support for family relations and school demands, Falan had little chance of developing the skills she needed to cope with her life.

Falan was well known to the juvenile justice system as a child at risk for suicide.  Once she turned 16, she left the familiarity of the juvenile system behind.  The police in the adult system were not privy to the information juvenile justice had regarding her mental health.  In the past, when Falan made suicidal gestures she was taken to a hospital emergency department or placed on a suicide watch that meant she would not be alone.  Suicidal gesturing may have been her method of coping with feelings of isolation and hopelessness.  On July 21, 2000, Falan was left alone in a jail cell.  There were reports that she called for help and no one answered.  She tied two socks around her neck before a camera and no one came.

Falan was a girl with clearly identified mental health needs.  Yet despite identification of her needs, treatment interventions directed toward Falan were never consistent from placement to placement.  Falan was a victim of multi-system failure.  She died an accused criminal instead of a patient.

Falan’s death has systemic implications that can be immediately remedied.  Enough is known about the development and mental health of young girls to guide policy effectively.  For example, adolescent girls have unique characteristics that place them at risk when living under conditions such as Falan did.  Depression is common among girls; they attempt suicide more than boys do, they internalize their distress, hurt themselves, and rely on relationships for confidence and self-esteem.  Girls can fall apart when transitioning to middle school; and fall further if they do not experience success or receive positive reinforcement from significant others.  Children have better outcomes when their care is consistently adhered to.  Yet no therapeutic intervention will help if a child lives with a family that is excluded from the therapeutic process, is unable to adjust their own behaviors, and is unable to recognize high-risk behaviors or triggers for crisis.

In this case, school faculty and staff were ineffective assessors of Falan’s development and related risk factors for depression and suicide.  They did not or could not take the time to assess Falan’s behaviors for referral to mental health services.  The school system failed repeatedly to refer her to a pupil planning team meeting, violating state and federal laws designed to protect and support poorly performing students like Falan was.  Poor communication between juvenile justice, child protective services, health providers and school officials deepened the void in the oversight of her health and well-being.  This raises concerns that similar problems occur elsewhere.

In Falan’s case, the system did not respond well to her mental health needs; a punitive response to behavioral problems only exacerbated her condition.  A delayed or inconsistent access to mental health care increased the risk of crisis occurring.  Without access to juvenile records, the police could not predict that Falan would harm herself in an adult jail.  Furthermore, it is possible that use of a suicide-proof cell, equipped with video monitoring in this case, may have bred a dangerous over-confidence and breach of procedure.  This is particularly dangerous in the initial hours of incarceration because in-custody suicides commonly occur in the first 24 hours of lock-up, half in the first 3 hours.  Isolation in a jail cell may aggravate the feelings of hopelessness that can drive a girl to suicidal gestures.

Falan’s story is a wake-up call; it is time to take seriously the prevention, early detection, and treatment of mental health problems that our youth are experiencing, including those of children in the juvenile justice system.  Up to 19 percent of youth in the juvenile justice system may be suicidal.  Suicide is the third leading cause of death among adolescents in the State of Connecticut.Self-inflicted injuries are the second leading cause of hospitalizations.  In a recent survey of Connecticut youth by the University of Connecticut Health Center, eight percent of the 7th and 8th graders surveyed agreed with the statement, “I wish I were dead.”  An astonishing more than 6 percent agreed they had “a plan to kill myself.”  When children are in the care and custody of state agencies, their risks of harm from others and themselves should be minimized, not increased.


Similar tragedies to Falan’s death are already occurring.Connecticut must respond decisively to prevent more adolescent suicides in jail and out.  While this report makes a number of critical recommendations for systemic improvements to protect children, at a minimum, the following legislative administrative changes must be adopted.
1.  Juvenile Justice Diversion  Divert children and youth with mental health needs who have come in contact with the juvenile justice system away from that system before they get “too far” into it.  Specifically:

·         Share children’s records between systems.  Record of a child’s mental health concerns noted by child protective services (CPS) or juvenile justice should be made available and shared with adult Department of Corrections facilities when identified needs or risks exist.  Intake protocols at both juvenile justice and adult DOC facilities must incorporate consultation with child protective services and/or Juvenile Justice to determine the presence of mental health concerns, in particular suicidal ideations.

·         Establish a single point of entry.  Facilitate coordination with, and referral to, KidCare services. Assure each child involved in the state systems has a medical-psychiatric “home” that can coordinate services across systems and enable children and youth to move back and forth with ease between levels of care as clinically needed.  Provide specialized staff to identify the child’s eligibility for services and health care coverage.

·         Conduct community-based behavioral health assessments that are more comprehensive than the court support services evaluation, but less intensive than a 30-day in-patient evaluation, to assess the child and his/her family’s needs.

·         Divert children who are identified as having behavioral health needs from jails and detention to programs that provide appropriate treatment, including specialized treatment for children with a history of trauma.

·         Develop alternatives to detentin for Families with Service Needs (FWSN) violators including more emergency shelters, priority access to specialized residential beds, and emergency foster care placements.

2. Prevention/Early Intervention
  • Reduce the number of children referred to the juvenile justice system
and promote the mental health of children and youth in their local communities through early intervention initiatives for children identified as being at-risk of delinquency. 
  • Increase alternative emergency placements that can maintain children who pose a risk to themselves or others, or cannot return home, where they can be assessed and stabilized.
  • Provide care for mental health-related problems before behavior results in school expulsions, arrests and involvement with the juvenile justice system.  Specifically:target and enhance early intervention efforts in schools and early care settings:include mental health consultants in early care and pre-school programs, family resource centers, and school-based health centers ensuring that the consultants work with a family-inclusive approach; reduce truancy and school drop-out rates through school-based early intervention programs for the families of elementary and middle school children with excessive absences; secondary school programs such as mentoring, after-school programs, on-site support groups like Alcohol Anonymous (AA), Narcotics Anonymous (NA), and peer mediation; train teachers and other school personnel in early identification of children and youth with behavioral health problems and in making appropriate referrals and interventions; hold school systems accountable for adhering to Connecticut and Federal law assuring evaluation and services for children with special educational needs.
  • 2.   Training and Preparation
    Train law enforcement and other first-responders (e.g., emergency medical personnel, pediatricians, fire personnel) in identification of children with behavioral health needs and appropriate interventions and referrals (e.g., police special response teams with mental health training who can assess whether a child should be referred for behavioral health care or into the juvenile justice system).