"What happened? Quite frankly, I don't know," DHS Executive Director Karen Beye said during the House Health and Human Services Committee hearing.
For about 30 minutes, Beye briefed lawmakers about what DHS is doing to correct problems that led to DHS overlooking the completion of the child fatality reviews. She explained that the reviews were dropped when two employees left the department and no one else on staff followed through to ensure they were completed.
The 10 child fatality reviews all involved children younger than age 4 who were in some level of DHS supervision when they died. One child, Chad Munoz, died Feb. 1, 2008, in Fort Collins after just 20 days of life.
The investigations are done to identify any mistakes made by county DHS officials and to prevent them from being repeated.
Beye said the two employees who left the department were not fired. She said as far as she knows the employees did not leave because the fatality reports were not being completed.
The incomplete reports about the 10 deaths became public after a Coloradoan investigation this month. DHS officials said they became aware of the problem in January. E-mails obtained by the Coloradoan under state open records laws showed no effort by DHS officials to complete the reviews until after the paper began asking about the situation in late February.
Lawmakers did not ask Beye who on her staff was responsible for ensuring the reports were finished after the two employees left and did not ask her what role she should have played in ensuring the reports were completed.
Rep. John Kefalas, D-Fort Collins, serves on the committee panel and said after the hearing that he plans to further investigate who at DHS was responsible for ensuring the reports were finished.
"I don't have all the evidence that things were in disarray," Kefalas said after Beye's testimony. "That's where I'm going to pursue more and try to determine where does the buck lie?"
Beye explained to lawmakers that the state's failure to produce a finalized report about the 10 reviews was the only part in the process that was not conducted. Beye said her staff worked with county officials in all 10 instances to identify problems and correct them.
That claim can't be immediately verified because the final report is the only part of the process that's ever made public. DHS is still working to finish most of the 2008 reports.
She said six of the 11 fatality reviews established a need for counties to adjust policy findings. And in all six of those instances, Beye said the counties involved adjusted policies and procedures without the state's completed report.
"Because counties were aware and took action without the final report being sent to them, children were not more vulnerable as a result," Beye said.
In the Munoz case, state and county DHS officials agreed the Larimer County agency had nothing to do with the baby's death.
According to the completed report, which was released last week about 26 months after Munoz's death, the county agency made policy changes allowing more employees to conduct background checks on families and other caregivers. The county also now screens referrals, or tips about possible abuse, with a team of employees rather than with the consideration of a single manager.
Beye also told lawmakers Monday there were no dropped reviews in 2009 and said no child fatality reviews have been submitted to the state so far in 2010.
Larimer County officials currently are reviewing the death of Summer Moon Hawk, a Loveland infant who died in January.
Kefalas said the improved handling of the cases was a good sign that Beye and her staff understood the importance of the errors they've made.
"That tells me they understand the magnitude of the issue and they're moving forward," Kefalas said.
Beye told lawmakers she has implemented the following changes to ensure future fatality reports are finished in a timely manner:
> Reviews will be subject to monthly status reports.
> State DHS regulations will include expected responsibilities for its employees. Beye said county guidelines already outline expectations for its employees.
> Transmission receipts will be submitted when fatality reports are sent from the county to the state and from the state to the county.
> Ability to complete reports in a timely manner and to communicate about the findings of reviews will be considered during the employee reviews of staff assigned to participate in the child fatality review process.
After the hearing, Beye said she and her staff are focused on moving forward and improving the fatality review process.
"I would hope that people can recognize that mistakes can happen," she said, adding that the most important thing is that those mistakes are corrected.
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