Is there any mention of child drug ingestion or overdose?

The fatality report states S.N.'s cause of death was "combined toxic effects of fentanyl and methamphetamine." This directly establishes that the child died from drug toxicity, constituting an overdose or ingestion of drugs.

Is there any mention of inappropriate supervision (e.g., child wandered off and drowned)?

The child died from combined toxic effects of fentanyl and methamphetamine. Law enforcement found "drug paraphernalia (methamphetamine pipe), fentanyl pills and fentanyl powder" in the home. The Committee "pondered how safe S.N. was in home with [redacted] parents due to multiple issues including the lack of cooperation by the substance use treatment provider and therefore an inability to verify substantive behavioral changes by the parents regarding substance use, the parent's lack of cooperation with the contacted in-home service provider, S.N.'s father's continued substance use, and the mother's untreated mental health needs." Having lethal substances accessible to a six-week-old infant implies inappropriate supervision.

Is there any mention of prenatal substance exposure (including fetal alcohol syndrome or neonatal abstinence syndrome)?

The fatality report states: "S.N.'s umbilical cord testing showed that at birth S.N. was positive for fentanyl, gabapentin, methadone, and cannabinoids." Additionally, the hospital reported that "the mother tested positive for methadone and cannabis" at the time of S.N.'s birth, and the report notes "prenatal care starting in the fifth month of pregnancy and the care was inconsistent."

Is there any mention of an unsafe sleeping environment?

The fatality report explicitly identifies an unsafe sleeping environment as a contributory condition of death: "contributory condition of unsafe sleep environment (co-sleeping with an adult and placed on [redacted] stomach)." The after-hours caseworker had also "observed and discussed safe sleep and Period of Purple Crying®" during an earlier home visit.

Was a biological father involved in the death?

The fatality report establishes that S.N.'s biological father had active substance use issues (positive oral swab for methamphetamine and fentanyl on October 20, 2023, just before S.N. came home from the hospital). Law enforcement found fentanyl pills, fentanyl powder, and a methamphetamine pipe in the home. S.N. died from combined toxic effects of fentanyl and methamphetamine. The father was the child's caregiver and his ongoing substance use and the presence of his drugs in the home are implicated in creating the conditions that led to S.N.'s death.

Was a biological mother involved in the death?

The biological mother was S.N.'s primary caregiver. The coroner's report identified co-sleeping with an adult as a contributory condition. The mother had a history of substance use, and S.N.'s umbilical cord tested positive for fentanyl and other substances. The Committee discussed the mother's untreated mental health needs and the home environment she maintained for S.N. She was present in the home when S.N. died and reported finding the child "discolored and not breathing."

Is there a history of child protection reports prior to death (for this child or siblings)?

The fatality report states: "Prior to S.N.'s death, DCYF received 12 intakes regarding [redacted] family. Of the 12 intakes, six screened in for CPS investigations." The report details a long history of intakes dating back to 2013, including intakes about siblings and two specifically pertaining to S.N.

Is domestic violence by the parent/caregiver referenced?

The fatality report states the Committee discussed "assessing for domestic violence and the possible impact that violence, even historical violence, may have had on all of the family members." Furthermore, the Committee member with substance use expertise noted that "it is the responsibility of a treatment provider to assess for needs related to mental health and DV. Which in this case both mental health and DV was identified as a significant need for S.N.'s mother." This references domestic violence as identified in the case, though specific incidents are not detailed.

Is the mental health of the parent/caregiver referenced?

The fatality report states: "S.N.'s mother had a significant trauma as a child and adult." It also identifies "the mother's untreated mental health needs" as a concern, and notes that "both mental health and DV was identified as a significant need for S.N.'s mother." The Committee also noted the mother had been "seeing a mental health clinician" during an earlier investigation period.

Is a history of arrests or criminal charges for the parent/caregiver referenced?

The fatality report documents prior criminal history for the mother: "In August 2014 DCYF became involved when the mother was arrested for driving under the influence." Additionally, the report mentions the mother had "outstanding criminal warrants" and the father had "pending criminal matters related to driving without proper interlocking device." These all predate S.N.'s death and are separate from the death incident.

Is substance use by the parent/caregiver referenced?

Substance use by both parents is extensively documented. The report states: "In April 2023 DCYF received allegations of parental substance use by S.N.'s mother and her boyfriend (who is S.N.'s father)." The father's oral swab tested positive for methamphetamine and fentanyl. The mother tested positive for methadone and cannabis at birth. Law enforcement found "drug paraphernalia (methamphetamine pipe), fentanyl pills and fentanyl powder" in the home. Both parents participated in substance use treatment and were prescribed methadone.

The fatality report identifies several significant systemic and procedural failures: (1) The substance use treatment provider routinely refused to cooperate with DCYF, and "DCYF staff also reported that this treatment provider routinely tells clients to not cooperate with DCYF." (2) The FTDM meeting notes "state that S.N. had negative substances testing at birth" when in fact the umbilical cord tested positive for fentanyl and other substances. (3) A safety plan was required by November 15 but "was not completed." (4) The initial investigation into S.N.'s death was "closed prior to DCYF receiving the toxicology reports from the crime lab." (5) Two intakes with duplicative information received the same day resulted in different screening decisions: "It is unknown why there were differing screening decisions made." (6) Staff turnover led to "larger caseloads and increased workload" and the area administrator was on extended leave without consistent coverage. (7) Staff reported being "verbally mistreated and bullied" by the dependency court and court partners.