Section 5 - Complaint Intervention and Investigation Summary

SECTION 5
Complaint Intervention
and Investigation Summary

A CENTRAL FUNCTION of the Office of the Family and Children's Ombudsman (OFCO) is to assure that government agencies fulfill their obligations to children and families in an appropriate and timely manner. Because the state's response to children in need of protection and to families who are the subject of allegations or findings of child abuse or neglect is so critical, OFCO dedicates most of its efforts toward activities that result in a state agency's direct and immediate response to their needs. This section provides a summary of OFCO's activities from December 2, 1997 to August 31, 1998. It describes those who initiated contact with OFCO, children affected by an agency's act or omission, the nature of complaints received, and OFCO's efforts to assist children and families through case-specific interventions. It also describes activities associated with OFCO’s administrative and systemic investigations.

Initial Contacts

OFCO received 863 contacts during the reporting period. Of these, 67 percent were:

Requests for information on laws, policies, or procedures affecting children in need of state protection, and families and children involved with the state due to child abuse and neglect issues; and/or
Requests for OFCO information and complaint forms.

The remaining 33 percent of contacts were either:

Complaints requesting either an intervention or investigation (27 percent of all contacts); or
Inquiries or requests for assistance on issues outside OFCO's jurisdiction (6 percent).

OFCO responded directly to inquiries and complaints, and referred all non-related inquiries to other agencies. Complaints arrived at the rate of about 6 per week, a 28 percent increase over the preceding reporting period. These complaints provide the mechanism through which OFCO is able to identify children and families at risk of harm and in need of assistance due to an agency's act or omission, and to pinpoint recurring and systemic problems that adversely affect children and families.

Office of the Family and Children's Ombudsman

April 1999

Complaints

Of the 230 complaints received by OFCO, 88 percent were requests to intervene in an ongoing matter for the purpose of preventing or mitigating harm to a child or family resulting from an agency’s alleged act or omission. One-fourth of the requests identified the matter as emergent, and sought OFCO’s immediate assistance. The remaining 12 percent of complaints received by OFCO were requests to conduct an administrative investigation of a specific matter, or an investigation of a potential systemic issue.

Source of Complaints

Complaints arriving at OFCO were made mostly by parents (45 percent) who were directly affected by an agency's act or omission, or by grandparents and other relatives (27 percent). Community professionals and service providers accounted for 10 percent of complaints, while foster parents accounted for 8 percent. Complaints were evenly balanced with the state population as a whole; 78 percent of the state's population resides in western Washington, and 76 percent of the contacts were from western regions. The profile of OFCO's clientele is provided in the following tables and charts.

Office of the Family and Children's Ombudsman

April 1999

Affected Children

Complaints received by OFCO involved 319 children. Children were typically young, over half were age seven or younger. About one child in four was from a racial minority group, and about one child in seven was Hispanic. One in three also had some type of physical, mental, developmental, and/or other disability.

Office of the Family and Children's Ombudsman

April 1999

Office of the Family and Children's Ombudsman

April 1999

Office of the Family and Children's Ombudsman

April 1999

Issues Identified by Complainants

The most frequently identified complaint issue during this period regarded child protection and safety; the next most frequent complaint issue was of unnecessary family separation and failure to reunify, followed by issues relating to children's well-being in foster care.

Frequently Identified Issues	Number of complaints that raised the issue*
Child Protection and Safety			65
Child in need of protection due to suspected physical abuse		18
Child in need of protection due to suspected neglect		18
Child in need of protection due to suspected sexual abuse		11
Child in need of protection because parent not capable		7
Child in non-relative foster care at risk of abuse or neglect		6
Child safety at risk due to recommendation to return home		5
Family Separation and Reunification			57
Failure to make reasonable efforts to reunify family		19
Child inappropriately removed from parent’s care		18
Failure to place child with relative		16
Failure to provide appropriate family-child contact		4
Foster Care Issues			22
Unnecessary or inappropriate change in child’s foster placement		18
Failure to provide for child’s mental health needs		4
Adoption Issues			14
Relative not considered/recommended to adopt		9
Foster parent not considered/recommended to adopt		5

*Some complaints raised more than one issue.

