This is one of the 88 stories of children dying at the hands of their caregivers reported in the recent Safe Passage For Children investigation of child death in Minnesota. The report suggests why this tragedy is happening in our state and how we can make life safer for at risk children (in the read more at the end of the article). Please share this with your contacts and State Representative.
Lylah Koob, Goodhue County
In November 2018, two-year-old Lylah Koob was killed while in the care of her mother’s boyfriend, who became frustrated with the child after she vomited, and subsequently admitted to shaking her. Lylah’s autopsy revealed she had sustained a subdural hematoma (bleeding on the
brain) as well as significant acute injuries behind both eyes.
Lylah’s 4-year-old brother was interviewed during the investigation and reported that the boyfriend hit Lylah on the face after
she threw up.
Prior to the child’s death, seven reports were made to child protection, five of which were assigned to Family Assessment, one of which was screened out, and one which was recorded as an investigation, though an investigation was never actually done but rather the case was
closed without services.
Child protection reports contained allegations of physical abuse, sexual abuse, and unhygienic and unsafe conditions, including rotten food, garbage, drugs, alcohol, and sharp objects accessible to children throughout the home.
A Family Assessment was conducted just 20 days before the fatality following a report that the mother and boyfriend were hitting the children with objects and dragging them by their hair. This assessment was closed with no services recommended or provided.
Combined Impact of Family Assessment
and Family Preservation Practices
As indicated in the Executive Summary, our analysis revealed a number of patterns where Family Assessment combined with ongoing casework practices gave undue weight to family preservation and reunification and resulted in harm to children:
• Repeated inappropriate assignment to Family Assessment.
• Inaction in the face of chronic multitype maltreatment, i.e., chronic neglect that
deteriorates over time into physical abuse and/or sexual abuse or torture.
• Neglect cases with seemingly limitless chances for parents to address chronic problems,
exacerbated by ineffective safety planning.
• Returning children from foster care before parents have made the necessary behavioral
changes.
• Red flags that were missed or ignored by medical providers.
• Concerning number of children killed in foster care, especially kinship placements.
• Alarming number of cases (12%-15%) that had signs of or clearly were torture.
• Children returned to parents with serious mental illness
We use each of the case summaries in the following sections to illustrate one of these patterns, although many exemplify a number of them. A summary of the SME comments is also provided for each section.
Repeated Inappropriate Assignment to Family Assessment
Out of the fifty-nine cases with Minnesota child protection history, thirty-one had at least one Family Assessment prior to the fatality. However, this number is likely higher because the court records did not consistently indicate to which track past cases were assigned.
The families in our study had a range of one to six Family Assessments prior to the fatality event. Sixteen of the fifty-nine cases (27.1%) had two or more Family Assessments, and there were three or more Family Assessments in eight cases (13.6%).
There may also have been previous maltreatment reports that were screened out, but neither court documents or county reports consistently recorded this information. We believe it is self-evident that the repeated use of FA in chronically referred families is inconsistent with the policy that FA be used only in low-risk
cases.
An alternative practice would be one used in past years by Illinois, which allows a case to be assigned to AR only one time.
Viewed from another perspective, 20 of the 59 fatality cases with Minnesota child protection history were never investigated by child protection services. The following cases of Lylah Koob and Sophia O’Neill represent a number of other child maltreatment deaths that might have been prevented through conscientious investigations, rather than the repeated, risky use of FA.
ALL ADULTS ARE THE PROTECTORS OF ALL CHILDREN
KARA Public Service Announcement (30 seconds)
KARA Signature Video (4 minute)
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