Child abuse “fatality review”: Rearranging the file cabinets on the Titanic

A government agency review of a child abuse death in Pennsylvania profanes the memory of the victim – Grace Packer – or as she always should have been known, Susan Hunsicker

 

She was born Susan Hunsicker.
When she died, at age 14, she was Grace Packer.

Child welfare systems, and a lot of reporters who cover them, put a lot of faith in the concept of child abuse “fatality reviews.”  Get experts to look at what went wrong, the theory goes, and we’ll learn the lessons we need to stop these tragedies from ever happening again.

Journalists vent much outrage at the lack of such reviews and/or the failure to make them public – and in fact, if you’re going to do them, they should be public. But too much faith is put in “fatality reviews” as a tool for systemic reform.

That’s because the whole exercise is based on two false premises:

● First, it assumes that broad, general lessons can be learned from the most extreme, most aberrant cases.  In fact, a process of random case review would be vastly more valuable, since you’d be more likely to find out what typically goes wrong. Such a process also would be a constant reminder that the errors go in all directions, with some children left in dangerous homes even as many others are taken from homes that are safe, of could be made safe, with the right kinds of help.

● Second, it assumes that reviews are done by people with the same professional experience, the same outlook and the same general mindset as the people who screwed up in the first place will produce get fresh, useful insight – instead of a collection of boilerplate, blather and excuses.

The failure of fatality review is most glaring when the agency is, in effect, investigating itself because the death occurred in a foster or adoptive home.

Case in point: A fatality review that actually profanes the memory of the child who died, a 14-year-old who was born Susan Hunsicker, but died as Grace Packer.

The facts of the case

When Susan Hunsicker of Norristown, Pa., and her brother were taken from their parents, Rose and Rodney Hunsicker, the ostensible reason was that her parents were not able to protect the children from abuse by others. 

Apparently based on the assumption that they could do a better job of this, a county child protective services agency (or as they’re usually called in Pennsylvania, Children and Youth Services) placed the child with a foster mother who helped her husband rape the girl.  After the first rapist was convicted, she hooked up with a boyfriend whom she helped rape the girl again - and torture her, and murder her.

If the horrible facts sound familiar, but the name does not, that’s because, as I noted earlier, by the time she was raped, tortured and murdered her name was no longer Susan Hunsicker. It was Grace Packer.  Her foster mother, Sara Packer, had been allowed to adopt her and change her name.

There are two salient facts about Sara Packer. 1. She had a penchant for bringing child rapists into the   2. She worked for the private foster care agency that approved her as a foster parent – and placed Susan and a sibling in her home.

There is one salient fact about Rose and Rodney Hunsicker: They almost certainly could have raised their daughter safely with some help.  It can be said with absolute certainly they’d have done better than the system that took their children away from them.

As the Philadelphia Inquirer reported in 2017:

“[Their lawyer David Tornetta] said he came to know the Hunsickers as a loving couple who were unemployed but could have become better parents with some help. … "’I can't imagine what that young child went through," Tornetta said. "I guarantee you if that child had been in Rose and Rodney's care, it wouldn't have been anything like this. Nothing, nothing.

Tornetta told WHP-TV the parents jumped through all the hoops thrown in their path by child protective services. 

But it didn’t matter.  The system wanted Sara Packer to have these children, and that’s what was going to happen.  So the Hunsickers’ parental rights were terminated.

How this affects the fatality review

As a result of all this, anyone who reviews the case has strong incentives to willfully blind themselves to the real issues.  That is what happened in the Susan Hunsicker fatality review. (Perhaps we can restore some of the dignity stolen from her by the review by at least calling her by her rightful name.) 

The format of the document is odd – in effect, two reviews in one: one review done by counties involved in the case, the second done by the state, which simultaneously responds to the county review. Nevertheless, the report is remarkably revealing – but not in the way its authors intended.

The report reveals a system mired in minutiae and buck passing.  Over and over one reads recommendations that boil down to: Counties: You should do this. State response: We’re already doing it. If you don’t want to face the real issues, you point fingers at each other.

The report is, almost literally, a case of rearranging the file cabinets on the Titanic.  At one point it  

reveals a system whose idea of reform is “Establishing protocols regarding file organization throughout all counties …” The state’s response to another recommendation: “[T]he Resources and Cross-System workgroup of the PA Child Welfare Council will be reviewing this matter.”

Wow. Don’t you feel better already?

The recommendations themselves usually amount to little more than the equivalent of cutting and pasting from some manual somewhere about best practices. Were the circumstances not so tragic, the report would read like black comedy – something that might turn up in an episode of The Office.