Office of the Family and Children's Ombudsman

April 1999

The DSHS Children's Administration was the subject of 83 percent of complaints received by OFCO. Of these, the vast majority, 97 percent, were directed at the Division of Children and Family Services (DCFS,, which includes child Protective Services), while 3 percent were directed at the Division of Licensed Resources (DLR0. The information on the next page shows the distribution of complaints across the state.

Children’s Administration Complaints by Region, Office

Children’s Administration Headquarters

	DCFS	DLR		DCFS	DLR
Region 1	23	2	Region 4	36	0
Regional Office-Spokane	13	2	Kent/King South	12
Moses Lake	3		Regional Office-Seattle	8
Newport	3		Bellevue/King Eastside	5
Colville	2		Seattle Central	4
Wenatchee	2		Seattle South	4
			Seattle North	3
Region 2	20	2
Toppenish	7		Region 5	39	0
Yakima	5	1	Regional Office-Tacoma	26
Richland/Tri-Cities	4		Bremerton/Kitsap	13
Sunnyside	2
Regional Office-Yakima	1	1	Region 6	38	1
Walla Walla	1		Regional Office-Lacey/Olympia	10	1
			Vancouver	8
Region 3	26	0	Aberdeen	6
Alederwood/Lynnwood	6		White Salmon	5
Regional Office-Everett	5		Shelton	4
Oak Harbor	4		Centralia	2
Bellingham	3		South Bend	2
Monroe/Sky Valley	3		Tumwater	1
Mount Vernon	2
Arlington/Smokey Point	1
Everett	1
Friday Harbor	1		TOTAL COMPLAINTS	187	5

DCFS = Division of Children and Family Services
DLR = Division of Licensed Resources

Office of the Family and Children's Ombudsman

April 1999

Interventions

OFCO's decisions to intervene in a matter are grounded in its unique role as an independent voice for children and families. Consistent with this role, OFCO intervenes in matters when, after a preliminary investigation, the office has concluded that an agency’s act or omission has clearly placed the interests or well being of a parent or child at risk of harm. Irrespective of the particular outcome sought by the complainant, OFCO’s interventions are aimed at preventing or mitigating harm to the child or family.

Preliminary Investigation

Prior to intervening in a matter, OFCO conducts a preliminary investigation of the agency’s alleged act or omission to determine whether it: 1) occurred as alleged; 2) constitutes a violation of law, policy or procedure; 3) is unreasonable under the circumstances; and/or 4) has had an adverse impact on a parent or child. OFCO conducts a preliminary investigation of each complaint received. A preliminary investigation generally includes a review both of the materials provided by the complainant and information available on the DSHS automated Case and Management Information System (CAMIS), as well as interviews of the complainant, front-line workers and supervisors, and others as appropriate. It may also include a review of DSHS and/or other agency case files.

Team Review

Team review meetings are held three times each month for the purpose of reviewing new requests and providing updates on matters in which OFCO has intervened. Each new request for an intervention is presented to the team by the lead ombudsman, who also describes the results of his or her preliminary investigation and provides a recommendation on whether and how OFCO should intervene. After the team discusses and evaluates the request, the director ombudsman decides whether and how OFCO will intervene. This decision is informed by team members’ diverse expertise, experiences and perspectives.

Office of the Family and Children's Ombudsman

April 1999

Interventions

OFCO intervened in 47 percent of the 160 complaints requesting an intervention that were closed as of September 1, 1998. Of these interventions, 66 percent were conducted on an emergent basis, where there was reason to believe that children or families might be in imminent peril without immediate action. Issues relating to child protection and safety most frequently prompted an intervention, followed by issues relating to the health and well being of children in the state’s care.

Most of OFCO’s interventions consisted of an informal contact with the DSHS Children’s Administration.

In most cases, it was not necessary for OFCO to contact anyone in the administration above the supervisory level.

