Over the course of the last 16 months, I have referenced the case of the 5 year old boy who died because I didn't do enough to protect him. In the past 24 hours or so, I have discussed the situation in the posts, Joe Must Go Now and An Ugly End. In the Summer of 2010, I discussed this case in more detail in 4 posts over a two-day period: My One Regret, My Public Crucifixion, Undue Strain and The Rationale.
The reason for this plethora of posts should be obvious: it's my penance. While I don't sit around thinking about this case 24/7, 365 days per year, I would be lying if I didn't admit that I think about it often. When I do think about it, it leaves me feeling empty and very disappointed in myself.
One of the things I have never shared in this space is the child's name: Stephen Earl Walters. I'm not really sure WHY I haven't wanted to write it out since it's part of the public record now. He went by the nickname, Stevie, and he was a cute kid.
I've never mentioned how he died. Stevie was a bedwetter and this singular fact seemed to enrage his father and stepmother. They had tried to beat him to get him to stop wetting his bed, but the strategy didn't work. So, one fateful day they decided to employ a very illogical strategy: They forced him to drink copious amounts of water!
Not only was Stevie forced to drink gallons of water, but he wasn't allowed to urinate. For reasons only known to his father and stepmother, they forced him to stand in the bathtub for hours under the threat of a thrashing, if he peed. At some point, it appears the child passed out and hit his head, if I remember correctly, on the water faucet.
At his father's trial, there was some question as to the exact cause of death. One expert contended that Stevie died of a dry drowning. It was theorized that the forced overconsumption of water led to an acute imbalance of electrolytes. The injury sustained in the fall was superfluous.
A second expert, however, believed the fall itself lead to fatal blunt force trauma. While not discounting the imbalance of electrolytes, this professional felt it was only a contributing factor.
The last part of the equation that I have not shared previously concerns the circumstances surrounding why I should have done more to protect Stevie.
Our county administrator was a very odd duck. She believed that many of the state's rules, procedures and protocols were inefficient or unneeded. So, she developed rules, procedures and protocols of her own -- several that violated state laws. And she seemed to change or alter these things frequently on little more than her own whims.
Our senior foster care worker and I complained to state administrators on several occasions. Each time we were told that the situation would be addressed and each time not a damn thing was done about it! All it did was outrage the county administrator!
The situation was maddening because it placed the workers in our office between a rock and a hard place. If we bucked the office protocols, the county administrator could easily fire us for insubordination and, believe you me, it most likely would have stuck. However, by following her perverse schemes, we often were violating state policy and, in some instances, state and federal law. While our young and inexperienced workers didn't really know any better, our senior foster care worker and I did. We hated the situation we found ourselves in.
This brings me back to Stephen Earl Walters. State law mandated that, as soon as a report of abuse or neglect was received by a county office, it was to be entered into an official logbook by the intake worker who took the report. The original copy of the report was to be sent to the state office and carbons of the report were to be transmitted to the casework supervisor.
Naturally, we didn't follow this mandated protocol in our office. While the worker who took the initial report was supposed to enter the information in the logbook, the original copy of the report was hand-delivered to the county administrator. What she did with it, we never were clear about; all we knew is that these reports didn't always find their way to the state office.
She would make photocopies of each report -- a big no-no -- and then hand them out to the casework supervisor and the Child Abuse Investigator (me).
As to the Walters case, she told the intake worker NOT to record it in the logbook -- he was told that I would take care of it. Of course, the county administrator didn't direct me to do it either and so I reasonably assumed this had been handled by the intake worker. Not only was this report NOT logged, but I was given the original copy of the report. (The carbons magically disappeared and no one ever found them.)
I didn't realize that it was the original because that wasn't the protocol in our office. Once my investigation was completed, I did what I always did with the photocopied reports in my possession: I shredded it.
I think you can see where this is going. Since the report was never logged and the report itself no longer existed, it never made it to the casework supervisor and, therefore, my recommendation for intensive family services easily fell through the cracks. It got lost amid a mountain of paperwork. Since no one was working with and keeping an eye on the Walters family, they decided to move to another county before someone caught the error.
They had nothing to worry about because we never caught it...that is until a report came across the TV that Stephen Earl Walters was dead. Upon hearing the news, I raced up to our office to try to ascertain what had gone wrong. The very first thing I did was to look in our logbook to help me remember the exact date when I conducted the initial investigation (it had occurred a month or two previous) and, of course, I couldn't find it because it wasn't there!!
Knowing how utterly screwed up our office procedures were in conjunction with the seriousness of the substantiated allegations, I should have followed up on this case. I should have checked with the casework supervisor a few days later to see how the intensive family services were going. If I had done this one simple thing, the error would have been caught early on and there's a very good chance Stevie would not have died at the hands of his father and stepmother.
This is where I failed that innocent little boy. Once I finished his family's investigation, I moved on to the next one, then the one after that and the ones after that. It was an out of sight, out of mind type of thing. It wasn't one of my official duties to checkup on completed investigations, so I didn't. Just like Joe Paterno, I did what was legally required of me, but I failed to do what was morally required for this situation.
I have to live with this -- a broken heart and the memory of a little boy who didn't deserve to die the horrible way he did.