Worst of all, of course, everyone overlooked the elephant in the room: Susan Hunsicker never should have been taken from her own home.  As long as CPS agencies don’t understand that children such as Susan Hunsicker can and should remain safely in their own homes with the right kinds of help, these tragedies will happen over and over.

“Misinformation … reported as truth”

It is sad but unsurprising that the reviewers gladly talked to caseworkers and supervisors but, apparently, never spoke to speak to Susan’s birth parents.  Were they too afraid of what they would learn?  Such an interview would seem particularly useful in light of one of the few findings from the county report that is useful:  “Reports provided to Lehigh County [by the private agency overseeing Susan’s foster care] contained many inaccuracies including wrong dates, and this misinformation was then reported as truth.”

Did it not occur to anyone to ask how much more misinformation has been reported as truth in this case – particularly about why Susan was taken away in the first place?  How many more children are trapped needlessly in foster care because of “misinformation … reported as truth”?

Making matters worse, the counties, in their report, have the gall to whine about how “overwhelmed” they are.  But what’s overwhelming them is the deluge of false allegations, trivial cases and cases in which poverty is confused with “neglect.”

Recommendations that would make things worse

Some of the recommendations made by the counties in their report would make this worse.  They suggest toughening enforcement of penalties for “mandated reporters” of child abuse who fail to report anything and everything.  That will only further scare them into further overloading the system with false reports.  That will both increase the chances of more children needlessly removed from their homes – like Susan Hunsicker – and more children in real danger being overlooked.

Another recommendation seems to suggest in effect, that agencies treat enough false reports as, in itself, evidence of abuse or neglect. That would encourage more malicious reports, as in: “If I just call often enough, they’ll have to substantiate it!” Still another recommendation would needlessly slow down reunification.

It’s the same idiocy that led to passage of similar laws in the wake of the revelations of abuse by another Pennsylvania foster parent – Jerry Sandusky. 

Then, having shown no vision, no insight into their own failings and no creativity about solutions, the county report says: Everything will be fine if you just give us more money! But Pennsylvania already spends on child welfare at the ninth highest rate in America –  even when rates of child poverty are factored in.

When the children are inconvenient – institutionalize ‘em!

But it gets worse still.

Having ignored the urgent need to keep children out of the system entirely, they actually recommend making it easier to use the very worst option for children – institutionalizing them. (Of course, they couldn’t know that this recommendation would become public just weeks after still another institution was exposed as a hellhole -- Pennsylvania’s own Glen Mills.)

But even when they’re not Glen Mills, Institutions don’t work --  except for CPS agencies. They can use institutions to get youth like Susan Hunsicker, whose problems the system did so much to cause in the first place -- off their hands and make them someone else’s problem.

The William Barr approach to full disclosure

A page from the report indicates how little
the State of Pennsylvania really wants us to know.

And finally, it’s a good thing there have been detailed news accounts describing what happened in this case, because it’s impossible to figure out from the public version of this report. That part of the report has been redacted into meaninglessness.  In fact, trying to figure out what happened to Susan Hunsicker based on this report is like trying to understand the Mueller Report based on William Barr’s summary.

Laws such as the Child Abuse Prevention and Treatment Act put a lot of faith in fatality reviews. So does the execrable report from the so-called Commission to Eliminate Child Abuse and Neglect Fatalities.

But, as the report on the death of Susan Hunsicker makes clear, fatality review can be fatally flawed.

An adopted foster child dies in Hawaii – but nobody seems to be asking the right questions

Ariel Sellers, as she was known before her adoption, was reported missing by her foster/adoptive parents.
Now they've been charged with her murder. (Honolulu police dept. photo)

We don’t know why six-year-old Ariel Sellers was taken from her parents. 

But we do know this: 

● Relatives were ready to take her in. They say Hawaii’s family police agency, known as “Child Welfare Services” (CWS) ignored them. 

● Instead Ariel was placed with strangers, Isaac and Lehua Kalua.  Ultimately, they adopted her and changed her name. At the time of her death, her legal name was Isabella Kalua.

● The foster/adoptive parents, who initially reported the child as missing, have been charged with murdering the child.  She allegedly died trapped in a dog cage with duct tape covering her mouth and nose. 

● Despite the pleas of relatives, Isabella’s siblings are still in foster care with strangers. The family is fighting to bring them home, and to overturn the adoption so at least in death Ariel will have her name back.

It’s all stunningly reminiscent of the tragic death of Sara Hunsicker in Pennsylvania.  (She’s better known as Grace Packer because before raping and murdering her, the foster/adoptive parents changed her name.) 