Office of the Family and Children's Ombudsman

April 1999

Intervention Results

Although OFCO does not have authority to impose its recommendations directly on an agency, OFCO's interventions resulted in an agency changing its position to address OFCO's concerns in 58 percent of the 76 interventions that were completed as of September 1. Well over half of the issues OFCO gets involved in result in changes in an agency's position.

In the 32 instances where the agency did not change its position, OFCO concluded that the agency's initial position was appropriate in 26 cases, and in six complaints the agency's position was consistent with existing law or policy, but the result was nevertheless problematic. Most of these related to the unavailability of an appropriate placement resource.

Intervention Examples

A 12 year-old girl, who ran away from her father’s home alleging that he had abused her, was taken into CPS custody pending disposition. At the hearing to determine if she should be returned to her father’s care or to foster care, a CPS worker testified without having interviewed the child and without having read the child’s record, which included very recent threats of suicide if returned to her father’s care. The court sent the child home and a minister who met with the child called OFCO. Upon investigation, OFCO learned of the recent suicide threats and recommended that a face-to-face interview be conducted. A second hearing was held during which the court was fully informed.

A professional child therapist called OFCO to advise that a DCFS social worker was in a pattern of inactivity regarding a family whose child was in an in-home dependency. As a result, the child was often unsupervised, had poor hygiene, and the family’s most powerful asset (a grandmother) had not been enlisted into the cause. The social worker was not responsive to the therapist’s concerns about the child’s safety, nor to those expressed by other service providers. OFCO intervened and the social worker agreed to place the child with the grandmother and to arrange a parenting evaluation for the mother.

A dependent teenager with a serious disability called OFCO to assert that his social worker had inappropriately rebuked him in front of others concerning hygiene issues related to his disability. Lacking confidence that this social worker understood his special needs, the teenager had requested a new social worker, but was denied. Upon investigation, OFCO obtained confirmation of the rebuke from others who were present, and intervened to support the teenager’s request. Following the intervention, a new caseworker with greater understanding of the disability was assigned.

A school counselor called OFCO concerned that several children were at risk of harm, including sexual abuse, in their home. She had made a CPS referral two-and-a-half months earlier, but no action had been taken to protect the children. She had since tried calling the worker on several occasions because she felt the children were still at risk. The worker had not returned any of her several calls, nor would anyone else from the department return her calls. OFCO investigated and learned that there was no open CPS case on the children, nor was there any evidence to indicate that the investigation of the counselor’s referral had ever been completed. OFCO found that the case had been mistakenly closed two months earlier after the assigned worker transferred to another unit. Since then, additional referrals on the children had been received, but not acted upon by the department. Upon calling this to the department’s attention, the case was reactivated, a worker assigned, and a full investigation was completed, yielding a voluntary service plan designed to address the needs of the family.

A mother of a seriously troubled older teen called OFCO to say that her son was about to be discharged from an inpatient mental health facility and she was unable to care for him due to his behavior and her illness. DCFS declined to provide a foster home. OFCO investigated and corroborated the situation with the teen’s therapist at the inpatient facility, who emphasized that, while the teen needed to be discharged, he needed the support of an appropriate placement, which his mother could not provide. OFCO called the matter to the attention of the DCFS supervisor, who initially said that DCFS had nothing to offer the family, but eventually agreed to file a new CPS referral. This in time lead to a suitable placement for the teen and a cooperative relationship between the department and the family.

A father of a five year-old girl called OFCO to say that CPS had taken custody of his daughter based on allegations of sexual abuse which he said were prompted by the girl’s mother. He explained that all the allegations had already been dealt with in previous CPS investigations and in the family court custody dispute in which the court awarded custody to him. OFCO investigated and suggested that CPS immediately convene a Child Protective Team (CPT) – a committee of community professionals who review all the evidence and advise CPS on the need for placement of a child or return home. In this case, after reviewing the history, the current situation, and hearing from all parties, the CPT recommended that the child be returned to her father.

