Every time Irving Faunce reads about another child death in Maine – and he’s been reading plenty lately – he’s instantly taken back to May 2012.

His grandson, Ethan Henderson, lay in a hospital bed in Portland, suffering from catastrophic injuries that were caused by the boy’s father, Faunce’s adopted son.

Faunce drove frantically for three hours from his home in Penobscot just to be able to hold the infant one last time before he died. By then, the father already had been arrested for manslaughter.

“It’s hard and frustrating and sad to watch because it brings back for us how preventable Ethan’s death was,” Faunce said in an interview. “He died nine years ago and in my perception there isn’t a lot that has changed, and it feels like all these recent deaths are evidence of that.”

Last week, Maine’s Department of Health and Human Services released an updated list of all child deaths dating back to 2007 that were either classified as homicides or where the death included signs of abuse, or were preceded by some involvement with the state’s child protective system.

The 143 deaths detailed in the DHHS report include:

• 30 homicides, as determined by the state’s medical examiner.

• 18 attributed to “sudden unexplained infant death.”

• 26 determined to be accidental.

• 35 resulting from co-sleeping, which typically occurs when a sleeping adult inadvertently smothers an infant.

• 34 resulting from natural causes, suicide or where the cause was undetermined.

Notably, the list does not include four additional child deaths since June — they are still active criminal cases — that have once again sparked the cycle of tragic headlines, public outrage, investigations and reform promises from child welfare agencies.

And in some ways, the list raises questions it can’t entirely answer, the biggest of which is: How many of these deaths were truly preventable?

A Portland Press Herald/Maine Sunday Telegram examination of the cases found that in 21 of the 30 homicides since 2007, children came from families that had been involved with child protective services at DHHS because of suspected abuse or neglect involving the deceased child or a sibling.

In 12 of those cases, DHHS did not conduct an assessment following at least one abuse or neglect report, although assessments may have been conducted following other reports related to that family. And sometimes tragedy quickly followed.

Christine Alberi, the state’s child welfare ombudsman, cautioned against drawing any meaningful conclusions from the data released by the state because many details remain unknown.

“Any child death is one too many,” she said. “Efforts to reduce child deaths to numbers sometimes allows us to distance ourselves from the individual cases. It also misses the point to some extent. Many of these deaths, especially the homicides and co-sleeping deaths, may have been preventable, by the parents, by the department, by friends, neighbors, services providers, policy and others in the community.”

Commissioner Jeanne Lambrew told lawmakers in a briefing last week that the disclosure is part of the department’s commitment to transparency as it awaits multiple assessments of its recent performance. Indeed, the report – which includes basic information about each victim, including age and month of death as well as a summary of any interactions with DHHS – is far more than was ever released during the two previous administrations.

DHHS has begun an internal investigation in response to the recent cluster of deaths and also has contracted with a national child welfare organization, Casey Family Programs, to conduct a review. Additionally, state lawmakers have once again summoned the Legislature’s watchdog agency to investigate the situation just three years after the agency documented failings and shortcomings within DHHS that contributed to two high-profile deaths in 2017 and 2018.

“These recent child deaths are a call for action, for urgent yet deliberate action,” Lambrew said last week.

Nineteen of the 30 victims in DHHS’s latest report were 2 years old or younger, and 14 were younger than 1.

Two-month-old Ethan Henderson was among them. His grandfather is as convinced now as he was nine years ago that the boy’s death should not have happened.

Just days before Ethan died, Faunce said, child protective caseworkers were in the home to investigate bruises reported by an employee at Ethan’s day care. But the caseworkers didn’t actually assess Ethan because he was sleeping, Faunce said, and instead accepted the parents’ explanations without investigating further.

The DHHS records show caseworkers investigated reports of abuse or neglect in the household before Ethan was even born, meaning older children were believed to be at risk. Yet Ethan was never removed.

And even before that report, Ethan was treated for a broken arm. None of the three health care professionals who treated him reported abuse.

“The evidence was right there,” he said.

REPEATED CONTACT WITH DHHS

Ethan Henderson wasn’t alone.

The data spreadsheets released by DHHS last week provide a snapshot of how extensively the agency’s child protective workers or other child welfare agencies were involved with families prior to a child’s death.

