Investigation into the Death of David "Ryan" K.
released September 17, 1998
conducted by Connecticut's Child Fatality Review Panel

Key elements of the report:

The full, 36-page investigative report, is available for download in Microsoft Word format by using the following link:  Ryan K.

David Ryan K., known as Ryan, was born on January 16, 1992 to parents with extensive histories of alcohol and drug abuse. His sister was born on January 18, 1994. From May 1992 to October 1995, two separate DCF regional offices received at total of four reports alleging substance abuse, possible domestic violence in the home and child neglect. The first three reports were investigated by DCF and closed at intake. As a result of the fourth report in October 1995, DCF invoked a “96-hour hold,” placed the children in the care of a family member and vacated their hold when, the next day, the maternal grandmother received temporary custody of the children through the Probate Court. Guardianship of the children was granted to her on October 25, 1995.Two months later, the grandmother asked to be removed as the children’s guardian because of continuing conflicts with the mother, who resided with her, and with the father, who was in and out of the children’s lives. The grandmother did not pursue the request at that time.

In May 1996, the mother asked to have her legal guardianship reinstated but did not pursue her request. In April 1997, the grandmother renewed her request to be removed as guardian and offered her daughter and son-in-law, Ryan's aunt and uncle, as guardians. On May 15, 1997, the children were moved to the aunt and uncle’s home. On May 16, 1997, at the request of the Probate Court, DCF conducted a home study, which was submitted on May 27, recommending the aunt and uncle as guardians. The next day, the mother and grandmother consented to the transfer of legal guardianship of the children to the aunt and uncle, who stated an intention to move out of the area. They were advised that counseling for Ryan, which all agreed was necessary, did not need to start right away. No specific orders regarding visitation were entered by the court.

Less than five months later, DCF received the first report of suspected abuse of Ryan while in the care of his new guardians. Over the next eight months four similar reports were made. Four reports were investigated by DCF; one was not. The reports involved two regional DCF offices because the family relocated from Town #1 to Town #2 in November 1997. There was some attempt by DCF to get the family involved in community services. The aunt and uncle did engage Ryan in family therapy, but refused to participate in other services.

On June 23, 1998, the therapist closed her case without informing DCF that the family had relocated to Town #3. DCF did not ascertain their new location until August 4, 1998. On August 12, 1998, the date set for DCF to visit the family in their new home, the Town #3 police responded to a report of a child with a mouth injury at the aunt and uncle’s home. There they found Ryan’s battered body clad only in a diaper. It was determined that he had been dead for several hours. The cause of death was determined to be blunt trauma to the head. The aunt and uncle were both initially charged with risk of injury to a minor and incarcerated. Their cases are pending in criminal court.

Summary of Findings

The ultimate responsibility for Ryan's death lies, of course, with the perpetrator. The State of Connecticut, however, has a complex system designed to identify those instances where a child's safety is compromised, before serious injury or death can occur. Tragically, this child protection system failed Ryan.
  • Despite clear and unambiguous evidence of physical child abuse, DCF failed to take the necessary steps to protect this child. The approach taken in this case was to view each report in isolation. This resulted in “snapshots” of Ryan’s case, and contributed to the agency’s failure to comprehend the full scope of the abuse he was suffering.
  • DCF lacks a standardized assessment process to evaluate new reports of abuse or neglect within the context of previously-gathered information. Such a process is critical to effective child protection, and should be developed and instituted without delay.
  • Ryan was a victim of numerous communications failures, both within DCF and between DCF and the community. The agency must embark on an aggressive public education campaign, with components designed specifically to reach community providers and the public at large. This campaign should stress the importance and, in some cases, the legal requirements, of reporting all suspicions of child abuse or neglect.
  • Probate Court cases involving allegations of neglect and abuse are not given the same attention and oversight as other DCF cases. Social workers assigned to those cases are provided with little guidance or training. DCF should, at a minimum, provide protective services in these cases and, preferably, take legal action in Juvenile Court when warranted.
  • A review of child fatality and critical incident investigations previously undertaken in this state reveals that substantially similar problems are apparent in case after case. Recommendations for corrective action, however, are not being implemented in a timely or permanent manner.
  • Recommendations

