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Chronic Child Maltreatment & Child Fatalities in Washington State

(Originally published February 2026)

I reviewed 30 Department of Children, Youth and Family Services (DCYF) child fatality reviews on 32 children completed in 2024-2025 by a committee consisting of staff from DCYF and the Office of the Family and Children Ombuds, as well as community professionals from substance abuse treatment agencies, public health departments, mental health and domestic violence provider agencies, etc. I also reviewed news stories regarding several of these child fatalities, stories which revealed the names and gender of child victims, information redacted in the child fatality reviews. In reading these fatality reviews, I had three main goals:

To better understand the relationship between chronic child maltreatment as reflected in deceased children’s family histories of child protective services involvement and child maltreatment (CM) fatalities.
To determine how and to what extent domestic violence and caregivers’ mental health conditions increased the risk of a CM fatality, and how DCYF caseworkers were addressing domestic violence and caregivers’ mental health challenges in service and safety plans developed for families in which a CM fatality occurred.
To understand the effects of the Keeping Families Together Act (KFTA) standard for child removal, i.e., risk of imminent physical harm, on placement decisions for children in chronically maltreating families and how caseworkers responded to apparent safety threats, including caregivers’ use of fentanyl in the home.

There has been much discussion in Washington during recent years of child fatalities due to accidental drug overdoses, especially of fentanyl. Thirteen of the 32 deceased children discussed in these reviews died due to drug overdoses and/or unsafe sleep practices. However, reading these fatality reviews was a shocking reminder that children sometimes die in horrible ways from assault, or possibly from starvation, or in mysterious ways that cannot be determined:

A four-year-old boy was stabbed 41 times by his mentally ill mother who “discarded” the child’s body by the side of the road.
A five-year-old girl was beaten and then chained to a toilet in a stress position for hours and then beaten again by her father until she died.
A five-year-old girl vanished in 2021 after setting the family’s home on fire and was never seen again. A county judge declared the child to be deceased in July 2025. This child had been placed in foster care from nine months of age until just before her third birthday. Law enforcement officials suspected homicide, but were unable to find the child’s body.
A four-year-old boy who had not been seen by anyone for almost a year was found buried in his father’s backyard. The father stated that he did not know the cause of the child’s death. There was a CPS report on the family alleging the father was locking the child and his siblings in their bedrooms from 6:00 PM until 10:00 AM the next morning, leaving the children to defecate and urinate in their bedroom.
Two children, ages 7 months and two years, died of dehydration or starvation. The drug addicted mother was arrested and charged with abandonment, criminal mistreatment and manslaughter, according to a news story.

Two young children died in a housefire with no adults in the home at the time of the fire. Two children died in car crashes with inebriated parents. At least seven children died due to physical abuse, but this may be an underestimate because the cause of death of the child who vanished and was never found is unknown, while the cause of death of the child buried in his father’s backyard is not stated in the fatality review. Another 2–3-day old infant taken to an emergency room had a brain bleed, though the cause of the child’s death was uncertain.

One child drowned.

Some of the most shocking information in these reviews does not concern the cause of a child’s death, but rather the circumstances in which the child’s death occurred:

A two-year-old child placed in foster care after ingesting fentanyl in his parents’ home died of a fentanyl overdose during the first overnight visit with the parents, a visit that had been agreed to by all parties despite indications that the parents were continuing to abuse drugs.
A two-month-old infant died due to physical abuse of his father, who had abused another infant in 2023 and been criminally charged for child abuse, after a CPS assessment concluded the infant would be safe in the parents’ care.
There was an open CPS case on the 7-month-old and two- year-old who died of starvation and/or dehydration, and grandparents described as the mother’s only support strongly warned the CPS caseworker that the children were not safe.

Lengthy histories of child maltreatment of multiple children in the families were frequently disregarded or given little weight, as caseworkers assessed risk of imminent harm to the alleged child victim in the family based solely on current conditions. Not surprisingly, it was usually the youngest child in the family who died due to a drug overdose, unsafe sleep practices, physical abuse, or other causes mentioned above. Child safety as reflected in CPS assessment described in the fatality reviews meant little more than “physically safe at the moment as far as could be determined by observing the child and conditions in the home.”