Many times, the family was on DHHS’s radar for years – often for multiple children – before the eventual tragedy.

Almost every case begins the same way: with a report to DHHS. The spreadsheets do not specify who made the report, but it could be a doctor, teacher, day care worker or school bus driver (all of whom are legally obligated to report suspected abuse) or from a neighbor, another family member or from strangers.

That initial report triggers what is known as a child protection assessment by a social worker to gauge whether there are legitimate safety concerns for the children. Social workers will attempt to speak with the parent and potentially the child, as well as others, to determine whether the concerns of abuse and/or neglect are “unsubstantiated,” “indicated” or “substantiated.”

Parents are not obligated to cooperate unless the social worker comes with a court order or police because a child is feared to be in imminent danger.

In cases where abuse or neglect is indicated or substantiated, DHHS’s response depends on the level of risk faced by children. For higher-risk cases, the agency may assign a caseworker to begin working directly with the family on a “safety plan” for the children or to connect them with services ranging from substance use treatment to mental health counseling and housing. The most severe cases end up in court as DHHS seeks to remove the child from a dangerous family situation.

Low- to moderate-risk cases often are handed off to independent, nonprofit social services agencies that contract with DHHS. Caseworkers with the state’s four “Alternative Response Program” agencies then connect the family with needed social services, make regular visits and provide guidance to the parents – all on a voluntary basis.

In 2020, 5 percent of the more than 24,000 referrals made to the Office of Child and Family Services were handed off to alternative response program partners, according to DHHS. Nearly half of those 24,000 reports were “not assigned for assessment” for a variety of reasons. Those can include parent-child conflicts that did not involve abuse, custody or visitation disputes among separated parents, or conflicts where the families were experiencing financial hardship, mental health challenges or other problems that did not involve neglect or abuse.

Alternative response agencies were involved with at least nine of the families in which a child death was later deemed a homicide, although not necessarily for the child who was killed.

The state has started the process of phasing out alternative response and bringing all of those cases back in-house.

Although the DHHS data does not include names, locations or exact date of death, most cases were identifiable through media reports based on the age of the child and the month and year of death.

Caseworkers often have repeated contact and interactions with families stretching over years.

In the 14 months preceding 10-year-old Marissa Kennedy’s death in February 2018, DHHS received five reports of suspected abuse or neglect from neighbors, teachers and others.

DHHS closed three of those reports without a full assessment and referred two others to alternative response agencies because of the perceived low or moderate risk. Two other DHHS assessments led to recommendations of mental health treatment and public health nursing.

During the murder trial of mother Sharon Kennedy, a social worker with the alternative response agency testified that she noticed bruising and scratches during a home visit. But the young girl was nonresponsive to questions and stepfather Julio Carrillo said Marissa had been harming herself again – an explanation he had given previously.

Marissa Kennedy died two days later of “battered child syndrome” after what the medical examiner determined was months of severe physical abuse.

DHHS apparently chose not to conduct an assessment of reports of abuse or neglect in a household in Garland in December 2014. Later that month, a man killed his girlfriend and her two children, ages 8 and 10.

And in some cases, there were no obvious warning signs.

In 2012, a 3-month-old boy died at a home in Bangor. There were no prior reports of abuse or neglect, but an autopsy showed the infant, Xander Brown, died from trauma.

The boy’s father, Dustin Brown, who was 18 at the time, later was convicted of manslaughter and sentenced to four and a half years in prison. At his sentencing in 2016, Brown’s attorney told the court that his girlfriend was pregnant.

‘SHOULD BE PREVENTABLE’

Dr. Lawrence Ricci, who recently retired but for three decades was one of Maine’s top child abuse pediatricians, said he understands how some people might look at the list of deaths and see the state’s child protection system as intractable.

“When you look at the data and see that the numbers don’t really change, the question becomes: Is this a problem that can be mitigated or resolved? Or is it the nature of the human condition that these deaths will never go away,” Ricci said. “I think this is a treatable problem. The reforms that Maine has undertaken have been well-meaning but flawed. We have not yet cracked a system to provide enough services to families to mitigate the problem.”

Still, Ricci said nearly all child deaths listed in the report “should be preventable.”

