June 2020 Court Monitors Report Summary

Following a mandate by the U.S. Court of Appeals for the Fifth Circuit, the Monitors of the Texas Foster Care System have released their first report. The Monitors ultimately concluded that more than two years after the Court issued its Final Order on the Texas child welfare system, the system “continues to expose children in permanent managing conservatorship to an unreasonable risk of serious harm.”

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Introduction | Child Deaths | Report Findings | Other Information


Following a mandate by the U.S. Court of Appeals for the Fifth Circuit, the Monitors of the Texas Foster Care System have released their first report. This report was created by the monitoring team following a 10-month investigation, which included the examination of:

  • Tens of thousands of documents and records;
  • Unannounced site visits across 20 Texas counties at 23 of 299 general residential operation (GROs) campuses;
  • Interviews with 75 of 1,418 conservatorship caseworkers who were assigned at least one child in permanent managing conservatorship (PMC);
  • Analysis of data from the Department of Family and Protective Services (DFPS) Statewide Intake (SWI) related to 372,897 calls placed to SWI from August 1, 2019 to January 31, 2020; and
  • Other research and interviews with relevant parties.

The Monitors ultimately concluded that more than two years after the Court issued its Final Order on the Texas child welfare system, the system “continues to expose children in permanent managing conservatorship to an unreasonable risk of serious harm.”

Despite claims by the State in 2019 that Texas was compliant with the Court’s remedial orders, the report provides great detail about how the Texas child welfare system has failed to address the three critical problems that the court found in 2018:

  1. Deficient investigatory practices
  2. No central tracking of child-on-child abuse
  3. Inadequate child care licensing enforcement policies

The report also goes into great detail on how the Texas system continues to fail in a number of other ways, endangering children (in three specific cases directly resulting in child deaths) and failing the children in foster care in Texas.

Child Deaths

Before delving into the specifics of the failures of the system, the Monitor Report reviews three child deaths that highlight a vast number of problems within the system, which directly and indirectly endanger children.

  1. The first is the death of “K.C.” who collapsed in a residential treatment center (RTC) from an embolism, which was the result of a vein issue in her leg. The RTC staff waited 37 minutes after she collapsed before calling 911. The RTC she lived in had been cited more than 60 times for minimum standard violations in a two-year period. K.C. had complained about leg pain for the week leading up to her death, and while most staff did not take the complaint seriously, one staff member did document the leg pain complaint. DFPS’s documented investigation makes no reference to these documents, though they were included in the documents provided to the Monitors. This death highlights multiple problems, from the RTC having no major consequences for having over 60 minimum standard violations in a short period, to the staff’s mistreatment of the crisis, to DFPS’s failure to investigate the death properly.
  2. The next fatality they outline was of “A.B.”, who was in the care of fictive kin at the time of his death. Prior to his death, there were multiple referrals to the SWI hotline, expressing concern for the child’s safety. These calls did lead to two separate abuse investigations, but neither resulted in the removal of the child from the placement, in spite of the fact that the second report led to the child receiving a forensic child abuse evaluation and the doctor who saw A.B. expressed concerns for “non-accidental trauma” based on the child’s bruising and injuries. On the day before his death, his caseworker received a text and photograph from the daycare center of A.B.’s eye, which was swollen shut. The caseworker had been told by the caregiver that A.B.’s eye was swollen due to allergies, and the caseworker repeated this in response to the text from the daycare. No one from the daycare was interviewed prior to A.B.’s death. A.B. was found unconscious on the floor the next day and later died in the hospital. Witnesses reported that A.B. appeared with a variety of injuries in the two months before his death. This death shows the failure of abuse investigations and a lack of intervention on behalf of the system.
  3. Finally, the report looks at the death of “C.G.”, who hanged herself in the bathroom of the emergency shelter she had been placed in by DFPS, following her stay in a psychiatric hospital. C.G. had a treatment plan required her to be “monitored by staff at all times.” Video clips from the night of her death show C.G. entering the bathroom by herself, where she remained for 30 minutes before a staff person found her. The day before her death, the shelter took away her MP3 player, which had been prescribed to her to help manage her anxiety, for “disciplinary reasons.” Immediately before her death, C.G. had been scolded and brought to tears by a staff person for going into the staff person’s purse to look for a hair tie. The last meeting she had with her clinical social worker was 24 days before her death and she had only met with psychiatrist once virtually since leaving the hospital. The emergency shelter where C.G. died has a troubled history, marked by a high number of minimum standards deficiencies and nine investigations of abuse and neglect resulting in one reason to believe that abuse and neglect occurred between September 30, 2014 and March 31, 2020. Her death showed a systemic failure to respond appropriately to the shelter’s violations, a failure of the shelter staff in following her treatment plan and the fact that the staff’s direct actions (and inaction) led to the event of her death.