There had been prior dependencies on behalf of siblings of deceased children in several families, as well as voluntary placements and informal placements of children with relatives.

Chronically referring families and child maltreatment fatalities

Most of the families of child victims had extensive histories of CPS reports, both screened in and screened out reports. The median number of CPS reports prior to the child fatality that was the subject of the review was nine, though the majority of reports concerned children other than the child victim. Ten families had 14 or more reports over a period of several years and one family had 85 reports. Seven families had less than 5 reports; only two families had one or two reports.

These families fit the profile of chronically maltreating families discussed in last month’s Sounding Board: lengthy histories of parental substance abuse, often with co-occurring mental health disorders; indication of domestic violence (DV) was noted in half the families, though it appears there was no attention to DV in some family assessments. Most families were reported for multiple types of neglect and also for physical abuse. Sexual abuse and/or sex trafficking was reported in a few families. In families with five or more CPS reports prior to a child fatality, allegations of chronic multitype maltreatment were the rule, not the exception.

I began reading the fatality reviews with the hypothesis that child fatalities due to drug overdoses and unsafe sleep practices occurred in families with different dynamics than with other families of child victims, especially families with a history of DV in which children died due to the physical assault of a caregiver. This hypothesis turned out to be mistaken. Much to my surprise, a history of DV was often noted in families of both abuse and neglect victims, including families in which a child died of a drug overdose or an unsafe sleep practice such as co-sleeping with a parent under the influence of drugs or alcohol.

The presence of DV was a marker for chronic multitype maltreatment that sometimes led to neglect related fatalities and, at other times, to horrific deaths from physical abuse. For example, B.L., a five-year-old supposedly (and suspiciously) was reported to have died from unsafe sleep. There were 15 CPS intakes on the family over several years. According to the fatality review, the father beat the mother “beyond recognition.” The family was uncooperative with CPS caseworkers, which was common among these families, and was not engaged in a service plan at the time of their child’s death.

Most of the chronically referred families were not interested in services, which left children living in high-risk families without caregivers’ participation in substance abuse or mental health services. When present, service plans almost always focused on substance misuse and rarely on parents’ mental health conditions which, in a few instances, included hallucinations and/or disorientation as well as DV. Child fatality reviews often mention inadequate attention to parents’ mental health service needs and DV, in part because of the lack of such services in rural areas of the state.

A case example

D.M., a child born in December 2022 died in October 2024 after ingesting buprenorphine, a drug used to treat opiate addiction. The mother stated that she found the pill on the floor of her grandparent’s home and left the pill on the counter. There was no explanation of how D.M. came to ingest the pill as the child was not walking at age 22 months.

There were 15 CPS reports (9 screened in), several from family members concerned about neglect of D.M. and the child’s older sibling and about drug and alcohol abuse by both parents, severe mental health concerns that included two suicide attempts by the mother and hospitalization of both parents during 2024, and recurrent domestic violence. During the summer of 2024 the father was arrested for “spitting on, kicking and hitting” the mother, who subsequently minimized the extent of violence directed at her. The father was incarcerated on numerous occasions, including once for attacking and damaging a police car.

Both children received inadequate basic care. The parents were reported for both dental neglect of D.M. and for chronic medical neglect of D.M.’s impaired vision and swollen feet and legs, conditions that are poorly described in the fatality review. One provider urged the mother during a home visit to take D.M. to an urgent care after the provider found D.M. to be severely dehydrated and to have “goopy eyes” and “swollen appendages.” D.M. was found to have facial injuries on several occasions which the parents stated occurred in falls or when D.M. grabbed for objects from his stroller. The fatality review raises the question of whether D.M. was walking, or attempting to walk, when these injuries occurred, given that the child was not walking during the days preceding the fatality.

This case was closed several times by caseworkers even though the parents had done little or nothing to address their substance abuse, mental health conditions and DV., or to assure that D.M. received adequate medical care. The most egregious deficiency of CPS interventions in this family was the lack of interest or concern in D.M.’s developmental delays and chronic health conditions, as if these concerns were tangential to the reasons for CPS involvement with the family. It seems that D.M.’s health and well-being was not a major concern of CPS caseworkers whose main goals were to investigate whether allegations in the most recent CPS report were founded or unfounded and to determine whether there was risk of imminent physical harm to D.M., per KFTA legislation.

