CHILD WELFARE MANUAL

Section 8, Chapter 9 (Fatality/Critical Event Reporting and Review Protocol), Subsection 1 – Critical Event Categories

(Effective:  05/01/19)

9.1 Fatality/Critical Event Reporting and Review Protocol

The Critical Event Protocol is a process for the reporting, reviewing and documenting the Division’s response to significant events involving a child, such as child deaths, suicides or serious physical injury as well as other circumstances requiring critical event response.

9.1.1 Critical Event Categories

Critical events are classified by category, which determines the Division’s response. Categories are as follows:  

Category A  

    • Child fatality, near fatality, suicide or serious physical injury;
    • Resulting from alleged CA/N;
    • There is relevant CD involvement.

Category B  

    • Child fatality, near fatality, suicide or serious physical injury;
    • Result of alleged CA/N or non-CA/N;
    • Involved in an open FCS case, IIS case or occurred during a pending hotline.

Category C  

    • Child fatality, near fatality, suicide or serious physical injury;
    • Result of alleged CA/N or non-CA/N;
    • The child is a foster child

Category D  

    • Child fatality, near fatality, suicide or serious physical injury;
    • Result of alleged CA/N;
    • There is no CA/N history or no relevant CA/N Involvement

Category E

Events that do not meet category A-D criteria; are still considered serious; and meet one or more of the following criteria:

    • Media Attention – has or is likely to generate media attention
    • Child in foster care who was subjected to sexual abuse, exploitation or assault
    • Human Trafficking – Reported allegations when a child is a victim of human trafficking (e.g., abusing a child through forced labor, slavery, involuntary servitude, peonage, sexual exploitation, sex trafficking)
    • Threats to employee safety

Definitions for Critical Events

Near Fatality

“An act that, as certified by a physician, places the child in serious or critical condition.” For example, if hospital records reflect that the child’s condition is “serious” or “critical,” this would be considered a “near fatality”.  See, Child Abuse Prevention and Treatment Act (CAPTA), as amended (42 U.S.C. 5101 et seq.) – sections 106(b)(2)(B)(x) and (b)(4)(A)

Serious Physical Injury

The term “serious physical injury” is defined under 42 USCS 247d-6d (10) as an injury that:

    • Is life threatening;
    • Results in permanent impairment of a body function or permanent damage to a body structure; or
    • Necessitates medical or surgical intervention to preclude permanent impairment of a body function or permanent damage to a body structure. Serious Physical Injury

Definitions for “Other” events requiring a critical event

 Sexual Abuse

The term “sexual abuse” is defined as, “any sexual or sexualized interaction with a child, except as otherwise provided in paragraph 2 below.

    1. Sexual abuse shall include, but is not limited to:
      1. Any touching of the genitals, anus or buttocks of a child, or the breast of a female child, or any such touching through the clothing; any act involving the genitals of a child and the hand, mouth, tongue, or anus of another person; or any sexual act involving the penetration, however slight, of a child’s mouth, penis, female genitalia, or anus by any body part of another person, or by any instrument or object.
      2. Any conduct that would constitute a violation, regardless of arrest or conviction, of Chapter 566, RSMo., if the victim is less than eighteen (18) years of age, section 567.050, RSMo if the victim is less than eighteen (18) years of age, sections 568.020, 568.060, 568.080, or 568.090, RSMo, sections 573.025, 573.035, 573.037, or 573.040, RSMo, or an attempt to commit any of the preceding crimes;
      3. Sexual exploitation of the child, which shall include:

(I) Allowing, permitting, or encouraging a child to engage in prostitution, as defined by state law; or

(II) Allowing, permitting, encouraging, or engaging in the obscene or pornographic photographing, filming, or depicting of a child as those acts are defined by state law. This includes the storage or transmission of any data depicting said obscene or pornographic acts, images, or recordings.

2. Any reasonable interaction with a child, including touching a child’s body for the purpose of providing the proper or necessary care or support of the child, shall not be considered sexual abuse. The touching of a child’s body, including a child’s genitals, buttocks, anus, or breasts for reasonable, medical, child rearing, or child care purposes shall not be considered sexual abuse.

3. The division shall not be required to prove that the alleged perpetrator received sexual gratification or that there was an exchange or promise of anything of value as a result of the act of sexual abuse to establish sexual abuse under Chapter 210 or 211, RSMo.

