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Press release from Oregon DHS

The Oregon Children, Adults and Families (CAF) Division Critical Incident Review Team (CIRT)
today released the first public review of the agency's actions in connection to a child who was killed in
Lane County last month. The parents of the child, Jeanette Maples have been arrested and charged with
aggravated murder.

The CIRT was launched within 24 hours of the child's death by Department of Human Services
Director Dr. Bruce Goldberg and this first report (more to follow) was completed within 30 days then
went through a review process with the Lane County District Attorney and Oregon Attorney General's
office to assure that no information in the public report would jeopardize the criminal prosecution of
the parents.
"Any time a child dies or is seriously injured at the hands of a family member, our communities suffer.
The pain is felt even more acutely when child welfare had knowledge of and contact with a child and
family before the tragedy occurred," said Erinn Kelley-Siel, Director of CAF. "As we join Oregonians
in grieving the death of Jeanette Maples, we also take seriously our responsibility to take action to
ensure that future tragedies are avoided."
Under the process of the CIRT, the case files are thoroughly reviewed and additional information, such
as staff interviews or audits of additional files, is gathered at the CIRT team's request. The CIRT review
looks at CAF policies, practices and staff training in each case to determine whether issues with any or
all three could have help avoid a critical incident.
"Oregon's child welfare workers receive more than 67,000 calls of child abuse every year and the
stakes for our responses are very high. When a child is hurt, we must move quickly to ensure that any
flaws in system are rooted out and improved immediately," said Dr. Goldberg. "We also must report our
improvements to the public so they know that when they call to report abuse and ask for help to protect
a child, we do our jobs well."
The CIRT report found that the department's responses to three of the four reports DHS received about
Jeanette Maples did not follow agency policy: two of those reports should have been referred to Child
Protective Services staff for assessment -- and one was referred for assessment, but not within the
appropriate timeline for referral. The first two reports were received in 2006, the third in 2007 and a
fourth in 2009. In responding to these reports, past history of abuse and neglect of Maples' family was
not adequately considered, and the child's ability to disclose abuse was not accurately assessed when
the reports were received. At issue in this CIRT review is whether the issues of the age of the child and
the degree to which she was isolated from the community were appropriately considered in the
screening and assessment processes.
In order to help the Department's improvement efforts, CAF director Erinn Kelley-Siel is calling in the
National Resource Center on Child Protective Services to analyze screening practices and make
recommendations on how to improve policies and practices. Outside medical experts will also be
consulting with the CIRT team to make recommendations specifically about how the Department
evaluates the safety of a child when that child is more isolated.
In addition, the CIRT team performed an extensive internal review to verify that the four reports
received about J.M. were the only reports the Department had record of. To ensure that no other calls
were received than those that were recorded, CAF is consulting with outside experts to deepen the
investigation and will report back in its next report on what is found.
The CIRT report released today is the first of several reports to be released as part of the review of the
case. It is DHS policy to make public the status of the investigation every 30-days until it is completed,
rather than wait until the final report is done or the criminal investigation of those who have committed
the abuse is final.
The CIRT team looked both at agency actions and what is known about the abuse Jeanette Maples
suffered. Because of the sensitive nature of the ongoing criminal investigation, at the request of the
Lane County District Attorney, and the recommendation of Oregon Attorney General, the actions of
Jeanette's abusers have been redacted from this report until the resolution of the criminal case.
"I have advised the Department of Human Services to redact certain alleged factual information in
order to protect the ongoing criminal investigation, prevent possible tainting of witness recollections
and maintain the integrity of the criminal justice process," said Oregon Attorney General John Kroger
in a statement this week.
No agency actions, however, have been redacted from the public review - and once the criminal case
has been completed, DHS will release the full, unredacted report.
In addition to the CIRT review, CAF is conducting concurrent review of personnel actions involving all
employees and supervisors connected to the case. To the degree that the agency finds that the
performance of an individual in this case did not follow policy or did not meet the Department's
expectations regarding the standard of care in child welfare practice, appropriate disciplinary action
will be taken.
"Every day, child welfare staff across Oregon work tirelessly in service to children and their families,"
said Dr. Goldberg. "Part of that work is a sustained commitment to improvement, and I am confident
that as a result of this case our system will be stronger, that staff practice will improve, and that our
communities will be even more committed to working with us to protect every child - those we see
every day and, perhaps even more importantly, those we sometimes do not see."