CHILD WELFARE MANUAL

(Effective:  01/13/2025)

 

8.9.1.1 Critical Event and Critical Notification Reporting

Critical events are child fatalities, near fatalities, and serious bodily injuries.  Staff are to report all critical events immediately to their supervisor, Circuit Manager, Field Support Manager, and the Regional Director, and the litigation attorney(s) if assigned to the circuit.  All child fatalities, near fatalities, and serious bodily injuries must also be reported utilizing the Critical Event Notification (CS-23) form. 

There are other instances that may not rise to the level of a critical event but should also be reported utilizing the Critical Event Notification (CS-23) form.  These are:

• Suspected abuse or neglect of a child that occurred while they are in the legal custody of the Children’s Division.
• Incidents that involve the arrest of a resource parent.

When the county office or contracted case management agency (FCCM) becomes aware of a critical event or need to make a critical notification, the supervisor or above will ensure the following occurs:

1. Complete the CS-23 within one (1) business day.
2. Send the CS-23 to CD.CriticalEventReport@dss.mo.gov and carbon copy (cc) the Circuit Manager, Field Support Manager, and Regional Director, and the litigation attorney(s) if assigned to the circuit.
3. If the county office and the Out of Home Investigation (OHI) unit are both involved, only one CS-23 needs to be sent. FCCM agencies are responsible for sending the CS-23 for critical events involving contracted cases.  The supervisors involved in the critical event should collaborate to determine the best staff member to complete/submit the CS-23.  When determining who the best person would be to complete the CS-23, be mindful of the impacts of secondary trauma. 
4. Upload the CS-23 to OnBase in the associated CA/N Report for the critical event. If there is no applicable CA/N Report, the CS-23 should be uploaded to the open case management function in FACES.
5. Provide important updates via the CS-23 as the critical event unfolds. Examples include but are not limited to: change in the child’s medical condition, arrest of an involved individual, change in circumstances that require a new safety assessment or reassessment, safety planning, or change in placement.

 

8.9.1.2 Children’s Division Review

Trauma Informed Approach

All personnel that respond to and review a critical event should be mindful of the impact these events may have themselves and others.  Supervisors, Circuit Managers, Field Support Managers, Regional Directors, CANHU management, FCCM management, and central office staff have a responsibility to support staff who have experienced a critical event on their caseload, are investigating a critical event, are supporting families and communities who have experienced a critical event or are otherwise at risk of experiencing secondary trauma.  All staff should be aware of the support resources that are available to themselves and other staff members so they can utilize them, assist in making referrals, and promote awareness of their availability.  These include, but are not limited to:

1. Secondary Trauma Consultation: This service is available for staff involved in a traumatic event or series of events.  It is a one-time individual or group consultation.  Requests for a consultation must be made by the Circuit Manager or their designee.  Referral information can be found at https://dssintranet.mo.gov/dss-childrens-division/well-being-behavioral-health-trauma/
2. Strive Employee Life and Family (SELF): The SELF program, offered through ComPsych, provides support, resources, and information to help state employees successfully deal with all of life’s challenges.  Employees eligible for MCHCP medical coverage and members of their household can access the SELF program 24 hours a day, every day of the year, and may receive up to ten free counseling sessions, per person, per problem, per calendar year.  SELF is confidential and available at no cost to the employee and members of their household.  Visit http://www.mchcp.org/stateMembers/self.asp for more information and instructions on how to access SELF services.

When responding to staff that are directly involved in a critical event, all personnel should be prepared to have difficult conversations.  Staff should balance an assessment of whether there is a need for Human Resources involvement, or other corrective action, with a trauma informed approach.  Some tips for having difficult conversations with staff after a critical event can include:

• Explain the review process and how information is used.  The Division reviews critical events not to assign blame, but to learn and improve as an agency.
• Listen far more than speaking, but still ask difficult questions.
• Respond to the individual where they are, not with a list of questions you need to have answered.
• Ask open ended questions and avoid leading or “why” questions.
• Be mindful of your own emotional state and tone.
• Be as transparent as possible.  Be upfront that these can be difficult conversations, even for you.
• Be prepared for staff to express a variety of emotions and learn to be comfortable with uncomfortable moments.  Do not try to stop a staff member from expressing their emotions.  Actively listen and avoid attempting to offer solutions.

*Adapted from University of Kentucky Center for Innovation in Population Health Safe Systems Debriefing training.