4. The use of force or coercion is not a necessary element for a finding of sexual abuse.

5. Sexual abuse may occur over or under the child’s clothes.

6. The division shall not be required to prove that the child suffered trauma or harm as a result of the act of sexual abuse.

7. A child cannot consent to a sexual or sexualized act or interaction with a person responsible for that child’s care, custody, and control.

Sexual Assault

 The term “Sexual Assault” shall include the following:

    • Chapter   566 Sexual Offenses – The acts of rape, forcible rape, statutory rape (1st and 2nd degree), sexual assault, sodomy, forcible sodomy, statutory sodomy (1st and 2nd degree), child molestation (1st and 2nd degree), deviate sexual assault, sexual misconduct and sexual abuse, or attempts to commit any of the aforesaid
    • 568.020   Incest.
    • 568.060   Abuse of a child and penalty. – The act of abuse of a child which involving sexual contact
    • 568.080   Child used in sexual performance, penalties. – The act of use of a child in a sexual performance; and
    • 566.151   Enticement of a child, penalties. – The act of enticement of a child or any attempt to commit such act.

Human Trafficking

    • 566.200 (16) “Victim of trafficking”, a person who is a victim of offenses under the following sections:
    • 566.203   Abusing an individual through forced labor–penalty.
    • 566.206   Trafficking for the purpose of slavery, involuntary servitude, peonage, or forced labor–penalty.
    • 566.209   Trafficking for the purpose of sexual exploitation–penalty.
    • 566.212   Sexual trafficking of a child–penalty.
    • 566.213   Sexual trafficking of a child under age twelve—affirmative defense not allowed, when–penalty.

9.1.2 Critical Event Report (CS-23) Procedure

    • When a Children’s Service Supervisor becomes aware of a critical event or any other event requiring critical event notification, the supervisor will:
      • Complete a CS-23 and send to Central Office and CC the Circuit Manager and Regional Director via email at: DSS.CD.CriticalEventReport@dss.mo.gov
      • If unable to access email, fax CS-23 form to 573-526-3971.   

The Supervisor must also assure the CD Director/Designee is notified immediately.

The CS-23 must be initiated as follows:

Category A, B and C

      • Business Hours – Within 3 hours
      • After Hours – By 10 a.m. the following business day

Category D or E

      • Within one Business day
      • Unless media involved (refer to A, B, C timeframes)
    • Thoroughly review the FACES system for current involvement or prior history with the Division on all persons listed with available DCN, date of birth, social security number, or name on the CA/N report using the Call/Case Prior History Search screen. 
    • If the residence county or state differs from the county receiving information, the county that received the information is responsible for completing the CS-23. However, the reporting county may need to explain on the form that the other county (or state) may have additional information.
    • Staff should provide designated probation and parole staff a copy of the CS-23 when a common client is involved and notification is reasonably necessary to ensure the safety of a child or to assist in the CA/N investigation.

9.1.3 Critical Event Response

The purpose of the Critical Event Response is to evaluate a Children’s Division employee’s performance and the employee’s ability to competently perform his/her duties following the fatality, near fatality, or serious injury of a child who is, or has been, involved with the Children’s Division. The process may include three parts, which will be referred to as Critical Event Response Parts I, II, and III. Parts I and II, if needed, shall be completed by the Regional Director or designee no later than three days after the child’s death or within three days of the Children’s Division receiving notification of a near fatality or serious physical injury.

Critical Event Response Part I:

The preliminary assessment (Critical Event Response Part I) will be completed by the Regional Director or designee. The preliminary evaluation is a process to determine whether further evaluation, including a review and assessment, is warranted.  The Critical Event Response Flowchart is available to guide the process and to assist with decision-making.  A review and assessment (Critical Event Response Part II) shall take place under the following circumstances.

    • A fatality, near fatality, or serious physical injury involving a child with an open Family Centered Services and/or Intensive In-Home Services case, or a child that is named in an open investigation or family assessment when child abuse or neglect is suspected;
    • A fatality, near fatality, or serious physical injury involving a child in foster care (legal status 1) when child abuse or neglect is suspected;
    • A fatality, near fatality, or serious physical injury of a child with relevant Children’s Division involvement when child abuse or neglect is suspected;
    • Upon the request of the Regional Director or designeeThe preliminary assessment shall be completed no later than three days after the child’s death or within three days of the Children’s Division receiving notification of a near fatality or serious physical injury.

