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MURPHY — “Oh, my God,” a woman moaned as the 911 call began on Jan. 22.
Others heaved wrenched sobs in the background as a 911 operator quizzed a boy who sounded barely old enough for grade school. She struggled to hear the home’s address through the boy’s pronounced lisp and the cacophony of screams in the next room, and then asked his name.
“My baby brother’s not breathing,” the boy shouted instead.
“How old is he?” the operator asked.
“He’s 5 months!” the boy yelled over the din.
“My dad is trying to do CPR,” the boy said as he tried to help his weeping father.
Nearby, the father’s long, keening wail drowned out the call, “Oh, my God,” he repeated over and over.
“Dad, listen to the operator,” the boy pleaded.
She told the father to clear the baby’s airway of food or vomit, then …
“He’s cold,” someone said.
The operator continued her firm instructions, and the father followed: blow two puffs of air over the baby’s nose and mouth, and 30 chest compressions with two fingers on the breastbone.
“Oh my God,” the father’s focus dissolved, and he collapsed in tears. The little boy’s older brother took over. With each compression, he counted out loud, to 30. Then, he gave two puffs and started the cycle all over again.
He continued CPR on his baby brother’s cold body while chaos swirled around him. Paramedics were on the way, the operator assured him. “You’re doing great.”
It took them almost 10 minutes to reach the house east of Andrews in North Carolina’s westernmost county, Cherokee.
When the first unit arrived, the operator told others on the way to stand down. There was nothing more that could be done.
The baby boy was dead.
Police arrived soon after, and the investigation began. There seemed to be no obvious cause of death, said Joe Wood, the chief deputy for investigations at the Cherokee County Sheriff’s Office.
“I examined the child,” Wood said in a February interview with Carolina Public Press. “He was a healthy, chunky little guy, 5 months old, with no obvious signs of trauma.”
The baby had been staying with his grandmother after the Cherokee County Department of Social Services removed him from his parents. But according to a discussion between a dispatcher and a sheriff’s deputy on 911 recordings related to the call, DSS had recently reunited the baby and parents about a week before.
Carolina Public Press is not identifying the family. Nobody has been charged with a crime, and identifying the parents could identify the boy’s siblings.
The death of any child whose family was in contact with a county DSS unleashes a hurricane of bureaucracy. In North Carolina’s system of state oversight and county administration, state workers examine whether county workers followed law, policy and accepted practice.
They put worker training and almost every other aspect under the microscope and examine whether the problems with one case extended to others, said Kevin Marino, interim DSS director for Rutherford County.
Marino said the state is looking to answer a specific question: “Did the child die, or was there a high probability that the child died, as a result of maltreatment?”
The death triggers a rapid response at the local and state level. The goal is to investigate whether faults with social workers contributed to or led to a child’s death and ultimately remediate those faults.
This was also the case for Cherokee County DSS, which was perhaps under even greater scrutiny than the typical county. Just four years ago, the county was the subject of the first state takeover of a child welfare office in North Carolina history.
Now, local attorneys representing parents in DSS court cases want more answers and have issued a subpoena to the county’s DSS director to testify in court about the state’s report. Although she did not appear Monday, one lawyer said he isn’t giving up.
The county’s difficult past may have been on the minds of state workers who evaluated Cherokee County DSS after the baby’s death. It didn’t take long to find the first mistake.
The child’s death should have triggered a mandatory investigation almost immediately. State policy says anytime a child dies in an open in-home services case, such as this one, the DSS agency must report the death within one business day of learning of the fatality.
Cherokee County DSS learned of the death on Jan. 22 and removed other children in the home that day, according to 911 calls from the scene. However, a spokesperson for the N.C. Department of Health and Human Services said the state agency did not find out about the Saturday death until three business days later, on Wednesday, Jan. 26.
“After the submission, we were informed that the incorrect policy was consulted,” said Cherokee County DSS Director Amanda Tanner-McGee. Workers had followed a different policy that allows five business days for a suspected maltreatment death.
While a delay in reporting the death is “of concern,” said Daniel Beerman, a former DSS division director of Forsyth County who has worked in the field for more than 40 years, Cherokee County has bigger problems.
