‘Missed warning signs.’ MO child welfare failed kids who died of fentanyl, panel says

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Missouri’s child welfare agency missed warning signs and failed to protect dozens of children from dying of fentanyl, according to a recent state report.

Written by a panel created by the Department of Social Services to study 2022 fentanyl deaths, the report further stated that safety protocols in place were inadequate.

“The Children’s Division’s (CD) approach to child safety lacked essential procedures, missed warning signs, and left vulnerable children at risk,” the Fentanyl Case Review Subcommittee’s report said. “The subcommittee identified issues like inadequate case assessments and families declining services, leading to case closures.”

In 2022 alone, 43 children in Missouri — from babies and toddlers to older teens — died of fentanyl. And since January, the subcommittee of experts, social workers, health officials, law enforcement, and child advocates have spent hours each week analyzing those deaths.

In the end, the panel said agency leaders now must focus on training, improve safety standards, and make sure drug concerns inside families are thoroughly investigated. Other recommendations include improving the coordination between the Missouri Department of Mental Health and CD and educating workers on the best options when fentanyl is involved.

“The loss of a child to a drug-related incident is a heartbreaking occurrence that should never transpire,” said DSS Director Robert Knodell in a letter included in the report. “It is imperative that we collectively strive for improvement on both a personal and communal level.”

Emily van Schenkhof, executive director of the Children’s Trust Fund, was a part of the subcommittee and said she was surprised by much of what she read in the case reports. The Children’s Trust Fund is the state’s foundation for child abuse prevention.

“There were cases where we knew at the birth of the child that there was a serious substance abuse problem,” she said. “And I think those cases were not handled the way they should have been. … So those were very hard to see.”

The state, van Schenkhof said, has changed some protocols since 2022, altering how those cases are handled.

There were other cases, she said, “where we have a hotline call, or someone would say, ‘Mom or Dad is using fentanyl, I’m really worried.’

“But there was a failure to adequately investigate that,” van Schenkhof said.

Jessica Seitz, also a member of the subcommittee, said as she reviewed the cases and met with the group she learned how fatal fentanyl is and how “much imminent danger a child is in if fentanyl is around.”

“It was shocking to me just how much the presence of fentanyl ranks you on the overall safety assessment,” said Seitz, executive director of the Missouri Network Against Child Abuse, formerly known as Missouri KidsFirst.

And in many of the cases reviewed, she said, the presence of fentanyl within the family “wasn’t properly assessed at that level of urgency.”

‘This threat is incredibly unique’

The Star’s series, “Deadly Dose,” first revealed late last year that babies and toddlers in Missouri were dying from fentanyl at an alarming rate. In 2022, 20 Missouri children — ages 4 and under — died from fentanyl. Seven of those babies and toddlers were from Jackson County.

Unlike other drug crises, including crack, these children didn’t suffer from debilitating addictions because their parents were using; they died of actual fentanyl overdoses. The babies and toddlers came across the synthetic opioid and its residue in their homes, inside hotel rooms and even at a city park.

Their deaths largely went unnoticed, ending up as statistics inside annual state reports on child deaths or in records kept by county medical examiners. Most of the attention on fentanyl has focused on teens or young adults and the awareness that “one pill can kill.”

The subcommittee also found concerns with the older children. While many of the babies and toddlers were known to Children’s Division, so were some of the teens. And many of those were the “hardest cases,” van Schenkhof said.

“What we saw were kids that over a period of 10 to 15 years, they never got their needs met,” she said, “and then in order to kind of cope with the trauma that they experienced they turned to alcohol and drugs.”

In December, two months after The Star’s report on children dying of fentanyl, Knodell formed the subcommittee.

“As the threat and the presence of Fentanyl across the country and in Missouri has escalated, DSS felt it was important that we review our practices and trainings, and update them with the help of professionals across the spectrum,” Knodell said in an email. “This threat is incredibly unique, and we view the subcommittee’s report as a vital starting point for a sustained effort.”

‘A perfect storm’

The report gives crucial insight into the struggles that Missouri has had in containing the devastating toll fentanyl has taken on the state, including its most vulnerable children.

The rise of the illicit drug — and the children’s deaths in 2022 — occurred at a time when the state’s child welfare system struggled with turnover and vacancies that plagued the Children’s Division in every pocket of the state. Underpaid and overworked employees told The Star back in 2022 that they were forced to carry caseloads up to two and three times the standard.

In Kansas City alone that year, officials scrambled to hire employees as the turnover rate in that office reached nearly 100 percent.

“It was a perfect storm of those very big risk factors that led to fatalities,” Seitz said. “And then a lack of understanding of all of the different options available.”

As the state continued to deal with the COVID-19, fentanyl was still fairly new in Missouri.

“When something emerges this quickly, our systems and our workforce are not equipped to be able to shift on a dime and recognize something until some time has passed,” van Schenkhof said. “And so it was just too new of an issue for a struggling overburdened, chronically underfunded, and under-resourced system to be able to adequately respond.”

She applauded Knodell’s actions in seating the subcommittee and telling members that he wanted to know what they found.

“The reason that the director asked us to do this is because it is the culture right now in the Department of Social Services that we take a hard look at where we are not living up to our obligations and that we make changes,” van Schenkhof said. “And so I think we will see good things coming out of this and I think we will see it soon.”

The report did not include a timeline for when the improvements should be made.

But Baylee Watts, a DSS spokeswoman, said the state’s child welfare agency is “assessing the recommendations provided in the report and will make every effort to establish procedures to tackle these issues.”

“The Department of Social Services, including the Children’s Division, is committed to enhancing processes,” Watts said in an email, “and working closely with our partners to enhance collaboration and ensure a safer Missouri for our most vulnerable citizens.”