Child protection agency blames its own errors in death of foster child

Child protection agency blames its own errors in death of foster child

By Marjie Lundstrom
mlundstrom@sacbee.com
Published: Thursday, Jun. 24, 2010 - 4:51 pm
Last Modified: Thursday, Jun. 24, 2010 - 6:41 pm
A searing internal review of Sacramento County's Child Protective Services has concluded that judgment errors and bias among agency workers were factors in the 2008 death of a 4 1/2-year-old foster child.

For the first time since Amariana Crenshaw died in January 2008, top agency officials acknowledged a series of CPS mistakes leading up to the girl's death - and how they plan to fix them.

"For all our good intentions, we were really not on track," said CPS Director Laura Coulthard, who became tearful at times discussing the case.

Key findings of the review
Amariana was not thriving in foster care. Her medical and mental health care were not adequately monitored.
Once in foster care, no one social worker had a sustained relationship with Amariana.
Case management was not anchored in Amariana�s well being.
Opportunities to fully inquire into Amariana�s well-being were missed because referrals were not investigated in accordance with guidelines and mandates.
Critical thinking errors were a common theme throughout Amariana�s Child Protective Services case.
CPS and partners lacked a cohesive response to Amariana�s death and the concerns uncovered in the aftermath.
Two years after Amariana�s death there continue to be unresolved questions about whether CPS can place a �hold� on a certified foster home. There is no apparent system in place to track concerns for these homes.
"As painful as it is, it's also just a great call to all of us that we can't work in silos, we've got to come together, we've got to be accountable."

Coulthard said the agency's internal review was in direct response to a Bee series published in January about Amariana's death while in foster care. The Bee's investigation raised numerous questions about the quality of care the little girl received in the crowded and tumultuous foster home of Tracy Dossman, who has since been decertified by the state.

CPS continued to place children in Dossman's care for more than two years after Amariana's body was pulled from a burning rental home owned by the foster provider. The case remains unsolved by Sacramento Police, who are investigating the child's death as a homicide after at least one Molotov cocktail ignited in the room where Amariana allegedly was sleeping.

The report and an accompanying letter released Thursday detail a "troubling combination of organizational, practice and communication issues" involving both front-line social workers and supervisors.



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