The state’s child advocate released a letter Thursday calling on the Department of Children and Families to be more transparent in how it reports to the public about internal reviews and improvements.

Sarah Eagan, the child advocate, focused on several incidents of child fatalities and near fatalities, including the death of “Kaylee S.,” a 1-year-old who died Feb. 8, 2022, of fentanyl and xylazine poisoning.

In December, Travis Schubel of Salem, Kaylee’s father, was charged with second-degree reckless manslaughter, risk of injury to a child, possession of a controlled substance and use of drug paraphernalia in connection with Kaylee’s death. He has pleaded not guilty in the case, and is being held in lieu of $3,3 million bail, records show.

DCF had opened a case in August 2021 because of reported concerns of physical neglect, according to Eagan’s letter. Kaylee’s mother also lived in the home.

“Multiple critical incident reviews from 2021 to the present, including the death of Kaylee S. … raised concerns for [the Office of the Child Advocate] regarding the lack of consistency in DCF’s assessment and management of family risk and child safety concerns, including timely connection of caregivers to appropriate services,” Eagan wrote.

“Given these observations, OCA requested information from DCF regarding its case reviews and the quality assurance measures it has in place to assess and improve the agency’s ‘safety practice.’”

In response, DCF Deputy Commissioner Michael Williams criticized the timing of the letter, coming a year after Kaylee’s death, and said it would not be useful to his department.

Eagan acknowledged steps DCF has taken “to clarify and strengthen practice expectations for staff, including distribution of memos and trainings on Safety Planning and fentanyl.”

However, she wrote, “DCF has not yet demonstrated adequate quality assurance to determine whether identified deficiencies regarding safety planning and service delivery are being remedied. Additionally, there remains no framework for routine public reporting by the agency and no articulated plan for transparency and accountability by the agency.”

Among the items she believes DCF can improve in terms of transparency are “critical incident reviews, service gaps, safety practices.”

Eagan wrote that “DCF’s internal reports are not publicly available and there is no requirement or other mechanism in state law or agency practice for disclosing critical incident review findings to the public or policymakers.”

She said Wednesday that the General Assembly ought to consider making those reports public, as well as give DCF resources it lacks. “It’s important that there be a mechanism for pushing that information out to policymakers and stakeholders so that the work can be supported with resources and oversight,” Eagan said.

“We have submitted a recommendation to the Children’s Committee, that it revive the … Children’s Report Card, that it clarify the reporting obligations and expectations for DCF regarding safety, permanency and well being and include information regarding fatality or near fatality,” Eagan said.

She said her office “has also requested additional resources through the appropriations process to be able to enhance our independent child-fatality reporting.”

Eagan said the letter “represents findings from certain fatalities and near fatalities in children, and even one preventable death of a child is one too many and requires urgent review of the efficacy of our service systems to support these children. And that’s what the letter is about. What it’s not about is an indictment of everything the department does.”

Eagan added, “The letter is not an indictment of the state’s goal of keeping children safely in their homes whenever possible. We’re not advocating for placing all higher-risk, highly vulnerable infants into foster care as the only way to keep them safe.”

DCF had issued a statement Dec. 22 describing its involvement in Kaylee’s case, which ended, “Due to the pending criminal charges, we are unable to release any additional information at this time.”

Williams said that after a child dies the department staff “quickly conference and huddle … just to make sure there were no practice deficiencies, no egregious work, no negligence on our part or anything like that, that could have contributed to the tragedy that occurred.”

In Kaylee’s case, Williams said, “overall our work was solid. By way of practice, by way of policy, by way of our standards. The folks who handled this case handled it well. And it was unfortunate that this child ended up in this situation due to the exposure of fentanyl.”

He said that in 2021 the department was well versed in how to handle cases in which opioids were involved, but that nationally fentanyl “was catching everyone off guard in trying to understand the exposures of fentanyl and the danger that it poses.”

Williams criticized the letter, saying, “To have a report come out right now a year later, after the same set of facts were present a year ago when we talked with them. … I would just say that it has no value to us and we’re just shocked that they would try to offer this into the field a year later, after the field has moved so far.”

He said DCF has consulted with national experts in substance use disorder but that the child advocate’s office does not have such expertise.

“When I look at the content of what this letter has, it offers nothing instructive, and the competency of her staff, of the child advocacy staff, to do that kind of analysis and critical understanding of substance use disorder, it doesn’t exist over there,” Williams said.

He said, “out of just respect for the incident itself, you want to learn and so our special qualitative review process is designed for that purpose,” including “long-term learning and continued growth and improvement of our system … and that process is designed to be very in-depth, very critical.”

He called Eagan’s use of internal reports “kind of disingenuous.”

“We stand by that work that we have internally to help us become a better agency,” Williams said. “But we don’t want that process to be turned and weaponized against us just to prove a point.”

He said the Special Qualitative Review “isn’t a got-you kind of blaming process. That’s not the purpose of that.”