    Social workers should be trained to be aware that generally positive factors such as the cleanliness of the home and the cooperation of the parents are sometimes superficial distractions that can mask serious problems within the family.
    • DCF should file neglect petitions in Juvenile Court in those Probate Court cases that meet the legal standard.
    • DCF should open a protective services case in all Probate Court cases where neglect or abuse is alleged and the case is not transferred to Juvenile Court.
    • DCF should establish uniform policy and clear procedures for social workers assigned Probate Court cases, and require comprehensive investigations of any relative seeking guardianship of a child.
    • DCF should notify Probate Court when referrals of neglect and abuse are received in those cases with prior Probate Court involvement.
    • The legislature should increase the resources of the Probate Court to permit formalizing the proceedings, i.e., to allow for the recording of all hearings and the mandatory appointment of an attorney or guardian ad litem for a child when a proceeding is initiated.
    • Any report of suspected abuse of a child coupled with an observable injury should be investigated on the day that the report is received.
    • DCF should develop an assessment tool that allows taking a fresh look at each new case or new referral within a family from a global perspective. This assessment must include carefully reviewing all past referrals, including those officially classified as "unsubstantiated," in order to identify problematic behavior patterns that may not be readily apparent in the snapshot of a single incident.
    • DCF should increase the allocation of Regional Resource Group staff to assist the social workers in assessing substance abuse, domestic violence and mental health issues.
    • DCF should assign members of the Special Reviews or Quality Assurance Units to conduct random reviews, in all regions, on a monthly basis, of open protective services cases that do not have court involvement, in order to determine the adequacy of case management. These reviews should include assessing record keeping and communication issues and should include a personal home visit by the reviewer.
    • The Child Advocate should conduct random independent reviews of DCF cases as she is made aware of cases that, in her determination, require such reviews.
    • Children in potentially abusive or neglectful situations are at their most vulnerable when the school year ends because their visibility in the community can be nonexistent. Therefore, on all open protective services cases, DCF should increase its vigilance through increased home visits and contacts with community providers.
    • By state statute, multidisciplinary teams must be established in every DCF region as of October 1, 1998. All open protective cases with multiple referrals of suspected abuse should be assessed by these teams.
    • DCF should make full use of the legal resources of the Office of the Attorney General in assessing whether a case legally constitutes abuse or neglect.
    • Continuing education in child welfare issues should be mandated for every DCF social worker.
    • Because the investigations unit makes life or death determinations regarding a child, those units of each region should be staffed by the most experienced and educated social workers and supervisors.
    • DCF should carefully assess the effectiveness and necessity of current paperwork requirements and make modifications accordingly. Additionally, DCF should explore alternate methods of documentation that free social workers to work in the field, such as increased use of clerical staff.
    • DCF should determine why policy regarding the entry of narratives on the LINK system is routinely ignored, and take corrective action immediately.
    • Increased numbers of social workers should be hired to insure that Consent Decree caseload and supervisory requirements are met. The Consent Decree should be modified to allow for increased supervision of field social workers.
    • DCF should standardize managerial and supervisory expectations and oversight throughout the regional offices. Uniform policy and guidance must come directly from the Commissioner's office.
    • DCF should require that diligent efforts be made to promptly inform all biological parents of substantiated reports of neglect or abuse involving their children.
    • DCF should develop policy and procedures designed to encourage and increase the level of interaction and discussion between social workers and between regions so that, when families move, or when new reports are received, vital information is passed on.
    • DCF policy regarding case transfer conferences between the investigations and the treatment units should be strictly adhered to, and supervisors should be encouraged to hold such conferences whenever possible even if not specifically required by policy.
    • All community service providers in a given case should be invited to its treatment planning conferences. Social workers should request verbal or, preferably, written information from those providers who cannot attend.
  • DCF should develop a closed records system that permits the immediate retrieval of past case records upon request. This must include the proper allocation of storage space at a central registry and sufficient staff to permit delivery of the record into the hands of the social worker within forty-eight hours of the request.
  • All DCF investigative and treatment unit staff should receive mandatory training in the recognition of child abuse, and in the behavioral indicators of an abused child.
  • DCF must insist, in its contracts with outside agencies, that those agencies provide regular and timely progress reports on DCF clients. In addition, contracted social services providers must be required to immediately notify the social worker when significant events, such as a move, an arrest, a hospitalization, or case closure, occur.
  • Every state agency which regulates or contracts with entities employing mandated reporters should require training of those reporters in the recognition of child abuse and in state reporting requirements.
  • Regional DCF offices should develop positive relationships with the school systems within their jurisdictions that will encourage increased cooperation and information-sharing when school officials suspect that a child is being neglected or abused.
  • DCF should undertake an awareness campaign to encourage medical providers to be alert for signs of neglect or abuse.
  • Every telephone call or report to police alleging suspected child abuse should be logged and maintained as a record.
  • Every police response to such information should be followed up if access to the child is not gained at the time of the initial response.
  • In the major cities in Connecticut, DCF should house an investigative social worker in the police department in order to conduct more thorough multidisciplinary investigations.
  • DCF should allocate more resources to prevention of child abuse. Additionally, DCF must actively work to integrate prevention efforts at the regional level, and involve all staff in community education initiatives.