Statutory Requirement

Statute: Pursuant to Section 210.135 RSMo, “In a case involving the death or serious injury of a child after a report has been made under sections 210.109 to 210.165, the division shall conduct a Preliminary Evaluation in order to determine whether a review of the ability of the circuit manager or case worker or workers to perform their duties competently is necessary. The Preliminary Evaluation shall examine:

1. The hotline worker or workers who took any reports related to such case;
2. The division case worker or workers assigned to the investigation of such report; and
3. The circuit manager assigned to the county where the report was investigated.”

Any Preliminary Evaluation shall be completed no later than three days after the child’s death.  If the division determines a Review and Assessment is necessary, it shall be completed no later than three days after the child’s death.”

Purpose: The purpose of a Preliminary Evaluation is to assess employee performance and ability to perform their duties following a critical event and to provide any support necessary to staff affected by the event.  The purpose of a Review and Assessment is to further explore and resolve active issues related to the critical event as they relate to child safety, practice, policy, training, service provision, as well as personnel and conduct concerns that were identified.

Critical Event Preliminary Evaluation

CANHU Review

Pursuant to statute, CANHU leadership will complete a Preliminary Evaluation within three (3) calendar days of the notification of a screened in critical event as it relates to prior reports made to CANHU.  The CANHU Fatality Review Team will ensure consistent and accurate screening of all fatalities that are reported each day.  At least two team members of the supervisory team are assigned to review each case.  They review the calls to determine if sufficient information was provided by the reporter to appropriately classify the information.  Information is gathered, documented, and reviewed to determine trends in critical events and accuracy in call classification.  If it is determined that the call does not contain sufficient detail, attempts are made to contact the reporter for additional information.  If the call was incorrectly coded or classified, the team member will make appropriate changes if within timeframes for being able to re-submit the report in FACES.  The call number and concern is forwarded to the team member’s supervisor for further review and action as appropriate.

Regional Review

Pursuant to statute, the Regional Director or FCCM Manager, or designee, will complete a Preliminary Evaluation following notification of a screened in critical event as it relates to staff’s involvement with the family.

The CS-23 is used to notify the Regional Director and/or their designee of the need to complete a Preliminary Evaluation.  The Critical Event Central Office Program Specialist will also notify the Regional Director or FCCM Manager and/or their designee when a Preliminary Evaluation is needed.  The regional Preliminary Evaluation shall be completed by the Regional Director or FCCM Manager or their designee within three (3) calendar days of the critical event when one of the following is applicable:

• • A fatality, near fatality, or serious bodily injury involving a child in the legal custody of the Division (Legal Status 1 children) at the time of, not as the result of, the critical event. This includes Non-CA/N Child Fatality “F” Referrals.
  • A fatality, near fatality, or serious bodily injury suspected to be due to CA/N involving a child with active agency involvement, such as an existing open Family Centered Services case; Intensive In-Home Services case; or a child in an open Newborn Crisis Assessment, Investigation, Family Assessment, or a Juvenile Assessment.
  • A fatality, near fatality, or serious bodily injury of a child with recent Children’s Division involvement with the family of concern within the past three (3) months. Three (3) months means from the time of the case closure or conclusion of the Division’s involvement with the family.

NOTE: If the Preliminary Evaluation indicates that a further Review and Assessment is necessary, that too must be completed within three (3) calendar days of the critical event if it involved a child death. 

To ensure compliance that a thorough Preliminary Evaluation is completed, the Regional Director or FCCM Manager or their designee will complete the Critical Event Preliminary Evaluation (CD-325) and e-mail it to the Critical Event Central Office Program Specialist.  

To assist in identifying any concerns in need of further exploration during the Preliminary Evaluation and to brief executive leadership and relevant program managers, the Critical Event Central Office Program Specialist will complete a cursory record review.

If the Preliminary Evaluation identifies or confirms personnel or conduct issues, the Regional Director, or their designee, will notify the Deputy Director of Field Operations and consult with human resources.  When the FCCM Manager identifies or confirms personnel or conduct issues, they will consult with their agency’s human resources officer.

Critical Event Review and Assessment

The Regional Director or FCCM Manager, or their designee, will do a more thorough Review and Assessment if the Preliminary Evaluation identifies any concerns regarding personnel or conduct issues as well as any practice, policy, or training issues related to the critical event.

