A special team named to find out what led to 6,554 cases of child abuse going uninvestigated concluded Friday there was a “systemic failure, a lack of accountability and transparency and bad decision making,” requiring a total revamp of how Arizona handles child welfare.
The report by the Child Advocate Response Evaluation team to Gov. Jan Brewer found there was no specific statute, administrative rule, policy or even an agency procedure at Child Protective Services that would have allowed someone to mark that many cases being marked as NI, as is “not for investigation.”
Yet Charles Flanagan, who heads the team — and has since been named to head the new Division of Child Safety and Family Services — said the practice did occur despite clear state laws requiring all complaints received to be investigated. He said what happened was essentially an accident waiting to happen.
“The basic problem here is you don't really have a system,” he told Capitol Media Services of CPS. “What you have is something that is set up to look like a system but it is operated based on personality, individual decision making, either because there are no policies and procedures or they're not followed.”
Flanagan said the reason those uninvestigated cases went undiscovered for years is because there was no real system of checks and balances.
“What they called ‘quality assurance,’ is the same people who ordered it (the NI cases) and directed it were quality assurancing it, which is nonsensical,” he said.
The CARE team concluded that the decision to shelve those complaints was far from harmless. Investigations that have since been conducted have resulted in 407 children now being removed from their homes.
But uninvestigated cases are only part of what the team outlined in its 53-page report.
More than a quarter of the 3,200-plus calls to a child abuse “hotline” last year were abandoned, with callers hanging up before someone picked up, meaning nearly 850 calls not answered.
“While we know that many of these callers do call again, it is reasonable to assume that some do not,” the report states. “Even one missed report of abuse is significant.”
Even when a caller gets through, that does not ensure a proper response: Flanagan said investigators found at least 142 “failure points” between a call arriving at the hotline and closing an investigation, meaning 142 places where a report — and a child — could fall through the cracks.
And Flanagan said that many abuse reports that do come in “will sit uninvestigated until resources are available.”
He said that shortage of investigators creates “an unwinnable game,” with CPS employees frustrated by the lack of sufficient staff to handle the caseload. That, in turn, contributes to high employee turnover — more than one in five workers will leave each year — which results in the agency having to hire and train new caseworkers.
Lawmakers moved to address some of that this week by approving funds to immediately hire 126 new caseworkers on top of the 1,194 already authorized. But the recommendations go beyond simply adding staff. Flanagan said the new agency, being created out of the old Child Protective Services, is going to revamp pretty much everything, from its mission and culture to its leadership.
That pleased critics of CPS.
“The CARE team recognizes that simply changing to org chart, or even simply getting more bodies, is not going to resolve it,” said Dana Naimark, president of the Children's Action Alliance, whose organization has been lobbying for changes in CPS for years. “That is all really hard but necessary work.”
Maricopa County Attorney Bill Montgomery, a frequent critic of CPS, noted the report focuses on more than just how to handle complaints that come in.
“There's a recognition of being able to organize and be able to deliver social services, too,” he said, rather than focusing only on whether a child needs to be removed from a home. “We've got a chance to do it right for Arizona, where other states are still struggling.”
One of the recommendations is already being implemented.
The team said the state should “create an agency that is laser-focused on the core mission of child safety with direct accountability to the governor.”
Brewer already has abolished CPS division of the Department of Economic Security and replaced it with the new Division of Child Safety and Family Services. And Flanagan will report directly to her.
One controversial recommendation says that when current CPS employees are transferred to the new agency they lose all merit protections that give them certain rights when a supervisor seeks to discipline or fire them. That concerns Naimark.
“That potentially could subject workers to political pressure on individual cases,” she said, noting that there have been multiple instances over the years where legislators and their families have come under CPS scrutiny. “We clearly have to avoid that.”
Flanagan, however, said he's looking at it from the other side of the equation. He said giving more latitude to supervisors means the ability to reward good employees with promotions and higher pay.
The report also focuses on transparency, with Flanagan saying the public will trust his new agency only if they get to see what it is doing.
Much is hidden based on federal laws that protect child privacy, but Flanagan said while that shield an individual's identity, he said the agency should still be able to provide information.
Flanagan said more openness also means the ability to tell the public when things go right.
Among other findings:
- Make better use of local police departments to help ensure that all complaints of abuse are investigated. The report calls law enforcement "a critical and underused partner.''
- Create "multi-disciplinary teams embedded in the community,'' to take a closer look at complaints. This would include not just law enforcement but also criminal investigators within the state's child welfare agency, social workers and others involved in offering social services.
- Provide better training to child safety specialists who will conduct field investigations. One option is to use existing community college law enforcement programs.
While Flanagan's team detailed out what happened, it will be some time before the public finds out exactly who was responsible for shelving those thousands of calls to the agency without even the barest follow-up despite state laws to the contrary.
That side of the problem is being investigated by the Department of Public Safety. DPS spokesman Bart Graves said he could not say when that inquiry will be completed.