Declines

Of the 160 complaints closed during the reporting period, OFCO declined to intervene in 52 percent. Although these complaints did not result in an OFCO intervention, each received a thorough investigation and careful evaluation. (Each complaint in which OFCO declined to intervene received on average almost 3 hours of preliminary investigation and evaluation.) Moreover, information from these complaints, including the subject of the complaint and the issues raised, were entered into OFCO’s automated complaint tracking system to help identify trends and patterns. Where OFCO declined an intervention, it was because OFCO:

Found insufficient evidence that an agency act or omission had clearly placed a child or parent at risk of harm (69 percent of declined complaints);
Determined that the issue was outside OFCO jurisdiction (22 percent);
Found that the issue had been resolved (8 percent);
Concluded that OFCO could not achieve the requested outcome (1 percent).

Investigations

In addition to intervening in particular matters to prevent or mitigate harmful administrative errors, OFCO conducts administrative and systemic investigations. Administrative investigations are aimed at assessing agency compliance with law, policy or procedure, while systemic investigations are aimed at identifying system-wide problems and recommending solutions. OFCO’s investigations may be commenced upon receipt of a complaint, or upon its own initiative.

Administrative Investigations

Because OFCO dedicates most of its efforts toward direct case intervention, OFCO conducts administrative investigations only when the case clearly involves agency conduct or systemic issues that are chronic and/or seriously harmful to children and parents. As with case-specific interventions, decisions about whether to undertake a case-specific administrative investigation are made after a preliminary investigation and team review have been conducted. OFCO did not accept any of the 30 requests for an administrative investigation that were closed during the reporting period. OFCO declined to conduct a full-scale investigation of these complaints because OFCO:

Found insufficient evidence to conclude that the allegations were credible, or that they involved agency conduct or systemic issues that are chronic and/or harmful (67 percent of declined complaints);
Determined that the complaint was outside OFCO’s jurisdiction (20 percent);
Found that the complaint had been resolved (10 percent);
Addressed the systemic issues raised in the complaint in OFCO’s review of the Wenatchee child sexual abuse investigations (3 percent).

Although OFCO did not undertake any administrative investigations during the reporting period, the office initiated several preliminary investigations that may result in full-scale administrative investigations in the upcoming year.

Systemic Investigations

In light of OFCO’s limited resources, it is not possible for the office to investigate all of the potential system-wide issues that adversely affect children and families. Accordingly, OFCO has, with the assistance of its advisory committees, developed criteria for selecting among potential systemic issues. These criteria give priority to issues that appear to have a seriously adverse impact on the safety, well being or permanence of children, and/or their families, and have been:

Identified as a pattern or trend in the complaints received by OFCO;
Identified as a problem by another source, but that have not been adequately investigated or addressed, and OFCO’s unique features (neutrality, independence, cross-system perspective) would make it effective in addressing the issue; or
Identified as an "invisible" problem by OFCO because they are not likely to be the subject of complaints to OFCO.

OFCO received only one complaint requesting a systemic investigation. Utilizing the criteria above, OFCO decided to conduct a preliminary investigation of the systemic issue raised in that complaint. In addition, the criteria provided the basis for OFCO’s initiation of the following two systemic investigations:

Review of 1994-95 Wenatchee Child Sexual Abuse Investigations

OFCO director, Vickie Wallen, announced on October 23, 1997, that her office would review the involvement of the state Department of Social and Health Services (DSHS), Children’s Administration, Division of Children and Family Services (DCFS), in the 1994-95 Wenatchee child sexual abuse investigations. OFCO’s review was prompted by a petition received in June 1997, within days after the office became operational. The petition alleged that DSHS social workers had inappropriately assisted law enforcement investigations of child sexual abuse allegations in various ways. An independent review of state social workers’ actions was requested.

The Wenatchee Investigations

The Wenatchee child sexual abuse investigations were conducted jointly by local law enforcement officials and DCFS Child Protective Services (CPS) workers. These investigations involved allegations against more than 80 adults, and led to the prosecution of 38 people in 1994 and 1995 in Chelan and Douglas counties.

