Report lists cause of 2008 death as ‘undetermined’ — infant died in ‘unfit’ living situation

Published 12:00 am Tuesday, December 1, 2009

By Kathy Chaffin
kchaffin@salisburypost.com
Emanuel Campusano Jr. was born Aug. 10, 2007.
On May 2, 2008 ó eight months and 22 days later ó the infant “was found unresponsive, lifeless at home, with failure to respond to resuscitation measures by EMS at the scene,” according to the findings of a Dec. 11-12 state child fatality review of his death.
Jeff Olson of the N.C. Division of Social Services shared the 15 findings with more than 20 Rowan County officials, including the review team members, Friday afternoon.
Olson said the cause of death is listed as “undetermined” pending additional studies and investigation information by the N.C. Medical Examiner’s Office. The infant had reportedly been sleeping on the couch with his father and sibling prior to his death, according to a report prepared by state reviewer John Weil, who has since taken another job.
The infant was “reportedly on a pillow on the couch between the legs of the father who had one leg on the floor, one on top of the couch, with a 19-month-old sibling sleeping on his chest,” the report said. Emanuel Campusano Sr. stated his son was fine when he got up, it said, and two to two-and-a-half hours later, the mother, Tana Maria Mings, “noted that the infant was unresponsive.”
Though the infant was born prematurely and had fluid on the lungs, the report said he had been healthy since that time. “The cause of death is unclear,” it said, “however in the context of inappropriate sleeping arrangements, overlaying/suffocation cannot be ruled out.”
A Salisbury Police Department Supplemental Investigation Report said two people interviewed were not surprised that the infant had died and went on to say that the mother has been known to take Oxycontin painkillers and that the father smoked marijuana.
One of the people interviewed said “the living room environment for both the deceased infant and his sister was unfit (with) bugs, filth and clutter. The infant has never had a bed, always slept on the couch …”
The Salisbury Police Infant/Child Death Investigation Report said, “Child always slept on a couch in the living room … No rails, bed sheets or blankets located at scene. Standard bed pillow, with cotton, loose fitting pillow case.”
A review is required by state law whenever deceased children and their families have received child protective services from the local Social Services department within 12 months of the death.
Among the findings are:
– Family members and community professionals had concerns of suspected child abuse/neglect and did not consistently make reports to the Rowan Department of Social Services.
– Community professionals frequently report concerns of suspected child abuse/neglect to Social Services staff, but not through the Intake Unit.
– Social Services staff frequently receive information/concerns from community professionals, but do not consistently forward information to the Intake Unit to be processed as a new report.
– Social Services assessments were not thorough at times, including documentation, contacts with the family and utilization of collateral contacts.
– The State Child Fatality Review Team believes court involvement could have been utilized at different times during Child Protective Services’ involvement to address the safety and well being of the children.
– Following the fatality, while Social Services was still involved, the family moved, and the staff did not transfer the case to the new county of residence.
– Social Services social work supervisor allowed/delegated case management responsibility to a social work intern.
Olson presented 10 recommendations in the report, noting that even if they had all been in place at the time of the infant’s death, “we don’t know whether it would have had an impact on Emanuel’s death or not.”
Among the recommendations are:
– The local Community Child Protection Team will continue existing efforts and explore additional opportunities to educate the public and community professionals on the risks of co-sleeping and safe-sleeping techniques.
– The team will also educate the public on the mandatory reporting requirements of suspected child abuse/neglect.
– Rowan Department of Social Services will explore ongoing/additional staff training on receiving information of suspected child abuse/neglect and making reports and/or forwarding information to Intake Unit.
– Social Services staff should follow guidelines outlined in the state Children’s Service Manual requiring all allegations and risk factors to be thoroughly assessed during the course of a Child Protective Services assessment. Social workers should use all internal and community resources to assist in assessing risk factors and completing a thorough assessment.
– Social Services should also follow state guidelines calling for the agency “to provide, arrange for and coordinate interventions and services, as needed, that shall focus on child safety and protection, family preservation and the prevention of further abuse or neglect.”
– Social Services should follow the department’s internal policy to maintain sufficient contact during an open assessment and/or case planning/case management case.
– Social Services should include relevant community professionals in Child and Family Team meetings in order to make effective use of the process. This will ultimately benefit the family.
– Social Services will utilize social work interns in a manner which is appropriate relative to their experience and abilities.
Arnold Chamberlain, a member of the Child Fatality Review Team, said if the social workers had initiated court involvement, “in my opinion, the child would still be alive.”
In 1997, when Rowan County had four child fatalities with Social Services involvement resulting in legislation requiring state reviews, he said officials decided: “We’re not going to continue to do the same thing the same way. That was the famous statement …”
“If the same thing is done here that we’ve done before,” he said, there’s a possibility this might happen again.
Review team member Wanda Allen said, “I think the DSS as a whole accepted what blame they felt was deserved and did so gracefully, and I appreciate that.”
Tom Brewer, program administrator for the department’s children’s services division, said there was a lapse of communication between the staff and community stakeholders. A response plan implementing the recommendations of the report addresses that, he said.
Jeff Morris, who heads up the Community Child Protection Team, said the response plan will be made public as soon as the staff is trained on how to implement it.
Social Services Director Sandra Wilkes said the dangers of co-sleeping will be addressed as part of a Child Well-Being Community Roundtable scheduled for June 30.
Jim Sides, Social Services board member and former county commissioner, said of the report, “Hindsight’s always 20/20. If we look back, we see a lot of things we couldn’t see in the situation.”
Sides said it’s important for the public to understand that Wilkes, her staff and board “go the extra mile” to serve the county.
Chamberlain agreed. When he was leaving Monday’s Rowan County Task Force for Child Abuse Prevention meeting, he said he told Wilkes, “Good job, Sandra.”
“She said, ‘Well, Arnold you continue to hold us accountable.’ That was the last words she said,” he said, “and that comes from the boss.”
Members of the Child Fatality Review Team for the Campusano case were: Sheriff George Wilhelm, representing law enforcement; Susan Thomas, a school nurse representing the medical profession; Wanda Allen, court improvement coordinator representing prevention specialist; Chamberlain, Community Child Protection Team member; Leonard Wood, Child Fatality Prevention Team Chairman and director of the Rowan Health Department; Brewer; and Wilkes.
Contact Kathy Chaffin at 704-797-4249.

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