March 21, 2006

Poutre Panel Recommends Reforms in Child Welfare System

The three-member Governor’s Special Panel for the Review of the Haleigh Poutre case today presented their findings and recommendations to Governor Mitt Romney. Among the recommendations for children in state custody are new levels of protection whenever there are physician decisions to withhold life sustaining treatment.

The report notes that this case represents a systemic failure in the child welfare, health care and mental health systems to provide the safety net that children deserve – not just at the Department of Social Services (DSS), but at all levels, public and private. Prior to the 12-year-old girl’s hospitalization, as DSS became increasingly alarmed for Haleigh’s safety, it was faced with significant opposition on the part of her health care providers to a plan that would have put her in a residential treatment program.

Romney thanked the review panel for its service and said he will work to implement the recommendations.

“As the Haleigh Poutre case demonstrates, errors in human judgment occur. What is unusual is how many people involved in Haleigh’s care – medical professionals, case workers and administrators from many disciplines – made errors. I welcome new systems and processes that will identify and guard against circumstances where human error may have severe consequences,” said Romney.

The Panel concluded after a thorough review of thousands of documents and interviews with key professionals involved with Haleigh’s case, and with local and national experts, that what happened to Haleigh should not have happened, and did not have to happen. The Panel found that this case represents a systemic failure on the part of the DSS, the Department of Mental Health (DMH) and the private sector health care community. The Panel has made concrete recommendations that the child welfare agencies and the health care community must embrace to protect and better care for high-risk children.

The Panel made its recommendations after consulting nationally prominent experts in pediatric bioethics, and experts in pediatric rehabilitation medicine and many others.

“Child protective services does not exist in a vacuum,” said Christine C. Ferguson, former Massachusetts Department of Public Health Commissioner. “The system relies on both DSS, to investigate and respond to reports of abuse and neglect, and on the medical and mental health community to identify and report signs of abuse and neglect. Haleigh’s case highlights a frightening confluence of a health care system ignorant of abuse and a child protective system ignorant of medicine.”

Recommendations:

Creation of a new process for DSS in the event a physician requests the withholding or withdrawal of life sustaining treatment:

• DSS should require more detailed information to explicitly elicit the basis and degree of certainty of the attending physician for his or her recommendations about life sustaining treatment;
• DSS must obtain a second opinion from an additional physician from outside the institution where the patient is being treated;
• DSS must obtain an opinion from the ethics committee of the hospital in which the child is being treated;
• DSS must provide all of this information to the court, the guardian ad litem, the child’s attorney to ensure that the court has access to comprehensive information prior to making its decision.

Making available to DSS critical medical, psychiatric, and child abuse expertise:

• DSS should place on retainer panels of medical professionals in the areas of child abuse and psychiatry, including specific expertise in post-traumatic stress disorder;
• major pediatric hospitals in the state must have child abuse teams established on staff, and the Commonwealth must find a way to make it financially feasible for the hospitals to create and maintain those teams.

Making it a DSS priority to gain a comprehensive profile of the child:

• DSS should establish a new system to ensure that workers in one easy step get vital information in the possession of DSS, from both inside and outside the Department, on a child who is the subject of an abuse or neglect report;
• DSS should not screen out reports solely because of ongoing voluntary services or parental compliance and should make this policy clear in their internal policies and procedures;
• DSS should immediately adopt a risk assessment tool to help identify high risk cases;
• The Legislature should consider extending the ten day period for investigations of reports of abuse or neglect to 20 days, to ensure that the current ten day period during which DSS can obtain access to medical records is extended to 20 days;
• DSS should establish an appropriate escalation process that can be triggered by additional reports on a high risk child, repeated reports on any child, or the request of any DSS staff involved with the child who has a “bad feeling” about that child’s situation;
• DSS should conduct a thorough analysis of the statistics for each region to determine if additional resources are needed in the western part of the state.

Increasing access to quality mental health services in both private and public sectors:

• There must be a multi-year, concerted effort on the part of state government to improve the quality of mental health services for children. DSS, in consultation with the Department of Public Health, should establish quality indicators and expectations that its private providers must meet. In addition, DSS should require each of its private providers to demonstrate a process for creating a culture of continuous quality improvement;
• Access to DMH services for children with serious and persistent mental health issues who are involved with DSS or who have completed a Collaborative Assessment Program review should be expedited and automatic.

Embracing strategies for improving error management, borrowing from health care and other high risk industries:

• The Governor should establish a panel to partner with key pediatric hospitals in the state to assess which approaches to the reduction of medical errors are applicable to the child welfare setting. The panel should work with the Department of Public Health to garner expertise in this area;

“We did not find carelessness or a failure to make best efforts to meet Haleigh’s needs,” said Ferguson. “Instead, we found health, mental health, child welfare systems that, for a variety of reasons, were unable to penetrate the proffered explanation for Haleigh’s injuries, unable to ask the questions that could have protected her and were ill-equipped to provide her with the care and assistance any of us would want for our children.”

Romney appointed the panel on February 3, 2006 and named as chairman Christine C. Ferguson, member of the board on Children Youth and Families for the Institute of Medicine National Academics and former Massachusetts Department of Public Health Commissioner. She also served as the Director of the Rhode Island Department of Human Services and as counsel and deputy chief of staff to the late U.S. Senator John Chafee (R-RI). The other members are Dr. Mary Anne Badaracco, Chief of the Department of Psychiatry at Beth Israel Deaconess Medical Center and the President of the Massachusetts Psychiatric Society and also the Bullard Associate Professor of Psychiatry at Harvard Medical School and Dr. Jeffrey Burns, Chief of the Division of Critical Care Medicine and Co-Chair of the Ethics Committee at Children’s Hospital Boston and an Associate Professor of Anesthesia (Pediatrics) at Harvard Medical School. Board certified in Pediatrics and Pediatric Critical Care Medicine, Dr. Burns is also Director of the Medical/Surgical Intensive Care Unit at Children’s and a member of the American Academy of Pediatrics Committee on Bioethics.

The panel was charged with the review of Haleigh Poutre’s case history to determine the timeliness and appropriateness of services that she received, as well as the process surrounding the court’s decision to remove her life sustaining treatment. The Westfield girl was hospitalized in Springfield in a comatose state on Sept. 11, 2005, but has since been transferred to a rehabilitation facility in Boston where she has shown signs of improvement.