Many of the cases involved allegations that groups of adults had sexually abused their own and others’ children. Ultimately, 25 people were convicted of crimes involving sexual abuse against children. In addition, these investigations led to the temporary or permanent removal of at least 42 children from the care of their parents.
The Wenatchee investigations have been the focus of intense and enduring controversy. Techniques allegedly employed by law enforcement and CPS investigators in eliciting statements from suspects and alleged child victims have come under public criticism, and formed at least part of the basis for state appellate court decisions to reverse or vacate criminal convictions. Law enforcement officials and CPS social workers, however, have consistently maintained that their investigative techniques were appropriate. In July 1998, a civil jury determined that law enforcement and CPS investigators did not violate the civil rights of the children and acquitted defendants who had filed suit.

OFCO’s Review

OFCO’s review represents the first full-scale independent review of the Wenatchee investigations by a government agency. In early 1996, United States Attorney General Janet Reno declined a request by then-Governor Lowry to undertake a review of the investigations for potential criminal civil rights violations. Reno said her office lacked jurisdiction because the allegations stated that psychological coercion, not actual physical force, had been used by investigators to elicit statements.

After conducting a four-month preliminary investigation into the issues raised in the petition, OFCO announced in October 1997 that it would conduct a targeted review of the Wenatchee cases for the purpose of identifying potential systemic problems with respect to:

How CPS social workers conducted themselves in child sexual abuse interviews.
How those interviews were documented by CPS social workers.
The provision of state-contracted mental health services to possible child sexual abuse victims.

Specifically, OFCO sought to determine whether new or stronger safeguards are needed to protect children who are the subject of investigative interviews, and to ensure that possible child sexual abuse victims are provided with appropriate mental health services.

OFCO’s review commenced in April 1998 and concluded in November 1998. During this period, OFCO’s investigative team reviewed over 60,000 pages of documents and interviewed over 40 individuals. To assist in understanding the diverse and complex issues presented by the Wenatchee investigations, OFCO convened a multidisciplinary panel of professionals from Washington State and across the country.

Findings and Recommendations

OFCO’s findings and recommendations are set forth in a report entitled, 1998 Review of the 1994-95 Wenatchee Child Sexual Abuse Investigations.¹ In the report, OFCO found that the 1994 and 1995 Wenatchee child sexual abuse investigations present a progression with regard to the kinds of allegations that are made in child sexual abuse cases. Specifically, the investigations present a progression from the types of allegations that are:

Common: Abuse of a child by a single family member or friend, to those that are

Less Common: Abuse of several children by both parents, and/or their friends, to those that are

Uncommon: Organized and systematic abuse of many children by many community members.

Whether the uncommon allegations occurred as alleged, or something went wrong in the child abuse investigative system resulting in factual distortions, could not be determined through OFCO’s review. The CPS investigations were not well enough documented to allow the ombudsman’s office to ascertain whether the kinds of mistakes that can cause factual distortions occurred. In addition, insurmountable constraints encountered by OFCO investigators during the course of the review made it impossible to establish the underlying facts with a reasonable degree of confidence.

Nonetheless, OFCO’s review produced the following findings and recommendations:

Interview Documentation: OFCO found that current law and CPS documentation policies are not sufficient to ensure that interviews are documented in a manner that permits meaningful external review. OFCO recommended that that CPS social workers be required to document interviews in a verbatim or near-verbatim manner that captures which questions are asked, in what order, and the exact answers given to the questions.

Child Interview Techniques: OFCO found that current law and CPS policies do not require that all CPS social workers receive specialized and ongoing training in effective interviewing techniques. Also, state-contracted mental health therapists who evaluate and treat children in state care who are possible victims of sexual abuse are not required to have specialized or on-going training about sexual abuse. OFCO recommended that specialized and on-going training in interviewing techniques be required of all CPS social workers, and that the DSHS Children’s Administration study whether state-contracted therapists should be required to have specialized and ongoing sexual abuse training.

Cross Discipline Collaboration: OFCO found that CPS social workers currently collaborate with law enforcement agencies and other disciplines on child abuse investigations without the benefit of specific guidance or formal training on the goals, expectations, and limitations of such collaboration. OFCO recommended that local jurisdictions be required to establish collaborative protocols for various disciplines involved in child abuse investigations, and that joint training opportunities be enhanced for CPS social workers and other professionals.