Diversion and double-standards 

But just as in the Hunsicker case, in this latest death the child welfare establishment has been quick to divert attention from its own failings.  And just as in the Hunsicker case, there’s been a tragic double standard in the response. 

CWS is actually whining about budget cuts and staff shortages – as though if you just made the agency that refused to place Isabella with relatives and rushed her into a quick-and-dirty adoptive placement even bigger, this wouldn’t have happened. 

And while whenever the alleged killer is a birth parent, there are accusations that government is going too much to keep families together, now that this child died in a foster/adoptive home, no one is asking if Hawaii is doing too much to tear families apart – even though Hawaii is another one of those states that has a hair-trigger when it comes to tearing apart families.  

In 2019, Hawaii took children from their parents at a rate well above the national average – even when rates of child poverty are factored in.  When you tear apart so many families, there is an enormous incentive to rush children into any home with a bed without looking too closely.  More than three-quarters of those children were taken not because of abuse, but because of “neglect” – which often is confused with poverty. 

We also know that abuse in foster care is widespread, and we know that agencies often turn a blind eye to such abuse. 

We also know that there are profound incentives to rush children into slipshod, quick-and-dirty adoptive placements.  Under the so-called Adoption and Safe Families Act, states are paid a bounty of $4,000 to $10,000 for every finalized adoption over a baseline number.  What happens to the money if the adoption fails – or if the adoptive parents are accused of murder? Nothing – the state still gets to keep it! 

But the incentives go beyond the financial.  The one way an agency like CWS is guaranteed good press is when it gets those adoption numbers up. How many news organizations questioning what CWS did in this case have done treacly features about “Adoption Day” celebrations? How many will do them again tomorrow? 

So no, you can’t stop these tragedies by throwing more money at CWS or going on a caseworker hiring binge.  The only way to fix foster care is to have less of it. 

Only then will there be plenty of room in good, safe foster homes for the relatively few children who really need them.  And only then will workers have the time to find children in real danger, whether in their own homes or in foster care.

Why the “Foster-Care-at-All-Costs” Crowd Will Never Surrender Their Horror Stories

Imagine the following scenario: A child is taken from her parents. When child protective services decides to reunify the family the foster parents object. They wage a fierce fight, but they lose.

Sometime later, the child is dead. She was raped and murdered, allegedly by her mother’s boyfriend while her mother watched. Her body was packed in cat litter and stashed in an attic for four months. Then the body was dismembered and the remains dumped in the woods. Years earlier, a previous boyfriend of the same mother also had raped the child.

Such a story would be front page news for days, perhaps weeks where it occurred. It might well become a national story. And the theme, of course, would be that the Vast Family Preservation Conspiracy had struck again. A supposed fanatical desire to keep families together “at all costs” had led to tragedy.

Many journalists and politicians would gladly accept these claims as fact. Everyone from frontline workers to the agency chief would be fired. And entries into foster care would skyrocket.

The Real Story

As it happens, there really is a case like this in the news right now, involving a child in Pennsylvania named Grace Packer. With two slight differences.

Difference number one: It was the birth parents who fought for the child. As the Philadelphia Inquirer reported:

Rose and Rodney Hunsicker battled Berks County child-welfare officials for two to three years to keep their children, according to their attorney at the time. They did not want to lose custody of Grace and her two siblings.

 But Children and Youth officials in Reading fought “aggressively” to remove the children, alleging abuse by other adults in the home, Norristown attorney David Tornetta told the Inquirer…

 “I can’t imagine what that young child went through,” Tornetta said. “I guarantee you if that child had been in Rose and Rodney’s care, it wouldn’t have been anything like this … The lawyer said he came to know the Hunsickers as a loving couple who were unemployed but could have become better parents with some help.

I’m sure you can guess the second big difference: The alleged killers are a foster parent and her boyfriend.

Sara Packer, a supervisor for a county child welfare agency who fostered and then adopted Grace, stands accused of her murder along with her boyfriend, Jacob Sullivan.

Back in 2010, when Packer was married to a different man, that man was convicted of raping Grace and another foster child. He was imprisoned, but they did not divorce for another six years.

Packer lost her county job. But she was allowed to keep Grace.

The story is generating headlines in Pennsylvania. But when it comes to “lessons learned,” the usual double standard is apparent. No one is saying the case proves that Pennsylvania relies too heavily on foster care. No one is saying that a push for “foster care at all costs” is endangering children’s lives. No one is asking if middle-class rescue fantasies are taking precedence over child safety.

Why not? Perhaps people feel it’s wrong to generalize based on horror stories.

I agree.

Let’s Make a Deal

That’s why I have a standing offer to the advocacy community and journalists who cover child welfare. While I will not unilaterally disarm, I am prepared to accept a mutual moratorium on the use of all horror stories to “prove” anything.

