Sen. Seminara: Report shines “bright light” on government failings

February 21, 2024

Report: CT agencies failed to follow protocols before New Haven infant died of fentanyl overdose

By Lisa Backus
Hearst CT Staff Writer
Updated Feb 20, 2024

A report released Tuesday by Connecticut Child Advocate Sarah Eagan indicates state agencies failed to follow some of their own safety practices in dealing with the family of a New Haven infant who died of fentanyl poisoning last June.

The state Department of Children and Families closed its neglect and abuse case with the family of 10-month-old Marcello Meadows three weeks before he died of acute fentanyl, Xylazine and cocaine intoxication, according to an arrest warrant and Eagan’s report.

At the same time, officials with the state judicial branch Court Support Services Division were holding violation of probation arrest warrants for the baby’s mother, Alexandra Polino, but they weren’t served until after the child’s death, Eagan said in the report.

“Fentanyl remains a game-changer in terms of impact on adults and its impact on children,” Eagan said. “If we want to avoid removing children for their parents’ opioid disorder, our safety planning has to be at the top of its game. We need to have a sober caregiver with the child and there has to be quality assessing how the case is being handled every week. We aren’t there yet.”

A judicial branch official in charge of probation said Tuesday the agency “addressed the policy violations identified in this report to ensure similar violations will not occur in future cases.”
“The Judicial Branch worked closely with the Office of the Child Advocate with respect to the branch’s involvement in this investigation,” Gary A. Roberge, CSSD’s executive director, said in a statement. “The branch has addressed the policy violations identified in this report to ensure similar violations will not occur in future cases. Although the branch’s policies and procedures were found to be sound in the areas reviewed, we will continue to review and discuss whether additional modifications should be implemented.”

DCF officials said they are working to address the issues outlined in the report including enhancing the fentanyl testing process for families and having better communication with providers and probation.

“The Department acknowledges the OCA’s observations regarding this case and our shared focus on continuous quality improvement for all agencies and partners who comprise the child welfare system,” said DCF Commissioner Designate Jodi Hill-Lilly. “While the Department may have a different perspective on some of the OCA’s findings and conclusions, we are reviewing the recommendations and remain committed to collaborating with the OCA, our sister agencies and other system partners to support and improve the safety and well-being of the children and families we collectively serve.”

The report on Meadows’ death is the third Eagan has done in the past year focusing on alleged shortcomings of other state agencies, including DCF and CSSD that were involved with the families when the fatalities of three infants and toddlers occurred since 2022.

Meadows was the 11th child under the age of 2 ½ to die of fentanyl poisoning in Connecticut since 2020. During the same period, there have been 30 cases of children under the age of 5 surviving fentanyl poisoning who were saved by emergency physicians and personnel who administered nalaxone to stop the overdose, Eagan said.

In the past year, Eagan previously issued the reports on the fentanyl death of one-year-old Kaylee Schubel in her Salem home with her parents in February 2022 and the death of Liam Rivera, a 2-year-old whose body was found buried in a shallow grave in a park in Stamford in early 2023. In both cases, the children had been placed in the home with a parent and were under the purview of DCF when they died.

Eagan concluded after both deaths that DCF needed better safety planning when dealing with high-risk families and the child welfare agency needed to continually assess whether employees were following the practice guidelines.

Schubel’s death sparked DCF to issue new guidelines in August 2022 on what protocols employees should follow to handle families dealing with fentanyl addiction.
But Eagan’s investigation into Meadows’ death indicates that some of the new guidelines weren’t followed, including that staff didn’t conduct required home visits in the weeks after the safety plan was formed and there was no indication a supervisor reviewed how the plan was working every two weeks, the report said.

“This report shines a bright light — yet again — on several instances where state government has failed a child under its supervision,” said state Sen. Stephen Harding, R-New Milford, and Sen. Lisa Seminara, R-New Hartford, in a joint statement issued Tuesday after the report was released. “This is the third report from the Child Advocate in a year which has pointed to systemic shortcomings. That is simply unacceptable. Equally galling is that new protective guidelines weren’t followed in Marcello’s case.”

“What we want as lawmakers, and what the people of Connecticut deserve, is accountability,” the senators said. “They want government to learn from its mistakes and not repeat them. We must hear directly — as soon as possible — from state child protection officials on what steps they are taking to bring about that accountability and prevent future senseless tragedies.”

The 10-month-old Meadows had been under the purview of DCF since birth after he was born with Neonatal Opioid Withdrawal Syndrome and failure to thrive, Eagan said in the report.

She concluded that DCF caseworkers had done the minimum number of in-person visits with the family, but didn’t fully review the history of the child’s father who was in the home. The 10-month-old’s case was closed with DCF despite his mother having repeated positive drug tests in the months before Meadows died, the report said.

“OCA found that while agencies involved with this family provided some supervision and multiple referrals to community-based treatment, they did not fully comply with their own policies/procedures regarding risk and safety management,” Eagan said in the report. “OCA also finds that agency and policies and processes for assessing and managing risk/safety need further improvement.”

As part of the safety plan, Meadows’ father was identified as the sober caregiver, even after a background check showed previous arrests, Eagan said. The agency didn’t obtain records from CSSD that would have showed his history of drug use or his prior involvement with DCF, Eagan’s report said.

Eagan also noted that as part of her investigation, DCF didn’t provide her with the original safety plan, only a revised copy that was issued six months after the plan was implemented. Eagan also said in the report that the plan didn’t include details of how Polino would parent a newborn and Meadows’ 3-year-old sibling with constant supervision when his father worked outside of the home.
“That’s not practical,” said Brendan Burke, assistant child advocate, who also worked on the investigation.

Although CSSD had obtained violation of probation arrest warrants for Polino based on arrests she incurred while pregnant with Meadows, some weren’t served until after his death, the report said. The report also indicated that no agency, including DCF, CSSD or a community service provider Polino was required to see, was responsible for making sure she was tested frequently for fentanyl use while she was caring for the children.

Many of the drug tests that were performed on Polino came up positive for fentanyl, Eagan said, but DCF closed the case in early June concluding she had met the requirements to be removed from the purview of the agency. On June 27, her methadone treatment provider asked for a welfare check for Polino since she hadn’t shown up for three weeks, the report said. Meadows was found dead in her New Haven home the next day, the report said.

Polino is being held in lieu of $272,500 bond after being charged with first-degree manslaughter, two counts of risk of injury to a child and three counts of violation of probation after her son’s death.
Hill-Lilly said in a lengthy statement issued Tuesday that the agency identified “system improvement opportunities” and “areas of best practice that have continued to be addressed and reinforced over the past six months.” Those areas include examining employee turnover in the service providers the agency hires to help families. In Meadows’ case, the service provider had high turnover leading the team working with his family “newer to their roles.”

The agency stopped short, however, of saying it would be more transparent in its dealings, citing Connecticut law. Under federal law, DCF is required to release information on children who have died or nearly died while under the purview of the agency.

Based on the findings of her investigation, Eagan is calling for more scrutiny of the DCF policy outlined in its employee contract allowing workers to be remote four days a week. She is also recommending that DCF become more transparent and comply with a federal law that requires the agency to report its history, involvement and the circumstances of deaths or near deaths of children who are receiving services from the agency.

DCF also needs improved safety planning, especially for high-risk children who are living with a caregiver addicted to fentanyl and Eagan said there needs to be more wraparound services available to families dealing with substance abuse.

“We value our ongoing dialog with the department and look forward to candid, constructive conversations about these challenging issues,” Eagan said. “We also look forward to working with the legislature, DCF and the governor’s office to address these challenging child safety and family support issues.”