It’s not unusual for a government agency report to anger lawmakers. It’s less common a report nearly brings them to tears.
This year’s child fatality report from the Office of Child Advocate did both at a May 21 meeting of the Rhode Island House Committee on Oversight.
“This, by far, is the worst oversight hearing I’ve ever had to sit through,” Rep. Julie Casimiro, a North Kingstown Democrat, said at the afternoon meeting, a flat and gray sky visible through the committee room’s windows.
Casimiro choked up as she addressed Child Advocate Katelyn Medeiros after Medeiros finished giving a presentation on the May 13 report, the first public documentation of child fatalities released in six years. The report, subtitled “A Review of Seven Fatalities and Twenty-Three Near Fatalities,” details dark and sometimes final chapters in the too-short lives of these young Rhode Islanders from 2019 through 2024.
The 30 incidents all involved substances, including a 1-year-old who almost died from taking suboxone that had been left next to candy atop a nightstand. All of the youths had past or present involvement with the Department of Children Youth and Families (DCYF). The report was the first public documentation of child fatalities released in six years.
Half of the report’s 118 pages are devoted to case-by-case narratives. Infants and toddlers accidentally exposed to substances comprise 14 of the cases, and teenagers who knowingly took drugs made up the remainder. Incidents involving younger children were more likely to occur when living with parents or relatives. The opposite was true for older kids, who often used drugs while in DCYF placements like foster homes or treatment centers, or while on the run from home.
The remainder of the report includes 19 pages of discussion plus 56 formal recommendations — some new, some old but unaccomplished, according to the child advocate. The Office of Child Advocate produced the report as part of its statutory responsibility to oversee DCYF. The hearing was attended by DCYF Director Ashley Deckert and Richard Leclerc, director of the Department of Behavioral Healthcare, Developmental Disabilities & Hospitals (BHDDH), which handles substance use prevention for young adults.
The week of the hearing marked Deckert’s second anniversary on the job; Leclerc assumed his role in March 2024. Medeiros became the permanent child advocate two months later, although she has worked in the office since 2012, with two of those years as interim director. But Committee Chair Patricia Serpa, a West Warwick Democrat, was unconvinced that much has changed even as agency leadership shuffled.
“This is the smallest state in the union,” Serpa said during the hearing. “And I just don’t know why we can’t get it together. This isn’t California. This isn’t Texas. The same things keep happening and happening and happening.”
‘Shared responsibility’
The DCYF budget for fiscal year 2025 was over $399 million. Deckert testified that DCYF currently has 43 vacancies out of 714 budgeted positions. That included 13 openings for child protective services investigators. The agency’s collection of social caseworkers is more complete, with only three vacancies out of 213 positions.
“Our staff do this work because they care deeply,” Deckert testified. “They carry the weight of every case and every outcome, even when the public doesn’t see it.”
DCYF became the first state child welfare agency in New England to receive accreditation from the nationwide nonprofit Council on Accreditation on Feb. 14. Accreditation guidelines suggest a maximum of 15 cases for one investigator, Deckert said, noting that maximum caseloads in Rhode Island range from 11 to 13.
“This report shows that the vast majority of what is being asked of us is already in process or has been done, and yet these tragedies still happen,” Deckert said. “Child safety is not the sole responsibility of DCYF, it is the shared responsibility of every system that touches a child.”
At the hearing, Casimiro asked Medeiros what she would do with the child welfare agency if she had “a magic wand.”
“That’d be a big magic wand,” Medeiros began, then went on to describe “a full continuum of care that can meet all levels of need here in Rhode Island” for children whose wellbeing is entrusted to the state. In 2024, there were over 2,300 children who had some contact with DCYF services, whether foster care, behavioral health referrals, or child protective services.
Among the report’s guidance is fortifying the state’s treatment options for adolescent substance use by forging a stronger connection between DCYF and BHDDH. Medeiros noted that 14 of the 30 incidents occurred in just the last two years, which she credited partially to “a fractured behavioral health system and a non-existent adolescent SUD [substance use disorder] continuum.”
