Uncovering Case Decision Errors in Child Maltreatment Investigations: The Illinois Experience

Background and Purpose. Child protection decision making typically occurs in highly stressful, complex environments. Mistakes in judgment leading to inaccurate assessments of risk are inevitable and occasionally result in tragic case outcomes. While individual caseworkers may be blamed for poor decision making, mistakes are likely to result as much from problems with organizational processes as individual misjudgments. Understanding sources of error provides a foundation upon which to build better organizational processes that will reduce the likelihood of similar mistakes occurring in the future and enhance child safety. Research question: What are common patterns of case decision error in child maltreatment risk/safety assessments when children have died or been seriously injured during or shortly after an investigation? Objectives were to (1) identify case decision making errors and organizational weaknesses contributing to serious child injury or death in families known to the state child welfare system; (2) identify strategies for improving the quality of child protection investigations. Methods. Mixed methods. For the qualitative study, ten cases of child maltreatment investigations were selected for in-depth analysis. Criteria for selection: (1) outcomes of child death or serious injury in families where there had been a child maltreatment investigation within the last year; (2) identified by the Illinois Department of Children and Family Services Office of Inspector General (OIG) as having problematic risk/safety assessments; (3) a variety of case characteristics, circumstances, and complexities. Root cause analysis was used to identify multi-level individual and organizational factors contributing to the tragic outcomes. We also applied a coding scheme derived from systems analysis literature to all OIG recommendations that addressed risk/safety assessment issues. A quantitative descriptive analysis, inter-rater agreement was 83%. Eighty-five recommendations representing 50 cases were analyzed. Results. Major themes included failures of child protection investigators to use multiple sources of information, to recognize cumulative risks, to consider other adults with access to the child, to access expertise or inappropriate reliance on non-expert opinion, and to establish or monitor a safety plan. Contextual factors contributing to errors in child maltreatment investigations included staff shortages, supervision problems and informal incentives for practice shortcuts, communication of policies, and marshaling the means to improve practice. Conclusions and Implications. Our study represents an innovative use of root cause analysis typically applied to accidents in other high-risk industries such as aviation, chemical plants, and hospitals. We recognize significant limitations to this study, however, including that cases investigated by the OIG are not representative of all DCFS child protection cases. We subsequently analyzed a stratified random sample of child protection cases to review case decision errors and confirmed findings from the study reported in this paper. Policy can go only so far as a guide for practice; other elements of the organizational environment support or impede sound case decision making. Our findings suggest that risk/safety assessments could be improved in a number of specific ways, even in an environment with resource constraints. This project influenced state legislation establishing child welfare error reduction teams that have begun to implement system-wide changes.