ACS Releases Preliminary Report on Death of Marchella Pierce
Today the New York City Administration for Children’s Services (ACS) released a preliminary report of its continuing investigation into the death of Marchella Pierce on September 2, 2010.
“Since Children’s Services had the job of protecting Marchella Pierce at the time of her death, we take seriously our responsibility to share with the public what happened and why. That is why we are taking the extraordinary step of releasing the results of our investigation to date,” said NYC Administration for Children’s Services Commissioner John B. Mattingly. “While more information will become available in the future, we believe that it is important to share a summary of what we know now.”
The five-page preliminary report details ACS’ involvement in the case including the initial report of the mother’s positive toxicology report at the birth of a son in November 2009, the actions taken by the Child Development Support Corp (CDSC), an ACS contracted preventive services program for families with substance abuse histories, the termination of the CDSC contract, the transfer process during the closedown, and actions taken by ACS’ Division of Child Protective staff.
The analysis of CDSC’s actions in the case shows that the preventive agency’s involvement in ensuring that the mother received drug treatment and making certain that the children were safe and adequately cared for was woefully inadequate.
- By contract, the agency was required to have 2-3 case contacts a week for the first four weeks or until sobriety was achieved. This did not occur.
- The agency at no time carried out its responsibility to make a new State Central Register report regarding the mother’s continued drug abuse, notify ACS of same, or request an Elevated Risk or Child Safety Conference with ACS to determine if the children could remain safely in the home.
- Marchella was only seen by the CDSC case planner on three occasions from February until June.
Additionally, there are several problems with ACS’ handling of the case:
- The initial investigation, while focused correctly on the mother’s drug abuse, should have involved an assessment of Marchella’s status and planning with CDSC and the family for when she was released from the hospital;
- The report in March 2010 was identified as “Additional Information” -- which does not automatically require a full investigation. However, ACS’ response to the additional information was not adequate;
- The Child Protective Services unit, while not doing an investigation and having very little contact with the family, decided to keep an active case open in the household when CDSC involvement ended. Prior to the fatality, it is simply not in the record that ACS representatives visited the family at all after June 2010.
Two Children’s Services employees have been suspended without pay for failing to follow standard policies and procedures. As the investigation continues, we will take other appropriate actions as necessary.
ACS is also implementing a number of recommendations stemming from the Marchella Pierce investigation, including to:
- Assess carefully how ACS can determine more quickly that a contract agency is failing. Although ACS ended CDSC’s contract and CDSC had been on corrective action status in the past, there was no clear indication in 2010 that their work had become so inadequate. ACS will take appropriate action on this recommendation by the end of November, 2010.
- Strengthen the monitoring of preventive providers' implementation of the family team conference model -- during CDSC's work with the Pierce family, it would have been appropriate to request an Elevated Risk or Child Safety Conference in response to several indicators of heightened risk. This recommendation will be implemented by the end of November, 2010.
- Improve the contract termination procedure to create more structured communication between the closedown team and the assigned child protective staff regarding the child safety and risk issues in the home, and the plan for services to the family. Changes in this protocol will be completed by the end of November, 2010.
- Review of cases transferred or closed during the CDSC closedown process to be conducted by the New York State Office of Children and Family Services (OCFS). OCFS will review a random selection of CDSC cases to determine if there may be families who need further intervention. OCFS expects to complete the review by the end of October.
- Review cases of families affected by program closures in the past six months to be conducted by ACS to assess the quality of decision making and follow through, and to determine if there may be families requiring follow-up. This will include cases that were closed altogether and those that were transferred back to the Division of Child Protection. ACS expects to complete this process by the middle of November.
- Require increased monitoring of supervision of casework, both for quantity and quality of work, including assessment of safety and risk, requirements for home visits and documentation of work done. The current policy provides expectations for both individual and group supervision along with a major emphasis on supervisory practice with borough specific plans over the past 2 years. In the next 60 days, ACS/Division of Child Protection will modify current policies and implementation efforts to reflect more specific and measurable requirements for supervision of cases.
- Review all Additional Information reports since January 2010; ACS has nearly completed its initial review of the reports, one per supervisor, and is re-assessing cases where warranted and expects to be finished within the next week. A complete review of all Additional Information reports since January 2010 will be complete within three weeks. Based on this review, by mid-November ACS will consider issuing new guidance to staff on assessing Additional Information reports to determine whether a full investigation is necessary.
- Require uniform note taking practice across the Division of Child Protection, along with monitoring of case contacts; this will be implemented by October 8, 2010. A policy for timely entry of progress notes into CNNX within a set number of days after contact will be completed by November 15, 2010.
There are several important limitations to this preliminary report: First, New York State law does not allow ACS to release any information on abuse or neglect reports made to the State Registry that are determined unfounded by the agency after investigation. Second, the City Medical Examiner has not yet ruled on the cause of the child’s death, so that any finding we make at this time is not final. Third, ACS cannot reveal the source of any report to the State Central Register. Finally, ACS must and will do everything it can to protect the privacy of any brothers and sisters of a deceased child.
“Clearly, whatever we do now will not change what happened. This was a terrible tragedy that might possibly have been avoided. A four-year old child who had seen too little of life is now gone. However, this child’s loss does call on ACS to look at how we can make it less likely that events like this will occur in the future,” stated Commissioner Mattingly.
Michael Fagan 212-341-0999