“This county has had some of the most intense and unique interventions by (the state) to help them correct their historic lack of following policy and procedure, showing a diminished capacity to protect children and families,” Beerman said.
The report to the state of the child’s death triggered a seven-day mandatory review under state policy.
The state’s review unearthed wider concerns about practices in the Cherokee County DSS office, and the state sent three DHHS workers to Cherokee County to review all open in-home cases. Remotely, the state also reviewed current open Child Protective Services cases involving substance abuse.
“During this review, NCDSS staff may require Cherokee County staff to act in cases as directed,” a Feb. 14 letter states.
Lisa Wells, the department’s assistant director, resigned the same day. Attempts to reach Wells were unsuccessful, and counties are not obligated to release the reasons people quit their jobs.
“Lisa Wells resigned on her own, and she’s doing things that suit her passions,” said Tanner-McGee on Friday.
Among the deficiencies, according to a March 4 letter from DHHS to Cherokee County:
- Supervisory oversight was not regular and did not provide appropriate directives for workers.
- Safety plans were not sufficient to provide protection.
- Overreliance on “drug screens” to determine case direction and determine safety plans.
- Failure of internal protocols to address tracking of assigned cases.
- Child welfare staff demonstrates an inability to have critical conversations with families.
The state required Cherokee County to complete a “corrective action plan.” In addition, a DHHS staff member “will remain on-site to provide program management oversight of the child welfare section. This oversight will continue until Cherokee County can demonstrate capacity with either contract or county staff to competently assume this role.”
DHHS workers staffed cases and provided supervisory direction, the letter states. The state agency said state-provided “intensive technical assistance will include but is not limited to … participating in supervision with staff and supervisors.”
Tanner-McGee was quick to defend her office, saying the problems the state identified are not at all like those discovered four years ago. Though her office is nearly fully staffed now, part of the problem in the past has been high social worker turnover.
Cherokee County DSS’ checkered past
In 2016, a Cherokee County DSS worker had Brian Hogan sign an official-looking form called a Custody and Visitation Agreement, or CVA, in front of a notary at the DSS office. No judge was present, and Hogan wasn’t represented by an attorney. He and his daughter were separated for more than a year, even though a judge had ruled he had custody in 2016.
In late 2017, Hogan approached Melissa Jackson on the courthouse steps and asked her for help getting his daughter back. She’s an attorney based in Cherokee County who had represented Hogan before. She soon learned he and his daughter had been separated outside of the legal system and facilitated by the government.
At a court hearing soon after, District Court Judge Monica Leslie invalidated Cherokee County’s CVA with Hogan.
Several months later, a different judge invalidated all additional CVAs the county had with other parents. The judge said the CVA was “the product of both actual and constructive fraud” by Cherokee County DSS, its agents, the attorney and the then-director, Cindy Palmer.
Three months after DHHS learned of the CVA, and shortly after it assumed all child welfare responsibilities in Cherokee County, the state issued a scathing report that pointed straight to the top:
“Ineffective leadership and management over the CCDSS has been central to the lack of competency in its child welfare services,” the March 30, 2018, initial assessment of Cherokee County DSS states. “The director’s leadership over child welfare services is at best described as inactive.”
Dozens of parents and children sued Cherokee County, and in Hogan’s case, the only case that has so far gone to trial, social workers described using CVAs to move along “stuck cases” that they thought a judge might throw out, but also where they thought, in their personal judgment, it was in the best interest of the children to be removed from their homes.
Social workers described presenting parents with a CVA, a document drafted with the veneer of legitimacy but which had no actual legal force behind it.
At the end of Hogan’s four-day federal trial, a jury awarded him and his daughter $4.6 million, a sum that he so far has not received, according to one of his lawyers.
It turned out that former director Palmer was not even qualified to hold that position, and the DSS board passed on a highly qualified candidate willing to take the job, according to a Carolina Public Press investigation published earlier this year.
To date, three people have won millions of dollars in judgments or settlements related to these removals, and Palmer pleaded guilty last year to felony obstruction of justice. The former staff attorney, Scott Lindsay, faces nearly two dozen felony charges for advising the workers to separate families unlawfully. He could face trial this summer.
