To work well, government must get the small things right. Yet a close review after a tragic incident or emergency too often reveals that that’s where the public sector falls down.
Take the case of Aliana Lavigne, the Grafton infant found dead on April 11, eight days after the Grafton Police tried to alert the state Department of Children and Families that the baby, whose mother had a history of psychotropic drug use and mental illness, might be in a dangerous home situation.
So-called mandated reporters — professionals whose regular work brings them into contact with children — are supposed to report their concerns about possible child abuse or neglect verbally, and then follow up with a written report within 48 hours. The Grafton Police omitted the oral report. Instead, police faxed a written report, known as a 51A, to DCF’s Worcester office.
But DCF also messed up something simple. For reasons still not satisfactorily explained, the faxed report was misplaced for six days. So two public departments both botched the basics.
In the aftermath of Aliana’s death, the state has revised its reporting form and changed other procedures. The new form lists the telephone numbers for DCF’s area offices, something the old form didn’t do. That’s a smart change — but should it really have taken a tragedy to bring it about? Further, shouldn’t email provide another way to ensure that DCF receives and acknowledges written reports from mandated reporters?
The problem is hardly confined to state government. If ever there was a federal agency that has had a problem getting the fundamentals right, it’s the FBI.
Consider: Back in July of 2001, Gary Lee Sampson, then wanted for several bank robberies in North Carolina, called the FBI’s Boston office in an apparent attempt to turn himself in. An agency employee filling in for a switchboard operator on lunch break cut him off when trying to transfer the call. The next day, Sampson embarked on a killing spree during which he murdered three people. It’s not fair to blame the fill-in receptionist for those deaths, but it is reasonable to note that if he had been better versed in how to transfer a call, Sampson might have been taken into custody before his murderous rampage.
We’d like to believe that examples of federal departments making simple mistakes are few and far between, but as we’ve seen from inquiries sparked by the Marathon bombing, key agencies bungled some basics. For example, the FBI agent in charge of assessing older brother Tamerlan Tsarnaev after Russian authorities warned he had become radicalized didn’t interview Tsarnaev’s wife, friends, or former girlfriend, according to a report done by inspectors general for the relevant federal agencies.
“I can’t tell you how many cases are solved by estranged girlfriends,” says US Representative William Keating, a former Norfolk County district attorney. “That is basic.”
Nor did the agent ask Tsarnaev about a planned trip to Russia, a trip now considered an important clue to his radicalization. Indeed, the inspectors general weren’t able to say with certainty whether the US Customs and Border Protection officer on the Joint Terrorism Task Force in Boston had informed the FBI about Tsarnaev’s flights to or from Russia. Why? Because the CBP officer sometimes shared information like that verbally or by passing a sticky note. The CBP has since changed its procedure to require that notification be done by email.
Nor did the FBI share important information with local law enforcement. Last year, Ed Davis, then the Boston police commissioner, told the House Committee on Homeland Security that none of his four appointees to the FBI-led terrorism task force had been informed that Russia had warned the FBI about Tamerlan Tsarnaev.
It’s impossible to say whether a more thorough investigation and better sharing of information could have prevented the bombings, but it’s fair to say the odds of doing so would have improved.
So what’s the lesson? That it shouldn’t take a tragedy to focus on getting the basics right. Effective public managers should periodically ask: Are we doing this correctly? Do our procedures make sense? Or are there cracks things could fall through — that is, could this system fail? Has technology given us a better way?
Those might not be glamorous tasks, but the time to ask is now, not in tragedy’s aftermath.