The family preservation community can afford to take such a deal for the following reasons:

§  We don’t need horror stories to show that Pennsylvania takes away too many children and journalists should be asking why. We’ve got the data showing the state’s rate of removal is above the national average and far above the rate in states where independent monitors have found that family preservation improved child safety.

§  We don’t need horror stories to show that foster care is often unsafe and journalists should question its overuse. We’ve got study after study showing appalling rates of abuse in foster care – with even higher rates of abuse in group homes and institutions.

§  We don’t need horror stories to show the inherent harm of taking away so many children needlessly. We’ve got those massive studies of typical cases which show that children left in their own homes typically fare better than children placed in foster care.

But those whose approach to child welfare really boils down to take-the-child-and-run/foster-care-at-all-costs wouldn’t dare take such a deal. Because take away their horror stories and you know what they’ve got?

Nothing.

When the journalism of child welfare fails, part two: A reporter in Scranton has her facts wrong – and her blunder is hurting children

Lackawanna County, Pa., County Courthouse

UPDATE, JULY 11: We reached out to the Times-Tribune and, to their great credit, they have removed the story from their website and are reviewing our concerns.  

UPDATE, JULY 17: The Times-Tribune published a new story about these issues. It still has serious flaws, but it is free of factual error and no longer implies that an alleged emphasis on keeping families together was responsible for the horror stories.

Most of the time, when I take issue with the journalism of child welfare, it involves reporters who mean well but have taken to heart decades of conventional wisdom.  They’ve been as conditioned by health terrorism as the rest of us.  That’s why I usually don’t name the reporter, or at least don’t emphasize it, and focus on institutional failures. 

But the lead story in Sunday’s Scranton, Pa. Times-Tribune by Terrie Morgan-Besecker is so breathtakingly flat-out factually wrong concerning the most basic statistics that I’m making an exception. 

The story involves classic, tragic horror story cases.  The local D.A. has taken advantage of it all, bringing criminal charges against caseworkers and supervisors.  And now Morgan-Besecker is piling on with the false claim that, as the headline put it: “Lackawanna County's child welfare agency places far fewer children in foster care than other counties.”  According to Morgan-Besecker, the main horror story case “reflects a pattern in Lackawanna County, which has consistently placed far fewer children in foster care than several similarly sized counties since 2017…” 

Normally at this point, I would discuss the research showing that there is no correlation between rates of child removal and horror story cases; sadly they happen everywhere.  So there is no “pattern.” In fact, the more you overload a system with false allegations, trivial cases, and cases in which poverty is confused with neglect the more likely it is that the cases that become the horror stories will be missed. And if the cases Morgan-Besecker cites supposedly show a "pattern" of taking too few children, what does the even more horrific case of the rape, torture and murder of foster and adopted child Susan Hunsicker (known in news accounts as Grace Packer) elsewhere in Pennsylvania say about a "pattern" of taking too many and taking them needlessly?  

The basic errors of fact 

But, as the lawyers would say, we don’t even have to reach that issue here.  Because Morgan-Besecker’s claim about Lackawanna County taking fewer children is simply wrong on its face.  She piles error on top of error on top of error.  Let's go through them one-by-one.

● Morgan-Besecker compares Lackawanna County to five other counties: Berks, Erie, Lehigh, Luzerne and York.  Using data from an annual report from Pennsylvania Partnerships for Children she gives a figure for raw numbers for each county and then claims that the “similarly sized counties” had “significantly higher placement rates.” 

But it turns out the counties are not so similar.  When you compare the actual rates – that is numbers compared to child population -- two of the five comparison counties have lower rates than Lackawanna and a third is only slightly higher. 

Here’s how it comes out: 

County            Children “served” in foster care per thousand

Berks               4.4

Lehigh             4.5

Lackawanna  5.3

York                5.7

Erie                 8.2

Luzerne           11.2

It’s not as if Morgan-Besecker would have to go find population figures and run these numbers herself.  Pennsylvania Partnerships for Children obligingly provides the rate per thousand right under the raw number.  Like this: 

But that’s only the start of the problem. 

