State child protective workers failed to follow policies and procedures in assessing the placement of a young girl who died as a result of abuse last winter, the Legislature’s watchdog agency concluded in a review released Thursday.

In the case of a second girl’s death, there were widely scattered reports of potential abuse or neglect, but information that might have led to a reassessment of the child’s situation and prompted officials to intervene was not shared at critical moments, according to the report by the Office of Program Evaluation and Government Accountability.

Marissa Kennedy, 10, of Stockton Springs died in February and Kendall Chick, 4, died in Wiscasset in December, both as a result of child abuse, law enforcement officials say. 

The agency released its nine-page report on the two abuse deaths at a meeting of the Legislature’s Government Oversight Committee, which commissioned the OPEGA investigation, but many details were lacking. The report didn’t specify which girl’s death it was referring to when it identified failures to follow policy at the Department of Health and Human Services and its Office of Child and Family Services.

OPEGA said it could not draw any firm conclusions outside of the “missed opportunities,” and its executive director, Beth Ashcroft, told the committee that investigators could not share more details because of pending criminal investigations, and federal and state laws that protect the confidentiality of child protective records.

“In one case, (Office of Child and Family Services) failed to follow policies and procedures in fully assessing the appropriateness of the placement and staying engaged with the child and family to ensure needed services and supports were provided,” the report said. “Poor job performance and inadequate supervision appear to have been factors.”

Ashcroft said there were “consequences” for state workers who failed to act properly, but she wouldn’t give more details.

Sen. Roger Katz, R-Augusta, co-chairman of the oversight panel, said it was “beyond frustrating” that so little information could be released. “We have miserably failed these kids,” Katz said. 

When there’s a “colossal failure” by state government, he asserted, public airing of the deficiencies in the system should trump privacy rights of people facing criminal charges.

“Agencies are being shielded from accountability because of the laws we have passed,” Katz said.

Katz and other lawmakers expressed frustration at the lack of detail in the report, saying the law now gives DHHS the authority to determine whether information about cases should be made public. Katz said he will introduce a bill in 2019 that would shift that authority to legislative committees.

Katz said it wasn’t OPEGA’s fault that the report lacks details, because the agency’s investigators were working with “two hands tied behind their back.”

“I don’t see one fact in here,” Katz said, referring to the vague references to the girls’ cases.

Gov. Paul LePage said in a statement that the concerns raised by OPEGA largely mirror those identified in an internal review by his administration, and he said DHHS already has made several reforms in how child welfare cases are handled.

“It is important, however, that we have as much information as possible from all parties involved in this system before making significant changes that may have to be revised after additional formal reviews are completed,” the governor said. “Our children deserve a system that works in their best interests.”

It’s not clear whether the administration recorded the results of its internal review in a document or report of any kind. 

LePage offered to share the administration’s recommendations with OPEGA and said more recommendations would be coming from DHHS and a standing committee within the agency, the Child Death and Serious Injury Review Panel.

The OPEGA report said DHHS has made some changes, including automatically referring a case for review after three reports of child abuse at one location, changing its intake system to make it less likely cases of abuse are overlooked, and “quality reviews” of casework practices to make sure caseworkers use effective techniques.

DHHS Commissioner Ricker Hamilton said in a statement that he welcomed external reviews of the agency’s activities to ensure that it does an effective job protecting children.

“I am eager for the time when the criminal investigations have concluded and additional information will be available for the public. I agree with the advice of the attorney general that nothing should jeopardize justice for these two victims,” Hamilton said. “Once that has been achieved, I am confident that the department’s internal review, combined with the findings of the reviews done by a number of different oversight entities, will provide substantive insight for reform and improvement. Evaluating the entire network of parties that make up our state’s child welfare system is critical to this process.”

OPEGA’s study focused primarily on the Office of Child and Family Services. Secondarily, the study looked at the actions of “mandated reporters,” such as police officers, teachers, health care workers and others who had a legal responsibility to report suspected abuse or neglect of the girls to DHHS.

The DHHS child protective system has been under an intense spotlight since the child abuse-related deaths of the two girls.

Kendall Chick died in December and Marissa Kennedy died in February. Sharon Carrillo, Marissa’s mother, and Julio Carrillo, her stepfather, have been charged with depraved indifference murder in the 10-year-old’s death. Shawna Gatto, Kendall’s caregiver, has been charged with depraved indifference murder in the 4-year-old’s death.

OPEGA was tasked with examining what shortcomings, if any, occurred in the state’s investigation into the two cases. It’s not clear how much Maine DHHS officials knew about the conditions the girls were living in. Marissa Kennedy was beaten daily for months prior to her death, according to police reports.

OPEGA investigators had to weigh what could be publicly released and what information had to be kept confidential because of the pending criminal cases and federal and state confidentiality laws.

“Consequently, this (study) includes only a high-level summary of OPEGA’s observations from the two cases, the role of DHHS and mandated reporters in protecting children, and potential areas for concern or improvement,” the study said.

It said the two cases “are nearly on opposite ends of the spectrum in terms of interactions with mandated reporters and other individuals that had opportunities to observe what was going on in their young lives.” The study also said the cases “differ substantially with regard to specific areas within the child protection system where there may have been missed opportunities to better protect them from harm.”

However, the study notes that both girls had suffered physical abuse in their homes over a period of time, and that when outsiders observed injuries that might indicate abuse, parents or other adults in the home explained them as injuries the children caused themselves.

“Observers appear to have found these explanations reasonable at those times given what they knew of the child and family,” the report said.

OPEGA plans to release a more wide-ranging report on the overall effectiveness of the state’s Child Protective Services program later this year.

Since the late 2000s, the caseloads for DHHS child protective workers have increased by about 50 percent, according to a federal report. Reports of suspected child abuse and neglect cases jumped 31 percent, from 6,313 cases in 2008 to 8,279 cases in 2016, the latest year statistics were available, according to state statistics.

Sen. Bill Diamond, D-Windham, said he realizes that OPEGA is constrained in what it can release, but he would like to see some action taken soon to help make sure children are protected.

“It’s driving me crazy to sit here knowing these situations continue to go on,” Diamond said.

Lawmakers said they would be interested in learning how agencies communicate with each other about suspected child abuse cases, and what happens when schools and police, for instance, notify DHHS about possible abuse. Ashcroft said school and police responses to possible abuse vary widely. She said school districts have differing policies for handling truancy, which could be an indicator that a child is being abused at home, and some police departments look for patterns if there are multiple service calls to one location for suspected domestic violence or child abuse.

Sen. Geoffrey Gratwick, D-Bangor, said when OPEGA does its full evaluation, the agency should look at systemwide issues and not be intent on blaming individual employees.

“Are we blaming the platoon grunt rather than the general?” Gratwick asked.

KEY FINDINGS

• In one case, the state Office of Child and Family Services “failed to follow policies and procedures in assessing the appropriateness of placement and staying engaged with the child and family to ensure needed services and supports were provided. Poor job performance and inadequate supervision appear to have been factors.”

 • In one case, there were several points “where greater information sharing among several parties might have prompted further action or reassessment of the risk level for the family. Periodic reassessments of the whole body of information known about the family might also have prompted different approaches to addressing the risks identified.”

 • “We believe we have gleaned a decent understanding of what occurred, and what did not, with regard to roles various entities played in these children’s cases. We are, however, still lacking a full understanding of the context from their various perspectives, particularly around what factors impacted their decisions and actions.”

Kendall Chick, 4, of Wiscasset and Marissa Kennedy, 10, of Stockton Springs. Police say both children died after being beaten for months. (Photos courtesy of Maine Attorney General’s Office)