The fatality review faults the CPS interventions in this family for being “incident-focused,” and giving insufficient attention to substance abuse, mental health, DV and child development issues. The review also notes caseworkers’ comments regarding the pressure in their office to close cases in a timely way which, in effect, meant to close out chronic maltreatment cases without waiting for parents to benefit from therapeutic services or to assure that children with developmental delays and chronic health conditions received services and medical attention.

KFTA

Several fatality reviews comment on the difficulty of meeting KFTA’s requirement that a child must be at risk of imminent physical harm to justify an involuntary child placement. Even after KFTA was amended to give ‘great weight’ to a caregiver’s use of fentanyl in judicial decision-making regarding removal of a child from the parents’ home, caseworkers in some offices commented on their confusion and uncertainty regarding how their juvenile court would apply the ‘great weight’ clause of the revised KFTA statute. (see M.K., 2024)

I read several cases in which “active safety threats” were present, some of which were pointed out by the review committee, e.g., a child who almost died due to untreated pneumonia repeatedly removed from the care of relatives by a mother experiencing periodic hallucinations. The fatality report states: “The committee acknowledges that the staff believed, based on their experience in prior cases, that the court would have denied the dependency petition.” From the caseworkers’ perspective, the law was what judicial officers said it was, regardless of statutory language. There has been far too little discussion regarding the influence of the judiciary in determining how KFTA has been implemented by DCYF caseworkers.

However, juvenile courts should not be blamed for the shocking ineptitude of CPS assessments and service plans that preceded many of these child fatalities, especially in regard to chronically referring families. Some fatality reviews comment on the incident focus of CPS investigations/ assessments in cases with well established patterns of child maltreatment, the lack of attention to parents’ mental health challenges or DV, and to children’s developmental delays and chronic health conditions. What is most distressing about caseworkers’ approach in many (but not all) of the chronically referring families was their implicit acceptance of conditions in the home and in the daily care of children with complex needs that would not meet any defensible standard of parenting. Any idea of a minimal standard of care had been abandoned.

It appears that some caseworkers and their supervisors became gradually desensitized to chronic maltreatment. In 2003, two English scholars wrote in an article on chronic neglect: “Over a period time, particularly when nothing changes, the social workers may find themselves getting ‘drawn in’, becoming used to a standard of care that, if encountered in a new situation, would strike them as unsatisfactory. In a sense, the worker stops seeing what is happening to the child and becomes quite ‘stuck’.” (Tanner & Turley).

The public policy debate regarding the increase in child maltreatment fatalities and near fatalities has been largely about revisions to KFTA. These fatality reviews strongly indicate that the KFTA standard for involuntary child placement, i.e. risk of imminent physical harm, is woefully inadequate to protect chronically maltreated preschool children. Still, the main lesson of these reviews is that DCYF must alter its approach to chronic multitype maltreatment, not just to prevent fatalities and near fatalities, but also to prevent and reduce severe harm to children’s health and development.

There was a marked deterioration in the quality and candor of 2025 fatality reviews compared with prior years. Information regarding cause of a child’s death and specifics regarding criminal charges filed on a parent is withheld in some 2025 reviews. There is also a reluctance to “call out” bad practice evident in some of the most recent reviews. ©

References

Child Fatality Reviews, 2024- 2025, Washington State Department of Children, Youth and Family Services, Olympia, Washington, available online.

“Federal Way man abused daughter, 5, to death,” Seattle Times, May 31, 2025.

Girgis, L., “Oakley Carlson, missing from Grays Harbor County since 2021, declared dead, Seattle Times, October 8, 2025.

Meyers, D., “Police in Eastern Washington arrest woman after finding dead baby, starved toddler in apartment,” The Chronicle, posted February 27, 2025.

Meyers, D., “Selah police locate body while investigating whereabouts of child.” Yakima Herald-Republic, April 19, 2025.

Perry, B., “Everett mom accused of stabbing her child 41 times,” Fox 13, Seattle, April 19, 2024.

Tanner, K. & Turley, D., “What do we know about child neglect? A critical review of the literature and its application to social work practice” (2003), Child and Family Social Work, vol.8, 1, 25-34.

See past Sounding Board commentaries

©Dee Wilson

deewilson13@aol.com