Report Findings

The report summary breaks down their findings into six different points (A-F):

A. The Monitors’ review shows the State is not in compliance with the Court’s remedial orders.

Across categories, the Monitors found that the State is not following or failing to appropriately meet the Court’s remedial orders.

B. The Monitors’ analysis found that the State’s failure to comply with the Court’s order related to appropriately screening, receiving, and investigating child maltreatment in care continues to put children in PMC at an unreasonable risk of serious harm.

The Monitors found lapses at every step of this process, from a high rate of abandoned calls to SWI’s child abuse and neglect hotline (18% of all calls are abandoned) to a high rate (33% of cases reviewed by the Monitors) of inappropriate downgrades of reports of abuse or neglect. In some of the inappropriate downgrades, Residential Child Care Investigations (RCCI) appears to have determined that behaviors like consensual sexual conduct between children or self-harming that is not suicidal were not serious, without consideration of the action or lack of action by caregivers to prevent the incident, even when the behavior caused or may have caused harm.

Of reports that are investigated, the Monitors’ review of cases also found substantial deficiencies in almost 29% of the investigations, which were often so cursory or so elongated and riddled with gaps, that the Monitors could not reach a conclusion regarding the result of the investigation.

The Monitors’ analysis also showed that when the State initiated an investigation, children’s caseworkers sometimes were not ever notified at all and at other times were notified well outside the required timeframe.  Caseworkers were not notified in 23% of cases reviewed by the Monitors and were notified more than 72 hours after the referral to SWI in another 27% of cases.  These failures prevent caseworkers from knowing about a risk of harm to children that would prompt them to check on them to ensure their safety during the investigation.

The Monitors discovered caseworkers and their supervisors reviewed the information with an eye toward the child’s safety in just over half of the cases that should have been reviewed and many of those (44%) were not reviewed within the 48-hour timeframe required by the court. Even when caseworkers and supervisors reviewed foster home histories, the Monitors found disturbing examples that overlooked obvious child safety concerns.

C. The State’s bifurcated approach to oversight of PMC children in care and data management contributes to risk of harm for PMC children and limits the State’s ability to provide data and information necessary to evaluate compliance with the Court’s orders.

The report found that the use of a dual system for managing data “has created a disjointed, inefficient system in which gaps between the two conspire to create risk of harm.” The Health and Human Services Commission (HHSC) and Department of Family and Protective Services (DFPS) use of two different systems, and the fact that there is seemingly no bridge in between the two, has created innumerable opportunities for vital information to “slip through the cracks.” The two systems also fail to provide almost any sort of unified data across the two platforms. Due to this, the Monitors encountered many barriers in their attempts to find patterns of child maltreatment and contract/policy violations across foster care placements. They ultimately concluded that Texas does not try to use their data for this purpose.

The Monitors found it almost impossible to establish a coherent dataset about child maltreatment and investigations related to a single organization or a single facility (both DFPS and HHSC said they would need at least six weeks to be able to provide that data), and the State was unable to provide a unified set of data that showed all referrals of abuse and neglect for a PMC child.

Additionally, in 31% of the State’s certifications of unannounced, on-site visits by DFPS staff to document awake-night supervision at licensed and verified placements, the list of children that DFPS staff brought to the visit did not match the children in the operation’s care on the date visited. In some cases, the operation could not account for the missing children.

D. The Monitors’ analysis of compliance with remedial orders intended to address high caseloads suggests that the State’s limited organizational capacity contributes to risk of maltreatment for children in PMC.

While the Court’s orders related to the agreed caseload guidelines were not yet in effect in the months for which the Monitors analyzed data, the baseline analysis shows that only 49% of conservatorship caseworkers had caseloads that would have fallen within the guideline of fourteen to seventeen cases. Of HHSC Residential Child Care Licensing (RCCL) inspectors, only 41% would have had caseloads falling within the guidelines and of DFPS RCCI investigators, 54% would have had caseloads within the guidelines if the guidelines had been in effect in the months reviewed.