“Of course you can’t go into every home and assess the sleep environment, but families who have had any kind of child welfare involvement, even if it’s just a report, we know those families are at higher risk of future problems.”

Ricci also said the number of deaths is alarming but it’s not the whole picture.

“You can increase that by a factor of 10 or more per year for kids who are seriously physically injured,” he said. “Those could easily be deaths.”

Shawn Yardley, who spent 17 years as a caseworker, supervisor and regional administrator at DHHS, said a key factor is the lack of resources for the support programs that help parents who may be struggling. Those programs include parental education – because “being a parent is the toughest job there is,” Yardley said – as well as counselors, substance use treatment, mental health services, assistance for parents with intellectual or behavioral disabilities, and safe places other than hotels or emergency rooms for kids to be sent in crises.

Yardley, who now serves as CEO of the Lewiston-based nonprofit Community Concepts that provides family and social services in three western Maine counties, said child welfare programs have “evolved” and caseworkers now enter the field with more training and education.

But insufficient resources has always been an issue. As a regional administrator for DHHS in Bangor, Yardley routinely made it clear in DHHS documentation that many at-risk children – hundreds if not thousands of kids annually – weren’t being “seen” because there weren’t enough caseworkers to get to them.

“What I’ve seen in my career is they just cut the pie differently; they don’t add to the pie,” Yardley said of inconsistent state investment. “We pay in lots of different ways when we don’t partner with families and with kids to make sure they make it to adulthood intact.”

Asked whether Maine’s child welfare system has markedly improved during his decades in the field, Yardley replied: “I don’t think it is any different. But I think they have new tools that help them do the job better.”

CASEWORKER BURNOUT

Caseworker shortages and high turnover were two major issues identified during the last major child welfare program investigations following the high-profile deaths of Marissa Kennedy in 2018 and 4-year-old Kendall Chick in 2017. Since then, state lawmakers and two administrations have funneled millions of additional dollars into the programs.

Since October 2018, the number of caseworkers, supervisors and support staff within DHHS child welfare programs has increased from 578 to 654. The department also has increased training, invested in coaching support for workers, increased reimbursement rates for foster families and made other changes.

Yet caseworkers still report persistent vacancies as well as feeling overworked, thinly stretched and unsupported by programs that are supposed to provide the critical follow-up services to families.

“My members have been reaching out to me because they are so overwhelmed with the work they are expected to do in a 40-hour work week,” said Robin Upton-Sukeforth, a labor union field representative for DHHS employees with the Maine State Employees Association-SEIU Local 1989. “It is a continuing problem and it has not gotten better. And they are very concerned about the safety of the children that they are charged with doing assessments on.”

Upton-Sukeforth said members are getting burnt out after logging sometimes 70 hours a week attempting to juggle their caseloads with the emergency shifts and other responsibilities they carry.

She compared caseworkers to code enforcement officers who determine whether a building is safe enough for occupancy. But code enforcement officers don’t perform the work to address those hazards. Instead, the building owner calls in a plumber, electrician or other tradesperson to correct the deficiency.

Similarly, DHHS caseworkers are trained to assess risks within a family, identify problems and then recommend services, counseling, treatment or even alternative placement of a child. But without those follow-up services from community support agencies, “you are not going to make a child safe,” she said.

“What I hear from caseworkers is an overwhelming sense of guilt because they are not meeting the needs of the child,” Upton-Sukeforth said. “And I have a lot of people telling me there is more focus on documentation rather than on the results.”

Irving Faunce said he’s sympathetic to the demands of child protective caseworkers but said something has to change.

“Reading about all these deaths is very grim – there is no other way to put it,” he said. “And these are just the cases we know about. There are so many children undergoing abuse that we don’t know about because they haven’t died.”

Faunce also shared that Gordon Collins-Faunce, who was convicted in Ethan’s death, was adopted by him and his wife at a young age after the boy’s biological parents lost custody of him and two sisters because of abuse. At one point, Gordon was even hospitalized.

“So, he came from a history of abuse himself,” Faunce said.

After Gordon was arrested, Faunce dedicated himself to doing whatever he could to make sure more kids like Ethan don’t end up dead. That’s why he keeps reading the stories, no matter how difficult they are, and why he keeps speaking out.

“I view it as honoring Ethan,” he said.

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