The state’s embattled child welfare agency failed a Lynn infant by leaving him in a chaotic home where he was fatally beaten last year, allegedly by his mother’s drug-addled boyfriend, according to a scathing report released Friday by the Massachusetts child advocate office.
After months of review, the independent office concluded that the Massachusetts Department of Children and Families should have taken into protective custody 3-month-old Chase Gideika and his twin brother, who were born with drugs in their systems.
“Chase and his twin were identified as substance-exposed at birth and were sent home from the hospital despite a clear risk of maltreatment,” the review concluded. “The personnel in this area office erred in their judgment by sending these infants home.”
The report comes just days after Olga Roche, the DCF commissioner, resigned amid mounting criticism of her job performance. During her tenure, at least five infants or preschoolers whose families were involved with DCF died, including Jeremiah Oliver, who was missing for months before authorities realized that was the case. Roche was in charge of DCF at the time of Chase’s death.
The infant died in July 2013 of a fatal beating, allegedly at the hand of his mother’s boyfriend, Anthony Gideika. Prosecutors said doctors who examined the body of the child, who had massive head injuries consistent with being violently shaken and slammed, had never seen abuse comparable to what was inflicted on the infant.
A year before Chase’s death, the agency had removed an older sibling of the twins from the home after receiving a report of neglect.
State officials asked the child advocate’s office to conduct the investigation after the fatal beating of Chase, which closely followed attacks on two other infants under DCF supervision. In each case, an infant was severely abused by a parent’s partner. One died, and the other had severe and permanent brain damage, the report stated.
The report did not provide details of the two other cases. It included specifics about the Gideika case that had been previously documented in news accounts.
In light of the abuse incidents, the report called on DCF to conduct “thorough and accurate assessment of all caretakers” to determine whether children are at risk of harm and criticized the agency for failing to heed clear warning signs with the Lynn family.
“During the DCF involvement with the families of Chase and the other two infants, DCF learned concerning information and failed to translate this information into interventions that protected the infants from harm,” the report stated.
Chase’s older brother was removed from the home in July 2012 after the toddler was found unattended in the street. His mother, Jennifer Nelson, and Anthony Gideika had passed out nearby after visiting a methadone clinic.
Court records show that both have a long history of drug addiction and erratic behavior. In the day’s before Chase’s death, Gideika learned that the twins were not his biological children, a discovery that led him to abuse prescription drugs, investigators said.
Chase's twin brother was not harmed and is in foster care.
The report acknowledged that deciding to remove children from troubled homes is often a difficult judgment call.
But Gail Garinger, the state’s child advocate, said the circumstances in the Lynn case were clear cut. “This is a child who should not have been in the home,” she said.
Garinger said that the agency did not give “sufficient weight” to the risk the infants faced at home and that the decision to leave Chase Gideika in his home was part of a broader focus on keeping families intact whenever possible.
That philosophical shift has come under criticism for leaving children in dangerous situations, the report noted.
“In the context of decision-making in individual cases, many felt that a shift in values had occurred and DCF was no longer taking custody of children when the agency should have done so and that children were remaining in their homes when they should have been removed to foster or kinship care,” the report found.
Between 2008 and 2012, the number of petitions filed by DCF to gain custody of children and put them in foster care fell 30 percent, the Globe reported last summer. During that period, reports of child abuse and neglect rose 6 percent.
Garinger said Roche, who took over leadership of the agency in April 2013, recognized the “pendulum had swung too far” toward keeping children in their homes and had worked to find a more balanced approach. Since Chase Gideika’s death, the agency has given sharper scrutiny to newborns with drugs in their system, she said.
Many child advocates said the renewed focus is long overdue and praised the report for directly confronting the agency’s mistakes.
“They absolutely failed the child,” said Laurie Myers, founder of Community Voices, a Boston-area child protection and victim advocacy organization. “We’ve seen it time and time again.”
Myers said DCF needs to “err on the side of caution” when children may be at risk and adopt specific guidelines for newborns who are exposed to drugs.
In a statement, DCF said it had already intensified its screening of young children in troubled homes.
“The tragic outcome in this case is deeply saddening, and we are using the lessons learned to implement changes to strengthen our child welfare safety net,’’ the agency said. “The department is aggressively adding new staff to reduce caseloads and strengthening our training and reporting around substance-exposed newborns as part of these comprehensive efforts.”
The agency said it had hired 150 social workers and staff in the past four months to ease caseloads, which have been criticized as excessive.
The agency has stepped up scrutiny of cases involving young children whose parents have a history of substance abuse, mental health issues, or domestic violence. Roche also directed that all reports of abuse and neglect involving a drug-exposed newborn be investigated and that clinical and legal specialists should meet to decide whether to assume custody. If DCF decides not to take custody, services should be in place before the baby comes home from the hospital, the report said.
Jetta Bernier — executive director of Massachusetts Citizens for Children, an advocacy group — said the cases of Chase Gideika and the other two children illustrate the heightened risk for children who live with unrelated male caregivers. Research has shown that children in such homes are far more likely to suffer physical, sexual, and emotional abuse and are 50 times as likely to die from inflicted injuries, she said.
“We see the same thing happening,” she said. “The department can be helping these mothers understand what the risks are.”
Bernier praised the review, saying transparency in child welfare cases is crucial. “We have to learn from our mistakes,” she said.John R. Ellement of the Globe staff contributed to this report. Peter Schworm can be reached at firstname.lastname@example.org.