If the critical event was a child death, pursuant to Section 210.135 RSMo., this Review and Assessment shall be completed no later than three (3) calendar days after the child’s death.  However, a Review and Assessment can be completed at any time if information is revealed that would warrant one. 

If the Review and Assessment identifies or confirms personnel or conduct issues, the Regional Director, or their designee, will notify the Deputy Director of Field Operations and consult with human resources.  When the FCCM manager identifies or confirms personnel or conduct issues, they will consult with their agency’s human resources officer.

If the Review and Assessment identifies or confirms practice, policy, training, or service provision issues related to the critical event, the Regional Director or FCCM Manager will attempt to resolve those concerns.  If any of these concerns remain unresolved or require a larger system response, the Regional Director or FCCM Manager will request a Critical Event Staffing as discussed below.

The Regional Director or FCCM Manager, or their designee, may choose to use the Critical Event Review and Assessment Guide (CD-213).  Once the Review and Assessment is completed, documentation of the Review and Assessment should be e-mailed to the Critical Event Central Office Program Specialist.

Critical Event Staffing

Any time during a preliminary review or a Review and Assessment, a Critical Event Staffing may be requested by any personnel that receives notification of critical events via the CS-23 email distribution list to explore and resolve any immediate and/or active practice, policy, training, or service provision issues related to the critical event.  This staffing may also be requested by the State Technical Assistance Team (STAT) when their critical event review process reveals active personnel or child safety concerns.

Requests for a Critical Event Staffing should be made by contacting the Critical Event Central Office Program Specialist, who will then schedule the staffing to include the appropriate leadership, program staff, field staff, contracted staff, STAT, DSS Director’s Office staff, and Division of Legal Services (DLS) staff. 

In addition to addressing any practice, policy, training, or service provision issues a Critical Event Staffing may be convened for the following reasons:

• Safety Assurance: The safety and well-being of all involved children will be prioritized, and any active child safety concerns must be addressed immediately.  If safety concerns cannot be addressed directly with field staff, a staffing may be utilized to raise concerns related to child safety and to ensure that the most appropriate protective measures are in place.
• Information Sharing: To create an open forum for the exchange of relevant information among all parties involved. This will promote transparency and collaboration to address immediate and/or active concerns revealed through the Division’s review of critical events.
• Support: To provide technical assistance regarding the critical event to address immediate and/or active investigative issues. Also, to ensure that local staff have access to the necessary resources and support to effectively manage the investigation.
• Staff Well-Being: To offer support to staff members affected by the critical event, ensuring their well-being and ability to perform their duties effectively.

Personnel related issues may inevitably be identified and/or discussed during Critical Event Staffing.  However, as much as possible these issues should be resolved between the regions, the deputy directors, and human resources.  If personnel related issues and/or practice, policy, training, or service provision issues are identified, the Regional Director may choose to handle them separately or they may choose to request a critical event review staffing to include human resources to discuss all the concerns in one forum. 

 

8.9.1.3 Media Attention that Does Not Meet Critical Event Criteria

Media only notifications are not to be reported through the critical event form (CS-23) UNLESS there is media attention regarding the critical event. If there is media attention, or if there’s a possibility for media attention, that is NOT associated with an incident that meets the criteria for a critical event staff will send notification to Media.Alerts@dss.mo.gov .   The notification must include the following information: 

• Case number;
• County;
• Persons involved;
• What type of media coverage; and
• Information around media involvement.

 

Forms

Critical Event Notification (CS-23)

Critical Event Preliminary Evaluation (CD-325)

Critical Event Review and Assessment Guide (CD-213)

 

Resources

Secondary Trauma Consultation

Strive Employee Life and Family (SELF)

Who Do You Trust with Your Child brochure

 

Related Policies, Memos, and Practice Alerts

PA23-IA-01 Firearm Responsibility

PA21-IA-08 Accidental Manner of Death Investigative Conclusions

 

Related Laws and Regulations

Section 210.135 RSMo

 

Definitions

Near Fatality

Pursuant to 13 CSR 35-35.100, near fatality is defined as any physical injury or illness of a child caused by suspected or substantiated child abuse or neglect that, as certified by a physician, places the child in serious or critical condition.

Serious Bodily Injury

Pursuant to 13 CSR 35-35.100 serious bodily injury is defined as bodily injury which involves substantial risk of death, extreme physical pain, protracted and obvious disfigurement, or protracted loss or impairment of the function of a bodily member, organ, or mental faculty.