The reason for this plethora of posts should be obvious: it's my penance. While I don't sit around thinking about this case 24/7, 365 days per year, I would be lying if I didn't admit that I think about it often. When I do think about it, it leaves me feeling empty and very disappointed in myself.
One of the things I have never shared in this space is the child's name: Stephen Earl Walters. I'm not really sure WHY I haven't wanted to write it out since it's part of the public record now. He went by the nickname, Stevie, and he was a cute kid.
I've never mentioned how he died. Stevie was a bedwetter and this singular fact seemed to enrage his father and stepmother. They had tried to beat him to get him to stop wetting his bed, but the strategy didn't work. So, one fateful day they decided to employ a very illogical strategy: They forced him to drink copious amounts of water!
Not only was Stevie forced to drink gallons of water, but he wasn't allowed to urinate. For reasons only known to his father and stepmother, they forced him to stand in the bathtub for hours under the threat of a thrashing, if he peed. At some point, it appears the child passed out and hit his head, if I remember correctly, on the water faucet.
At his father's trial, there was some question as to the exact cause of death. One expert contended that Stevie died of a dry drowning. It was theorized that the forced overconsumption of water led to an acute imbalance of electrolytes. The injury sustained in the fall was superfluous.
A second expert, however, believed the fall itself lead to fatal blunt force trauma. While not discounting the imbalance of electrolytes, this professional felt it was only a contributing factor.
The last part of the equation that I have not shared previously concerns the circumstances surrounding why I should have done more to protect Stevie.
Our county administrator was a very odd duck. She believed that many of the state's rules, procedures and protocols were inefficient or unneeded. So, she developed rules, procedures and protocols of her own -- several that violated state laws. And she seemed to change or alter these things frequently on little more than her own whims.
Our senior foster care worker and I complained to state administrators on several occasions. Each time we were told that the situation would be addressed and each time not a damn thing was done about it! All it did was outrage the county administrator!
The situation was maddening because it placed the workers in our office between a rock and a hard place. If we bucked the office protocols, the county administrator could easily fire us for insubordination and, believe you me, it most likely would have stuck. However, by following her perverse schemes, we often were violating state policy and, in some instances, state and federal law. While our young and inexperienced workers didn't really know any better, our senior foster care worker and I did. We hated the situation we found ourselves in.
This brings me back to Stephen Earl Walters. State law mandated that, as soon as a report of abuse or neglect was received by a county office, it was to be entered into an official logbook by the intake worker who took the report. The original copy of the report was to be sent to the state office and carbons of the report were to be transmitted to the casework supervisor.
Naturally, we didn't follow this mandated protocol in our office. While the worker who took the initial report was supposed to enter the information in the logbook, the original copy of the report was hand-delivered to the county administrator. What she did with it, we never were clear about; all we knew is that these reports didn't always find their way to the state office.
She would make photocopies of each report -- a big no-no -- and then hand them out to the casework supervisor and the Child Abuse Investigator (me).
As to the Walters case, she told the intake worker NOT to record it in the logbook -- he was told that I would take care of it. Of course, the county administrator didn't direct me to do it either and so I reasonably assumed this had been handled by the intake worker. Not only was this report NOT logged, but I was given the original copy of the report. (The carbons magically disappeared and no one ever found them.)
I didn't realize that it was the original because that wasn't the protocol in our office. Once my investigation was completed, I did what I always did with the photocopied reports in my possession: I shredded it.
I think you can see where this is going. Since the report was never logged and the report itself no longer existed, it never made it to the casework supervisor and, therefore, my recommendation for intensive family services easily fell through the cracks. It got lost amid a mountain of paperwork. Since no one was working with and keeping an eye on the Walters family, they decided to move to another county before someone caught the error.
They had nothing to worry about because we never caught it...that is until a report came across the TV that Stephen Earl Walters was dead. Upon hearing the news, I raced up to our office to try to ascertain what had gone wrong. The very first thing I did was to look in our logbook to help me remember the exact date when I conducted the initial investigation (it had occurred a month or two previous) and, of course, I couldn't find it because it wasn't there!!
Knowing how utterly screwed up our office procedures were in conjunction with the seriousness of the substantiated allegations, I should have followed up on this case. I should have checked with the casework supervisor a few days later to see how the intensive family services were going. If I had done this one simple thing, the error would have been caught early on and there's a very good chance Stevie would not have died at the hands of his father and stepmother.
This is where I failed that innocent little boy. Once I finished his family's investigation, I moved on to the next one, then the one after that and the ones after that. It was an out of sight, out of mind type of thing. It wasn't one of my official duties to checkup on completed investigations, so I didn't. Just like Joe Paterno, I did what was legally required of me, but I failed to do what was morally required for this situation.
I have to live with this -- a broken heart and the memory of a little boy who didn't deserve to die the horrible way he did.
I hope that by telling this story you are able to mend your broken heart and lay down your burden of guilt and move on. No one here would blame you. It was a terrible but hardly unique system failure, but ultimately it was the parents' lack of "parenting skills"...a phrase I actually detest...that resulted in his death. Our social safety nets are always full of holes...because they are just webs of humans.
ReplyDeleteI've made peace with almost everything in my past, but not this one. I don't think I will ever be at peace with it.
ReplyDelete