Critical Event Response Part II:

If it is determined, based on the preliminary evaluation (Critical Event Response Part I,) that criteria is met to warrant further review, the Regional Director or designee will complete Critical Event Response Part II to determine whether the investigator, case manager, supervisor, and/or circuit manager are able to perform his/her duties competently. Based on the Regional Director or designee’s knowledge of the situation, he/she will identify the parties to be reviewed.  A thorough review of staff ability and competency should be completed.  A “Review and Assessment Guide” is available to assist with this process; however, use of the form is not required. 

Child Abuse and Neglect Hotline Unit management will receive notification of incidents that warrant an assessment and review (Critical Event Response Part II.) Following notification, they are to assess staff competency, specifically as it relates to prior reports made to the Child Abuse/Neglect Hotline Unit involving the child who is now deceased or who has sustained serious physical injury.

The assessment and review (Critical Event Response Part II) shall be completed no later than three days of the child’s death or within three days of the Children’s Division receiving notification of a near fatality or serious physical injury. A “Review and Assessment Guide” is available to assist with the review; however, use of the form is optional.

Competencies and functioning of Children’s Division staff should be considered during this review. Information related to the Children’s Division’s knowledge of, and involvement with, the family should also be considered. 

Two tracks have been developed with questions and suggestions to assist with this process.

CD STAFF TRACK

CHILD/FAMILY TRACK

How long has the CD staff member worked for the agency and/or worked in this capacity?

What was the family’s history with the CD?

How long has the CD staff member been assigned to work with this child/family?

Was this case appropriately assigned?

 

What is the CD staff member’s caseload size?

What was the safety plan?

Have there been concerns related to this CD staff member’s performance?

What additional information can be provided through a review of the record?

What information does a review of the record provide about the worker’s ability to follow CD policies?

What is the current situation?

How are the CD staff member(s) and the Circuit as a whole coping in response to the recent event?

 

Critical Event Response Part III:

After completing Parts I and II, the Regional Director or designee may determine that further assessment is warranted. Critical Event Competency Guides for Children’s Service Workers, Children’s Service Supervisors, Circuit Managers, and Program Managers/Field Support Managers are available.

The Regional Director or designee should complete the Critical Event Competency Guide if it is determined that further assessment of worker competency and ability is warranted.   Use of the available forms is optional.  The person assigned to complete the review should consult with Children’s Division Personnel as appropriate.

9.1.4 The Critical Event Review Process

The critical event review process consists of the following parts.

    • A review of the critical event
    • A log of prior history (CA/N, AC, FCS and IIS)
    • A review of each open case
    • A review of each prior relevant to the current event
    • Staff Interviews
    • Observations from Critical Case Review  

9.1.4.1 Critical Event Tool Kit

What is a critical event tool kit?

A collection of tools used to guide a critical event reviewer through the case review process in response to critical events.

Who completes the reviews?

        • For categories A and B the reviewer must be internal to the region of the critical event. 
        • For category C the reviewer must be external to the region of the critical event.
        • Division Director/Designee has the discretion to request a review by another region.

When is a Critical Event Tool Kit Required?

Every critical event requires completion of a CS-23, however; not every CS-23 requires a Critical Event Tool Kit.

        • Category A – a Critical Event Tool Kit is required.
        • Category B – a Critical Event Tool Kit is only required if CA/N is suspected or a review panel is requested by the Division Director/Designee.
        • Category C – a Critical Event Tool Kit is required
        • Categories D and E – a Critical Event Tool Kit is not required unless requested by the Regional Director or Central Office.