The Monitors case record reviews also revealed:

  • 26% of Priority One abuse and neglect investigations are not initiated timely and 26% did not initiate face-to-face contact with alleged victims within the required time frames;
  • 16% of Priority Two abuse and neglect investigations are not initiated timely and 18% did not initiate face-to-face contact with alleged victims within the required time frames;
  • 79% of Priority One and Priority Two investigations were not completed within the required time frame and only 2% had an approved extension and were completed within the extension time frame;
  • While RCCL inspections and investigations were completed within 30 days in the majority (95%) of cases reviewed, only 59% of investigations of minimum standards violations initiated face-to-face contact with an alleged victim within the required time frame.

The State initiated a project in November 2019 to clear backlogged cases, but still had more than 500 “delinquent” cases (45 days or older) as of April 2020. These time lapses have serious negative consequences. As the report states: “The Monitors identified ten separate allegations of physical abuse against a single perpetrator at different facilities in Texas between March 2015 and February 2020. Six of those allegations surfaced since September 2019, and in numerous instances, long periods of inactivity plagued those investigations, allowing the perpetrator to continue to hurt children, unchecked by the State’s lethargic investigations and undetected by its weak, bifurcated approach to oversight.”

E. The Monitors’ analysis of remedial orders related to licensing and oversight suggest the State’s failure to comply with the Court’s remedial orders places children at risk of harm due to the failure to appropriately identify and address clear indicators of safety concerns.

The Monitors found that RCCL issued more than 30,000 citations for a minimum standards violation between September 30, 2014 and March 31, 2020, more than half of which were for standards weighted medium-high or high for child safety. Yet, during the same period, RCCL placed only twenty operations on probation, suspended one license and issued “intent to revoke” letters to six placements, although the agency did not actually revoke a single license.

F. The State’s failure to comply with remedial orders associated with preventing sexual abuse leaves children at an unreasonable risk of serious harm and suggests the State may be prioritizing identification of victims and aggressors, but not prevention of sexual abuse.

A consultant’s review of the State’s policy implemented to comply with remedial orders associated with preventing sexual abuse showed that the State is prioritizing identification and reporting of victims and aggressors. When the consultant’s review was shared with DFPS, the State suggested that prevention of child sexual abuse was beyond what was required.

The Monitors Report also found that the State’s identification system had issues and was not in compliance. For example:

  • Approximately 9% of children’s files reviewed during on-site monitoring visits to GROs revealed a history of victimization or aggression, yet these children’s electronic files did not include the appropriate indicator
  • Of direct caregivers interviewed by the Monitors, only 57% indicated they received notice from the GRO when a child had been identified as having a history of sexual aggression and only 50% indicated they received notice when a child had been identified as having a history of sexual abuse

Additionally, there were compliance issues with awake-night staff. While the Monitors found awake-night staff present at all their over-night visits (the Monitors did encounter a sleeping staff member, and were left alone with 20 children during a riot, so not all GROs were in compliance), the State’s own reports show lapses in awake-night supervision. Seven operations reported non-compliance to the State at some point between October 2019 and January 2020.  Six certifications sent by DFPS to the Monitors indicated that DFPS staff suspected the facility awake-night staff had been sleeping or appeared drowsy when DFPS arrived, and four indicated DFPS staff observed or were advised that awake-night staff left their assigned unit, leaving children unsupervised. There was also a disturbing report of a DFPS worker making an unannounced visit and walking in on a supervisor with their pants down and “got the impression that he was masturbating as they walked in.”

Finally, children still do not report knowing about the Foster Care Ombudsman (FCO). Of the children interviewed by the monitoring team during on-site visits, 71% reported they had not heard of or did not know of the FCO. Additionally, 40% of the children interviewed by the monitoring team reported they were not aware of the child abuse and neglect hotline.

Other Information

The report provides an in-depth breakdown of the demographics of the children in PMC, a background and summary of each of the 6 points above, an in-depth analysis of each remedial order that the State is failing to comply with, and a plethora of statistics and examples demonstrating how the State is failing to comply.

Read the full, 363-page report from the Monitors.