Other mistakes included delays in coordinating care across agencies, the use of residential treatment as a first rather than last resort, and the exclusion of youth from decisions about their own care. Sometimes, DCYF referrals to care providers failed to include diagnostic information or insights into the youth’s history, Medeiros said.
“We’re seeing a net cast so wide that sometimes the providers that are receiving the referrals are not even specifically addressing, or do not address, the specific needs of that youth,” Medeiros told the House panel.
In a phone interview, Medeiros acknowledged structural quirks in how the state handles youth with both substance use and behavioral health needs. Other states may sweep behavioral and substance use treatment for youth under the same umbrella of governance. But years ago, Medeiros said, the state carved out substance use as the sole responsibility to BHDDH, regardless of age group.
That means every adolescent in the fatality review had both substance and behavioral issues and needed to access services from two different state agencies — not an ideal model for planning treatment.
“We don’t want kids to have to tell their story multiple times,” Medeiros said.
Tension between agencies
Deckert told lawmakers she found the Child Advocate’s report timing problematic. “The decision to release multiple years of reports simultaneously, though rooted in a desire for transparency, does present a significant emotional and practical burden,” Deckert said.
She said DCYF has already done much of the work the report suggests.
“It is also troubling that the Office of the Child Advocate made numerous recommendations without first acknowledging that DCYF is already implementing many of them,” Deckert told the Oversight Committee. “This omission not only misrepresents the current state of our work, but it also undermines the efforts.”
DCYF spokesperson Barb Francella confirmed in an email to Rhode Island Current that of the advocate’s 56 recommendations, 22 were already underway or completed. Only three recommendations require funding: expanding DCYF’s runaway investigations unit, adding a substance use coordinator position and establishing a referral policy for caseworkers whose clients need substance use treatment. Eight recommendations did not apply to the agency, Deckert said at the hearing.
This report shows that the vast majority of what is being asked of us is already in process or has been done, and yet these tragedies still happen.
Francella’s email highlighted recent efforts that address some of the report’s concerns, including joining a national child safety partnership to improve fatality reviews, launching an interagency collaboration to prevent child fatalities, and expanding its slate of community-based programs by 82% to 62 partners overall. The agency is also prioritizing family-centered care as part of its 2025-2030 strategic plan.
Rhode Island Current shared the email reviewing DCYF responses with Casimiro. She replied in a followup phone interview that she was “happy with most of them” and that her communication with Deckert, which she said began strong, has improved recently.
“I believe she is making changes,” Casimiro said. She later added, “I think Ashley is doing a great job. I mean, in these responses that you sent me, there was a little bit of fluff.”
Casimiro thought Deckert “needs to push back harder” to accomplish more profound change, but she also acknowledged the intense demands placed on Deckert’s role. That was made tangible at the hearing, as Deckert, like Casimiro, had to pause and gather herself as she began to broach the serious topic at hand.
The question of why the report took so long to emerge came up during the hearing. Medeiros told the House committee that for nearly two years, from 2022 to 2024, the office only had six people.
“We were kind of frozen in place with hiring,” Medeiros said. “I was in limbo, serving as both the child advocate and the assistant child advocate.”
Also taking place in that timeframe was the office’s 2023 investigation and report on abuses and neglect at the now-shuttered St. Mary’s Home for Children in North Providence. That report had made Medeiros a protagonist in a January 2024 oversight hearing. The child advocate’s office reviews all fatalities and near-fatalities of youth who have or had a DCYF connection.
Medeiros said her office is now working on another fatality report with 40 additional cases from 2019 to 2025 under review.
“Wait. Forty more?” Serpa replied.
“Yes, Madam Chair,” Medeiros said.
“That’s … unbelievable,” Serpa said.
This story was originally published by the Rhode Island Current.
