OCA: Investigation into the Death of Tabatha B.

Investigation into the Death of Tabatha B.
released November 30, 1998
conducted by the Child Fatality Review Panel

Part I: Child Welfare Management
Part II: Long Lane School

Key elements of the report:


The full, 40-page investigative report, is available for download in Microsoft Word format by using the following link: Tabatha B

Summary of Findings

  • Although the Panel understands that progress has been made since the Juan F. Consent Decree was implemented, DCF’s failure to provide Tabatha with adequate intervention and protection during her first five years set the stage for an ominous pattern of deterioration in her mental health.
  • Over the course of her life, Tabatha did not receive the proper care and treatment necessary to address her need for permanence and her mental health issues.
  • After a long series of failed placements in foster homes, shelters, and a residential facility, Tabatha was ultimately placed in Connecticut’s only juvenile correctional facility, an institution that is overcrowded, lacks resources, is understaffed and does not provide the therapeutic milieu necessary to treat a diverse population of emotionally disturbed children.
  • Because Connecticut lacks appropriate treatment resources for emotionally disturbed children, Tabatha moved from one end of a continuum where she once had been regarded as a deserving victim to the opposite end where she was viewed as an undeserving delinquent.
  • DCF’s Long Lane staff failed to recognize the significance of Tabatha’s multiple suicidal behaviors exhibited prior to her death, and failed to conduct a comprehensive assessment of her mental health issues.
  • The State of Connecticut does not have a secure in-patient residential setting to treat those children who are not serious offenders but who are at risk of flight.
  • Long Lane School is a DCF correctional facility that operates without outside oversight, without accreditation and without licensing.
  • Staffing at Long Lane School is grossly inadequate to meet the needs of its diverse population
  • Long Lane School is failing to meet the mental health needs of many of Connecticut’s most troubled children. There is no comprehensive approach to mental health treatment, nor does Long Lane provide the intensive psychiatric care that many of the children require.
  • The environmental conditions at Long Lane School contribute to substandard living conditions and, in some respects, serve to jeopardize the safety of the children in residence.
  • Reports of abuse and neglect against children by staff and agency police officers are investigated by DCF Hotline, another branch of the same agency, without independent oversight of those investigations. The Panel believes that this practice presents a conflict of interest.
  • Use of force incidents involving DCF Long Lane police officers are not subject to an internal administrative review process within the police division of the institution.
  • Children at Long Lane School are routinely mechanically and physically restrained, often under circumstances which violates DCF’s policy.
  • Record keeping at Long Lane School is seriously deficient, to the extent that critical information regarding the children and their care is not being recorded.
  • Each department at Long Lane School operates as a separate entity with little or no sharing of information pertaining to each child’s condition or care.

Summary of Facts

Tabatha B., a bi-racial child, was born on
August 17, 1983 to a mother suffering from significant physical and mental health problems. No father was listed on the birth certificate, although paternity was later identified. Records indicate that her mother parented seven children, lost custody of five, and two other offspring died in a house fire.

The records reflect that Tabatha was the victim of physical abuse as early as two weeks of age and on numerous subsequent occasions. From infancy until her placement at Long Lane School, she was the subject of many referrals of sexual abuse and chronic neglect. She attempted suicide at the age of five and throughout her youth experienced numerous foster care placements and disruptions as well as psychiatric hospitalizations. A number of psychological and psychiatric evaluations were conducted over the course of Tabatha’s lifetime and the termination of the mother’s parental rights was recommended by professionals as far back as 1988. No action was taken to follow through on this recommendation. Tabatha was the subject of neglect petitions, a family with service needs petition and a delinquency petition. The courts had involvement with Tabatha and her family, including her younger sister and her mother, over the majority of her lifetime.

 

It was not until 1996 that, at the mother’s request, a petition to terminate her parental rights to Tabatha was filed by DCF. This petition was granted by the court on August 9, 1996. After this, Tabatha’s foster placement disrupted and she experienced additional placements in both foster homes and residential facilities. By the age of fifteen, Tabatha had periodically threatened suicide, had been the victim of physical assault, had been the victim of rape and had an established pattern of running away from placements. She experienced court intervention as both a neglected child and as a delinquent child which resulted in her dual commitment to DCF. After being committed as a delinquent, Tabatha was placed at a residential facility where she assaulted a staff member. She was then transferred to Long Lane School.

 

Tabatha’s stay at Long Lane School was fraught with minor behavioral infractions. She experienced a series of setbacks and disappointments over events that occurred during that period and over relationships with family and former caretakers. She made statements about suicide and, on one occasion, unsuccessfully attempted suicide. She was placed on safety/suicide watches on numerous occasions during this period. On September 26, 1998, a series of events occurred that led to administrative charges of assault, disciplinary action against her, and a planned suicide attempt on that day. She was found hanging in her room, was transported to a local hospital and placed on life supports. Those supports were terminated two days later, by agreement of medical personnel, DCF and Tabatha’s biological family. Tabatha died on September 28, 1998, at the age of fifteen.