The Critical Event Tool Kit consists of the following forms:

They may be found at: http://dssweb/cs/forms/

Critical Event Case Review

CD-164

 

Critical Event Case Review

Used to review the current Critical Event Case Review in a family home

CD-164 RF

 

Critical Event Case Review – Resource Families

Used to review the current Critical Event Case Review in a resource family home

Log of Prior History (CA/N, AC, FCS and IIS)

CD-164 A

 

Log of Prior History

Used to log all prior history including CA/N history and current open or closed AC, FCS or IIS cases

Review of Open and Prior CAN, FCS, IIS, AC Cases

 CD-164A_Narrative

Critical Event Case Review Narrative

 Used to review all open and prior relevant CAN, FCS, IIS and AC cases

 

 

 

 

Staff Interviews

CD-164 B

 

Critical Event Case Review – Staff Interview

Used to conduct interviews with staff connected to the current event, open case or prior cases (relevant to current critical event)

Observations from Critical Event Case Review

CD-164 C

 

Critical Event Case Review – Observations from Critical Event Case Review

The reviewer will summarize findings from all case records reviewed and interviews noting any practice concerns or practice trends. Observations may include issues related to law, policy, practice and training.

Critical Event Protocol Grid

Critical Event Protocol Grid

Summary Grid of Critical Event Process Protocols.

http://dss.mo.gov/cd/info/forms/pdf/cd168.pdf

Staff shall retain CS-23s in the administrative section of the file. The Critical Event Toolkits are not to be retained after the review has been submitted to Central Office.

9.1.4.2 Review of the Critical Event

A CD-164 is used to review of the critical event in a family home.

A CD-164 RF is used to review and document the details of a current critical event that took place in a resource home, which may include:    

        • Traditional Foster Care
        • Medical Foster Care
        • Licensed Relative/Kinship Care
        • Unlicensed Relative/Kinship Care
        • Foster Family Group Home
        • Residential Care
        • Respite Care
        • Elevated Needs Level A Care
        • Elevated Needs Level B Care
        • Adoptive Home

Log of Prior History (CA/N, AC, FCS and IIS)

The CD-164A_Narrative is used to review and document the details of each incident (CA/N, Referrals) or case (FCS, AC, IIS) listed in prior history on the CD-164 or CD-164 RF.

Review of Open Cases

CD-164 B- – Used to assist reviewers in interviewing staff in regard to the current critical event or relevant prior history.

Review of Prior Cases

The CD-164C- Used to document the reviewer’s observations, overall impressions and practice trends.

Critical Event Reviewer Required Level

        • Must not have supervisor responsibility for staff involved

Assignment of Reviews

          • Category A – Internal to the region of the critical event
          • Category B – Internal to the region of the critical event
          • Category C – External to the region of the critical event

The Division Director/Designee has the discretion to request a review by another region.

Critical Event Tool Kit Submission Timeframe

Complete within 30 business days unless essential information to complete a thorough review is not available. Submit the completed review to:

DSS.CD.CriticalEventReport@dss.mo.gov

Providing Case Records for Critical Event Reviews:

If requested by Central Office, the Circuit Manager will ensure a copy of the complete case record is forwarded to Central Office within 2 working days. (Case Records may include CA/N files, FCS files, AC files, resource home files, and any other related material from all locations).

Procedure for generating case records from FACES:

        1. Log into FACES
        2. Click on the Report Management Screen
        3. Click on Case Record
        4. Enter Call/Case Number

9.1.4.3 Critical Event Review Panels

        • A multi-disciplinary panel designed to bring insight from outside the Division
        • The goal is to look at agency systems and causal factors that may have impacted the event

Panel meetings are held for:

        • All Category B fatalities if CA/N is suspected
        • All Category C events if CA/N is suspected
        • Panel meetings are not held for categories A, B (non-fatalities), D and E, unless requested by the Division Director/Designee

How does a Critical Event Review Panel Operate?

The reviewer and staff from the incident county present an overview of the incident, comment on the findings, and provide case updates.

Who typically attends a Critical Event Review Panel meeting?

        • The Reviewer
        • Department of Social Services (DSS)
        • DSS Communications Office
        • Division of Youth Services (DYS)
        • Department of Mental Health (DMH)
        • Division of Legal Services (DLS)
        • State Technical Assistance Team (STAT)
        • Children’s Division Central Office, Regional Director, Field Support Manager, Circuit Manager, and the Division Director
        • Contracted Management CEO  (Attendees are preferably management or above.)

Trends and Action Steps

        • If a need arises from a Critical Event Review, the critical event will be discussed at Executive Team meeting. Critical events and trends will be discussed for law, policy, practice and training implications statewide.
        • Regional Directors will discuss findings and address appropriate plans of action within their regions.