DSS agencies under scrutiny
The state’s letter regarding the child’s death in January also says workers incorrectly used a “structured decision-making” tool used to guide risk assessment, in which different characteristics of a child’s situation can contribute to risk or safety concerns.
Using the tool is like grading a paper. If domestic violence is present in the home or any caretakers have drug or alcohol problems, the risk to children is higher. Add up the points at the end of a dozen or so questions, and the total tells social workers whether children face low, medium or high risk for neglect or abuse.
Certain actions, such as the nonaccidental injury of an infant or sexual abuse where the perpetrator is likely to have access to the child, are automatically scored high risk.
When the state says Cherokee County incorrectly used the tool, it may mean social workers are off by only a single point, Marino said.
When he worked at another county, there was a child fatality that was not connected to the abuse of a child, and DHHS “put me in corrective action because the risk assessment was off by one point. We had scored it moderate; one more point would have tripped it to high (risk).”
However, he said his staff at the time was treating all in-home cases as high-risk cases “because (family) reunification matters. … I could not argue with them. We got put under corrective action for that. One point.”
Cherokee County DSS has faced recruitment and retention challenges — as do many others throughout the state. A CPP investigation earlier this year, Dodging Standards, explained how workers leave smaller, less resourced or rural counties for neighbors with bigger budgets.
This means DSS offices are in a perpetual cycle of training new workers only to have them leave and then have to find new workers and train them — only to have them also leave. And the cycle continues.
In addition, when a worker leaves, those remaining have to pick up the slack, causing more disruption in an office that’s meant to provide stability for children and families.
Tanner-McGee, who became the Cherokee DSS director in late 2018, said that’s been the case in Cherokee County, too. Low pay combined with emotionally draining work and rotating shifts to cover nights and weekends quickly leads to burnout. Some workers also don’t want to live in a rural area away from city amenities.
For some lawyers in the far west, the problems seemed eerily familiar.
“All of those things are exactly what the problem was before, which was negligent supervision, the inability to assess safety, inability to appropriately balance safety versus risk, communication with families over case plans and over direction,” said David Moore, an attorney who represents parents in DSS cases and is also the attorney for other DSS offices in the region.
While tension always exists between families and a DSS office, Moore said, “It is disturbing, and on some level mind-blowing, that it is still an issue given the events of the last four years.”
Jackson, another attorney who represents parents in DSS cases and is also one of the attorneys to represent Hogan, said she’s disappointed.
“It’s disappointing in the sense that there apparently continues to still be issues with supervision, with training, with communication. And the ability for social workers to communicate with families — and so much so that it rises to the level of state intervention,” said Jackson, who grew up in Cherokee County.
She was stunned, too, that the letter said DSS “must provide remediation training to all child welfare staff” on practices for court intervention, Child Protective Services assessments and in-home services.
“Why don’t they have that training?” Jackson said. “Why does that have to be part of a corrective action plan?”
However, social workers can take a class from a decade ago and still be qualified to practice, even if standards change in the interim, Marino said. That means sometimes workers can make a mistake based on their past knowledge that could now be outdated.
Prescribing remedial training is common, but training an entire office on remedial methods is no small feat, especially due to a county’s distance from the training site or availability, Marino said.
“You could get into corrective action for a year or more because you can’t get your staff into the remedial training,” he said.
Tanner-McGee said she “owns” the recent policy and training flaws identified in the state’s letters.
“This is not in any way similar to anything else that has happened here,” Tanner-McGee said. “This is a corrective action plan for flaws that were found in a record that could probably be found in any DSS office. We obviously take this very seriously.”
Even now, DHHS staff remains in Cherokee County one day per week, a DHHS spokeswoman confirmed Monday.
Moore said he and other attorneys heard the state had visited the Cherokee County DSS office after the infant’s death but did not know the scope of its review until he saw documents provided to him by CPP.
“Now that I know this information, it’s absolutely critical that I know it and that I try to get to the bottom of how that may affect any of the clients that I represent in Cherokee County,” Moore said.
Hours after receiving a copy of the state’s letter from CPP last week, Moore said he sent a subpoena to Tanner-McGee ordering her to appear in court and asking her to bring all documents related to the DHHS supervision and oversight since Jan. 1, 2022.
