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Child deaths preventable with greater transparency of agencies


A week ago, Phoenix police responded to a report of child abuse. This was not the first call for this address, and when the officers arrived, they found five children, ages 6, 4, 1, and two newborns. They were infested with lice, wearing diapers wet with urine and soiled with feces. They had insects crawling out of their ears.

One of the infants couldn’t breathe due to a brain bleed. The toddler had multiple skull fractures.

Police immediately removed four of the children for medical treatment.

The fifth child, a baby born just weeks ago, was not taken for help. This baby was taken to the morgue. 

Rebecca Masterson

Rebecca Masterson

We read stories like this every day. Part of our mandate at Gen Justice, an organization dedicated to mending the child protection system, is to study cases of unimaginable violence against children and develop recommendations to prevent fatalities.

 We’ve read about Dylan, an Ohio 2-month-old, tortured, chained, and thrown down a well after the child protection agency returned him to his meth-addled father. We’ve read about Anthony, age 10, who, despite a long history of being abused, was returned home to his California parents to be tortured, beaten, starved, burned, and ultimately murdered.  

 If these grisly details aren’t enough to move us into action, the fact that every one of these kids –  just like the five Phoenix children – were known to their local child welfare agency, is. Authorities knew these children and had multiple opportunities to keep them safe.

 The most recent Arizona child fatality report shows something every lawmaker needs to know – the majority of Arizona children who died from abuse were known to the Department of Child Safety with, either, open cases or prior involvement with the agency when they died. The report’s conclusion? The deaths were “100 percent preventable.”

 We can’t applaud the reduced numbers of kids in foster care if the reason fewer children are entering state care is because they’re being left in violent homes with known abusers.


Darcy Olsen

Darcy Olsen

Is that the case? We can’t tell you. Because, hands down, the largest barrier to meaningful reform for abused children is the lack of transparency in the child welfare system.

 Consider this example. A local foster family reached out to our legal clinic for help on learning the cause of death for a baby they’d cared for. Most of the infant’s short life was with this foster family, and the baby died shortly after being moved. The family submitted the appropriate records request, and the agency replied in a form letter that the autopsy report was “confidential.” But it wasn’t. The Maricopa County Medical Examiner’s Office released it.

 Or when Arizona Republic journalist Mary Jo Pitzl reported on a meth-exposed baby who was removed to a safe family where he lived for a year, only to die weeks after he was returned home – and one week after caseworkers were in the home investigating another complaint of abuse. When Pitzl questioned DCS, the agency offered “no comment.”

 Arizona can and should lead the charge in transparency. We should start with the most urgent need – the children dying on the state’s watch.

 We can reduce child fatalities by performing independent reviews every time a child previously reported to DCS dies of abuse. One approach may be found in a 2004 executive order creating an inspector general for the Arizona Department of Transportation. ACCCHS, the Department of Corrections,and other large agencies also receive auditing oversight and assistance. As in the private sector, an independent auditing body can help lawmakers identify areas of improvement, and indeed, that would be its mandate.

 An independent body should investigate the circumstances leading up to every child’s death. The auditing body should review decisions made by the department, and importantly, identify where improvement can be made. The review should culminate with a timely written report, available to the public. This independent audit could be coupled with supporting legislation eliminating the agency’s excessive paperwork burden, initially designed to improve transparency, but much of which is not informative, outdated or redundant.

 It is too late for the baby taken to the Phoenix morgue last week. It is too late for the thousands of children in our nation’s child protection system who have already died on the state’s watch. But it is not too late to save the lives of children going forward by making it a priority to require agency transparency including immediate, independent investigations.

The state’s fatality report says these deaths are preventable. Let’s make it so.

Rebecca Masterson is chief counsel and Darcy Olsen is founder of

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