Conn. Child Advocate Finds Agency, Judicial Errors In Death

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Connecticut judicial branch staff, the state's child protection agency and others did not follow proper procedures in the months prior to the death of a toddler who was found buried in a Stamford park in January, a fatality report from the Office of the Child Advocate in Connecticut found.

The Office of the Child Advocate released a 59-page report on Tuesday reviewing the events leading up to 2-year-old Liam Rivera's death, finding that the judicial branch made missteps in its monitoring of the toddler's father after he was released from prison and that the Department of Children and Families didn't follow policies to ensure the child's safety.

Rivera's body was found buried in Cummings Park on Jan. 2. His death was ruled a homicide and while both of his parents, mother Iris Rivera-Santos and father Edgar Ismalej-Gomez, are facing criminal charges, neither has been charged in connection with the toddler's homicide.

Child Advocate Sarah Eagan, who is also an attorney, reviewed records from state agencies, the court and the child's medical providers and found that DCF workers failed to follow several policies, such as not conducting unannounced visits once Rivera was back in his mother's custody or routinely reviewing his medical records.

Eagan also found that the judicial branch's adult probation services failed to verify Ismalej-Gomez's address. An internal review found that Ismalej-Gomez's case needed a domestic violence screening, which would have resulted in a "high supervision" level and more contacts with the judicial branch, the report said.

OCA recommended that the judicial branch's court support services division work to strengthen policies that impact children, such as enhanced home visits, address verification and the explicit requirement for administration of domestic/family violence screening.

A summary of the report also stated that the Superior Court for Juvenile Matters was not given complete and reliable information in Rivera's case and that state law should be amended to require "judicial inquiry regarding the child's right to: appropriate medical and developmental services; a safe and/or licensed placement; be seen by their lawyer and DCF worker; and ensure DCF and the child's lawyer/[guardian ad litem] has obtained and provided information about the child's medical/service/support needs."

"The judicial branch worked closely with the Office of the Child Advocate with respect to the branch's involvement in this investigation," Rhonda Stearley-Hebert, judicial branch spokesperson, said in a written statement. "The branch has addressed the policy violations identified in this report to ensure similar violations will not occur in future cases. Although the branch's policies and procedures were found to be sound in the areas reviewed, we will continue to review and discuss whether additional modifications should be implemented."

DCF had previously investigated Rivera-Santos on allegations of child abuse or neglect from 2017 to 2020, but those cases were closed, according to the report. In January 2021, Rivera's parents took him to the hospital after claiming he fell off the bed. A medical exam revealed in addition to his new broken arm, Rivera had heavy bruising on his torso and a two-week-old healing fracture of his left leg.

Rivera and his sibling were placed in foster care after the incident and both were appointed an attorney to represent them in juvenile court and later a guardian ad litem, the report said. Rivera was diagnosed with failure to thrive as he was significantly underweight for his age and had developmental delays.

After entering foster care, Rivera lost his failure to thrive diagnosis and was showing positive developmental gains, according to the report.

Ismalej-Gomez was arrested for risk of injury and assault due to his admission that he may have hurt his son's arm while trying to keep him from falling off the bed in August 2021. An order of protection was entered against Ismalej-Gomez with Rivera as the protected party.

His parents were living in separate households and DCF began working on a reunification plan with his mother. In October 2021, DCF received a call alleging Rivera-Santos was using drugs but agency records didn't show any follow-up and didn't inform the court, children's attorney or the guardian ad litem of the call.

DCF informally reunified Rivera's sibling with their mother, without court approval, and in early December, DCF filed motions asking the court to give his mother custody of his sibling again and approve a goal of restoring custody of Liam.

The court reunited the mother and sibling and a week later DCF informally reunified Rivera "under DCF commitment" without approval from the court. DCF did not provide notice to the court and no assigned staff member visited Liam for three weeks.

In January 2022, his mother called the police and said he was kidnapped by a paternal relative. Rivera was found with his father, who was arrested and detained until April. His mother later recanted and said she gave Rivera to his father for a visit.

DCF did not inform the court or Rivera's attorney and guardian of the January violation of the protective order or DCF's concerns. The agency delayed filing a legal motion to restore the mother's custody.

The report also stated Liam's attorney and guardian did not request any DCF records during much of the case and did not visit him during this time. They only visited him once at home before his death.

Ismalej-Gomez was released in April and probation staff failed to verify his address or conduct screening. He stopped contacting probation in June, the same month DCF filed to restore custody. The motion included information about the protective order violation but didn't inform the court of the mother's false complaint charges or DCF's investigation.

DCF "erroneously" told the court the toddler was in the 50th percentile in weight when he was actually losing weight since leaving foster care, inaccurately listed the injuries that led to his placement in foster care and incorrectly stated that Ismalej-Gomez's previous arrest incorporated all of Rivera's injuries. Custody was restored and the court ordered nine months of protective supervision.

From July 2022 until Rivera's death in December, DCF staff visited the home twice a month and all visits were announced. They also didn't use an interpreter although English wasn't his parents' first language. Staff didn't contact Rivera's doctor, a violation of federal law and DCF policy, the report said.

In September, staff noticed Rivera looked thin again and was unable to verbalize, so they made a referral for Rivera to be assessed. The next month, Rivera was rediagnosed with failure to thrive and the doctor reported the concerns to DCF, whose record did not reference the call until a month after Rivera's death. In December, DCF noticed Rivera looked thin again and made a referral but did not contact his doctor.

"Liam's lawyer and GAL did not visit with him during the period of protective supervision and did not obtain any DCF/provider records regarding his care during this time, thereby not meeting the standards established by federal law, state law, and the Public Defender's Office for representing children," Eagan said in the summary.

The report recommended that the Office of the Chief Public Defender strengthen the legal representation of children by exploring quality assurance measures and ensuring attorneys can bill for activities required by contractual expectations and federal law, such as reviewing records and speaking with service providers. The performance guidelines for guardians should also be strengthened, the report said.

Chief Public Defender TaShun Bowden-Lewis declined to comment on Thursday.

OCA's report also said the Legislature should create a working group to review the delivery of legal services to children in child protection proceedings.

The OCA made the most recommendations to DCF, including strengthening its quality improvement framework, ensuring external oversight of the agency and reliable notification to attorneys and guardians for meetings and new allegations of abuse or neglect.

DCF Commissioner Vannessa Dorantes said in a statement that Rivera's siblings are no longer in the home and are being well cared for.

"In the aftermath of this fatality, consistent with our standard practice, DCF initiated its Continuous Quality Improvement process to evaluate our work and identify opportunities for system enhancements," Dorantes said. "This review includes our knowledge about the family, supports provided, casework decisions, adherence to policy and best-case practices, as well as communication with multiple community stakeholders (who were also actively involved with this family)."

Dorantes noted that the majority of the interactions with the family in this case happened during the COVID-19 pandemic, which impacted normal operations and procedures.

As a result of the review, Dorantes said DCF has continued to enhance its ongoing work in working with undocumented families; identifying and assessing failure to thrive, refining trial home visits for committed children; partnering with foster parents; reinforcing safety practice and in-person family contact post-pandemic; partnering with stakeholders; and developing post-consent decree practice workgroups.

"The circumstances surrounding Liam's death remain under active investigation by law enforcement," Dorantes said. "The department cannot, and will not, release any information to the public that could in any way jeopardize a full and fair investigation into the circumstances of this untimely death."

Eagan, Connecticut's child advocate, did not immediately respond to a request for comment on Thursday.

--Editing by Robert Rudinger.

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