● Morgan-Besecker never explains why she chose these particular counties except to say they’re similarly sized.  In fact, there are several other counties that are closer in population to Lackawanna than some she included.  Look what happens when they are added to the mix: 

County            Children “served” in foster care per thousand

Butler              3.6

Berks               4.4

Lehigh             4.5

Westmoreland 4.5

Cumberland    4.8

Northampton    5.3

Lackawanna  5.3

York                5.7

Monroe           5.7

Erie                 8.2

Luzerne           11.2 

● In any event, Morgan-Besecker used the wrong line in the Pennsylvania Partnerships report for each county.  She used a line clearly labeled “Unduplicated Number of Children Served – All children in Foster Care During the Year.”  This is a figure that combines entries into care over the course of a year with the number of children already in care at the start of the year.  Check out the description:  

This figure can vary for all sorts of reasons.  It does not, in fact, measure what Morgan-Besecker claims it measures: “the number of children placed in foster care … in 2021, the latest year for which data is available.” 

There actually is a line in the Pennsylvania Partnerships report for each county that does measure this.  It’s the last line on the same page.  It’s the one conveniently labeled “Children Entering Foster Care – All Entries into Foster Care During the Year.”  This is what it looks like: 

When you use those figures, even the raw numbers tell a different story.  Berks County actually took fewer children and Lehigh took only six more.  Oh, and one other thing: The rate of removal in Lackawanna County turns out to be almost identical to the Pennsylvania statewide average.  (Unfortunately, this line does not compare rates, but the population data for such a comparison are readily available from the Census Bureau.) 

This still doesn’t tell the whole story.  Because poverty is both a cause of actual abuse and, far more often, something confused with neglect, the fairest way to measure rates of removal is to compare entries into foster care with the impoverished child population in each jurisdiction. Do it that way and, looking only at the counties Morgan-Besecker chose, the results are – the same. The rates of removal are lower – in fact, they’re a lot lower – in Berks County and Lehigh County.  And the rate of removal in Lackawanna County is very close to the state average.  (Again, you can get these data by comparing entries into care to Census Bureau data for impoverished children in each county.) 

An odd county to use as a model

The first county Morgan-Besecker singles out in her skewed comparison does indeed take away far more children than Lackawanna County or any of the others.  It’s Luzerne County.  But then, Morgan-Besecker has shown a fondness for that county’s approach for decades. 

I first noticed Morgan-Besecker’s byline on a story from 2002 when she was at the Times Leader in Wilkes-Barre.  The story no longer appears to be available online, but it's in NCCPR's database of "child welfare" news coverage. The headline on that one was: “From families first to kids first: The death of a girl in 1999 is a local case that brings into focus the new stress on protecting a child over preserving a family.”  The story goes on to quote the then head of the Luzerne County family police agency (a more accurate term than "child welfare" agency) almost bragging about the increase in the numbers of children his agency tore from their homes. 

The ugliest quote came from Pennsylvania’s single most fanatical advocate for tearing apart families, Frank Cervone.  Then, and until quite recently, Cervone ran Philadelphia’s rough equivalent of a CASA program. Here’s what he said in that 2002 story: 

"What AFSA has done is it says to the family, 'get well or get on.' We can't spend years trying to rehabilitate a family if those years are going to cost the child their childhood." 

As for opponents of ASFA, they were dismissed as “parents’ rights advocates” – the classic Big Lie of American child welfare - and one we were permitted by the Times-Leader to rebut in an op-ed column at the time.  

Now, in fairness, a lot of reporters believed the b.s. in Morgan-Besecker's 2002 story at the time. We didn’t yet have as much data showing that it was ASFA itself that would cost hundreds of thousands of children their childhoods – though the trend already was clear.  That's why plenty of children's rights advocates opposed it then and oppose it now.  Back then, Cervone was the Godsource for Pennsylvania media – and that’s one reason why, until recently, Philadelphia tore apart families at one of the highest rates among America’s biggest cities.  

And it wasn’t until five or six years later that the Juvenile Law Center exposed the kids-for-cash scandal that would make Luzerne County notorious across America. 

In the intervening years, Morgan-Besecker did write the occasional story about Luzerne County families who said their children had been wrongfully removed, and about failures in the county’s public defender office leading to missed deadlines for appeals.  And she covered the kids-for-cash scandal.

But now comes a story in which she still seems to think Luzerne County is some kind of model.  While other reporters have learned to treat his pronouncements with skepticism, Besecker still backs up the misleading out-of-context figures in her story with inflammatory quotes by, yes, Frank Cervone.

And once again, the token comment warning that the criminal charges against the caseworkers are likely to lead to more removals is presented solely as something that would be “unfair to families who don’t deserve to have their children removed” – as opposed to unfair to children who don’t deserve the trauma of needless foster care and the high risk of abuse in foster care just because their caseworker was scared of the district attorney – and/or the local newspaper. 

Responding to the data (or whatever he was told about the data) the D.A. declared that "The numbers speak for themselves.” 

They do.  But they’re not saying what either the D.A. or Terrie Morgan-Beseker says they’re saying.