He said he hadn’t heard from her as of Friday. CPP requested a copy of the subpoena from Tanner-McGee under North Carolina’s public records law. When contacted Friday, Tanner-McGee said she hadn’t seen anything from Moore. Moore said he sent the subpoena to Cherokee County DSS attorney Andria Duncan.
When a reporter informed her of the subpoena’s location, Tanner-McGee said Duncan had been sick all week and she had not seen her all week. However, Moore said, “I saw Andria in court this morning, so that’s not accurate.”
Tanner-McGee said she was “unaware of a subpoena” and was “unaware of her (Duncan’s) court involvement” on Friday.
The following Monday, during Cherokee County’s monthly DSS court hearings, where a CPP reporter was present, Tanner-McGee didn’t show.
“I’m attempting to get a hearing to happen, but they are dragging their feet,” Moore told CPP.
Later in the day, the department did agree to hand over documents related to the investigation, but the process has been, as Moore described, “slow as molasses.”
Duncan told the judge during the court session that she had not read her email until 4 p.m. Sunday and that Tanner-McGee did not receive the subpoena until 7:45 a.m. Monday, Moore told CPP.
When asked about getting a copy of the subpoena Tuesday, Tanner-McGee said she wasn’t sure it was a public record because she’s now included it as part of the child’s confidential record.
“Until (Duncan) decides that’s not part of the record, that’s the answer,” Tanner-McGee said.
Even so, Moore said he is determined to get answers. Moore plans to once again subpoena Tanner-McGee to testify during the next DSS court date in June.
DSS recruitment and retention tough in small counties
Without an influx of money, counties like Cherokee may continue to have recruitment and retention problems.
“The high turnover will continue to deplete the trained workforce, and recruitment of skilled staff will remain difficult to impossible,” said Beerman, the child welfare expert.
“This is one of the serious flaws in a state-supervised/county-administered system. Each county pays at their own levels, and it is no surprise that super-small counties, like Bertie and Cherokee, cannot compete with larger, neighboring or regional counties.”
Small counties could really use funding from the state to stabilize their workforces, Tanner-McGee said.
“I feel like the (state) division should be doing a lot more than they are,” she said. “I think a lot of the strategies they put in place are chaotic and hectic and aren’t going to result in actual change.”
Tanner-McGee also criticized mandatory training that she called ineffective. Murphy is more than two hours from Asheville, where some in-person training is offered.
“Counties do their own training because the state training doesn’t work,” she said.
“The Division (of Social Services within DHHS) simply has not put the resources together to where they change the way they think about training.”
But even if the training was to Tanner-McGee’s standards, it still won’t help a county with high turnover rates, like Cherokee County.
DHHS could propose legislation to the General Assembly, Beerman said, that could address this issue with “economic incentives for small counties that would allow them to increase salaries to a competitive level for all counties with a population under a defined number with a demonstrated turnover issue.”
“The death of a child may be the spark for such an effort.”
To alleviate some of the problems that lead to worker churn, Cherokee County has since hired five people to work night and weekend shifts: four credentialed social workers with a starting salary of $60,000 and a supervisor to oversee their work, Tanner-McGee said. It’s an effort to reduce the burnout of social workers in her county.
“It’s very expensive to launch a whole team — but it’s expensive not to,” Tanner-McGee told CPP last week.
So far, the state has not exercised its authority to take over the office officially, as it did in Bertie County earlier this month, or as it did in 2018 in Cherokee County. Tanner-McGee doesn’t expect that will happen.
On March 30, months after that terrible January day, a medical examiner ruled the boy’s primary cause of death as due to intrathoracic petechiae, or in common terms, an upper airway obstruction commonly found in babies with sudden infant death syndrome. There were no drugs in his system, the report said.
After that date, Tanner-McGee said the state’s “posture toward us and how they behaved toward us changed. … It took away the question of whether or not a grave error was made in our practice.”
She said DSS will meet with state child welfare leaders on Friday to review its corrective action plan.
“I fully anticipate the corrective action plan will be completed and will be able to be closed after that very successfully,” she said.
Clarification: Lisa Wells resigned as Cherokee County DSS assistant director on Feb. 14. The article has been revised to reflect this based on new information that became available.