In addition to these findings and recommendations, OFCO’s report includes a description of documented and alleged events in Wenatchee that are illustrative of investigative errors that experts agree can increase the possibility of factual distortion. The report was released to Governor Locke, the Legislature, and DSHS officials December 1998.

Guardian ad Litem Representation

OFCO’s investigation into the issue of children’s representation by guardians ad litem (GAL) was prompted by a pattern of complaints received by the office in which the affected child was reported as having no one to represent him or her in child abuse and neglect proceedings.

Federal Funding Requirements

The federal Child Abuse Prevention and Treatment Act (CAPTA) requires states receiving CAPTA grants to certify that the state has in effect, and is enforcing, a state law that for every case involving an abused or neglected child which results in a judicial proceeding, a GAL be appointed to represent the child. It is the role of the GAL "to obtain first-hand, a clear understanding of the situation and needs of the child, and to make recommendations to the court concerning the best interests of the child." Washington State receives approximately $1.25 million per biennium in CAPTA grants, and has made the required certification.

State Law

Consistent with CAPTA requirements, Washington law requires the court to appoint a GAL for children who are the subject of a dependency proceeding. However, Washington law also allows the court to decide not to appoint a GAL if it finds for "good cause" that the appointment is unnecessary. Washington State is the only state in the country with a statutory good cause exception.

OFCO’s Investigation

OFCO commenced its investigation in July 1998. OFCO investigated the number of children who are not represented by a GAL in child abuse and neglect proceedings by collecting data on the number of children in Washington State who are the subject of such proceedings, and the number that have been appointed a GAL to represent their best interests. The Washington Office of the Administrator for the Courts (OAC) provided OFCO with numerical data in several areas. OAC data were clarified, verified, and augmented in telephone interviews with county officials.

Findings

OFCO’s investigation produced the following findings:

Children Not Represented by a GAL: OFCO found that approximately one-third of Washington children who are involved in child abuse and neglect proceedings do not have a GAL to represent their best interests. These children are concentrated in seven Washington counties: Benton, Franklin, Clark, King, Kitsap, Snohomish, and Spokane. Over one-half of the children involved in proceedings in King, Snohomish and Spokane counties did not have a GAL during the one-year time period surveyed by OFCO.

Caseload Concerns: Information obtained during OFCO’s survey of county officials indicates that children in three counties are served by professional GALs with extremely high caseloads. In Pierce County, each professional GAL represents about 140 children at one time, while Spokane County reports that at least one professional GAL has a caseload of about 90 children. Yakima County reports that the single, full-time professional GAL represents about 400 children, while a half-time professional represents about 150 children.

Recommendation

Based on these findings, OFCO made three recommendations:

Increase the Number of GALs: OFCO recommended that the number of GALs be increased to a level that is sufficient to ensure appointment for all children who are involved in child abuse and neglect proceedings. OFCO also recommended that state policy makers consider appropriating funds to establish or expand GAL programs involving trained volunteers.

Delete the Good Cause Exception: OFCO recommended that the statutory exception to the state mandate to appoint a GAL be deleted. This will make clear that it is the state’s policy that a GAL be appointed to represent the best interests of every child who is the subject of a child abuse and neglect proceeding.

Review Caseloads: OFCO recommended that county officials in Pierce, Spokane and Yakima counties review and take appropriate steps to reduce the caseloads of professional GALs in their jurisdictions. OFCO also recommended that the caseloads of professional and attorney GALs in other jurisdictions be reviewed for this purpose.

These findings and recommendations are set forth in OFCO’s Report on Guardian ad Litem Representation of Children in Child Abuse and Neglect Proceedings.² The report was released to Governor Gary Locke, the Legislature, and superior court officials in January 1999.

¹The report may be obtained by contacting OFCO, or by accessing OFCO's web page at: www.governor.wa.gov/ofco.
²The report may be obtained by contacting OFCO, or by accessing OFCO's web page at: www.governor.wa.gov/ofco.