The Office of the Child Advocate has found numerous alleged failings in the state Department of Children and Families ’ handling of a case in which a 10-month-old boy died from fentanyl, xylazine and cocaine intoxication.

Child Advocate Sarah Eagan’s report, issued Tuesday, states that, in particular, “in-home cases” require “urgent attention.”

Marcello Cash Meadows of New Haven, whose death was ruled a homicide, was the 11th child to die of opioid ingestion since 2020, Eagan said in her report, while “there have been more than 40 fatalities and near fatalities of children under the age of 5 from Fentanyl/opioid intoxication, with many children surviving due to the documented administration of Naloxone by first responders,” she wrote.

“This is the third fatality report that (Office of the Child Advocate) has published in the last year regarding the death by homicide of a child under active or recent DCF supervision (two of the children died from Fentanyl intoxication),” Eagan wrote.

Marcello’s mother, Alexandra Polino, had outstanding warrants for violating probation, which were issued shortly after Marcello’s birth, and which were served when Marcello died. She had been arrested July 20, 2022, on charges of larceny and risk of injury to a minor for alleged shoplifting with her 3-year-old present.

Marcello was born Aug. 10, 2022. He was diagnosed with neonatal opioid withdrawal syndrome and failure to thrive, according to the report. He died June 28, 2023, according to his obituary.

Polino had “a long history of involvement with the criminal justice system, and had been on probation for several years prior to Marcello’s birth,” Eagan wrote. “Records reflect persistent concerns about opioid misuse.”

An older sibling, born in 2019, had tested positive for illicit opioids, the report said.

Polino had successfully completed community service, but there was no home visit as part of DCF’s supervision, going against the agency’s policies, Eagan wrote.

Background checks on Marcello’s mother and father, Colt Meadows, were not completed and probation records were not obtained, the report states, and the father’s DCF history was not reviewed for several months. Meadows never completed a toxicology screen. “Nonetheless he was identified early on as the ‘sober caregiver’ in the DCF Safety Plan,” according to Eagan.

A safety plan was drawn up, but allegedly was followed only partially, the report states.

“Between August and December 2022, no lab testing for Fentanyl was conducted,” it states. “Once lab testing commenced, Ms. Polino tested positive multiple times, including three times in March and April 2023, after which she denied knowingly using illicit substances. No DCF Safety Plan was renewed as required by policy, despite staff being aware of the positive tests.”

DCF closed its case on June 7, “citing Ms. Polino’s successful completion of treatment,” the report says. Her methadone provider requested a welfare check on June 27, because she had not reported in since June 6. Police reported no vehicle in the driveway and no movement inside the home.

Marcello was found dead the next day.

Eagan pointed out that “available data” allegedly “shows a marked decline in DCF’s risk and safety assessment and case supervision over the last two years. …

“DCF is making numerous efforts to strengthen practice,” Eagan stated. “However case reviews and DCF systems data continue to show persistent deficiencies in safety planning and case management.”

Among her recommendations, Eagan wrote:

—The Judicial Branch Court Support Services Division “should ensure consistent real-time audits of high supervision cases to determine systemic fidelity to agency expectations.” This is being implemented, the report states.

—”Quality assurance protocols by the Family Based Recovery model developer should be revised to strengthen audit protocols across provider sites to ensure fidelity to the model expectations.”

—A call for “Further operational improvements to DCF’s safety planning in caregiver substance abuse cases.” The report states that Eagan’s office and DCF are in dialogue on these issues.

—Policymakers and legislators need to act to improve DCF’s practices, staffing and services.

—Legislation should be passed to strengthen the role of DCF’s Statewide Advisory Committee.

DCF Commissioner-designate Jodi Hill-Lilly issued the following statement:

“Fentanyl related overdoses of adults and children is a public health crisis — an epidemic that knows no boundaries — impacting children, adults, and families across Connecticut and the country.  All members of our community — professionals, family members, friends, and concerned citizens are encouraged to remain diligent in their efforts to protect children.

“We keep Marcello in our thoughts as we do his family, friends, neighbors, community members, and Department staff who mourn his untimely death,” Hill-Lily wrote. “To honor Marcello’s legacy, we remain in consultation with state, local, and national experts to revise our substance use disorder policy and will continue to partner with the Department of Mental Health and Addiction Services (DMHAS), the adult substance use community, law enforcement, medical professionals, and others to enhance the systematic approach to this public health crisis.

“DCF remains committed to transparency in how we discuss the Department’s involvement with Marcello’s family. At the same time, we must follow state law regarding the confidentiality of case-specific information,” she wrote. “On June 8, 2023, about three weeks before Marcello’s passing, the Department assessed — along with an intensive in-home provider — the children in the home as being safe and thus ended its involvement with the family.”

Hill-Lily said the department continues to review opportunities for “case practice and/or systems improvements.” The improvements have included, but are not limited to:

“This work follows the Department’s intensive efforts to address child safety as the Fentanyl crisis began impacting our state. In late Spring/early Summer 2022, DCF assembled a Fentanyl Senior Advisory Council — a multidisciplinary group comprising the Commissioner, Executive Team, and others with substance use and legal expertise — to review the impact of Fentanyl,” the Hill-Lily statement said.

Interim best practice guidelines were developed in October 2022 with updated guidelines developed in August 2023 which can be found here: Enhanced Safety Guidance for Cases Involving Fentanyl and Substance Use. ( https://shorturl.at/pwzHO )

“As a result, over the past 16 months, the Department has conducted approximately 745 multidisciplinary team meetings where substance use is known or suspected in a home where children are present of which over 550 consults pertain specifically to Fentanyl,” Hill-Lily said.

“Focusing our efforts on the high-risk nature of the 0-5 population is a priority in my administration as are continued community partnerships. We are continuously introspective about how we enhance and improve our case practice,” she said. “DCF is in frequent communication with OCA regarding our overlapping work and we remain committed to collaborating with the OCA on our shared mission of supporting and improving the safety and well-being of the children and families we collectively serve.”

Hill-Lily said that community-based supports are available throughout Connecticut and can be found by calling 211 or the Substance Use Access line at 1-800-563-4086. Information for families seeking behavioral health services can be accessed at: www.connectingtocarect.org.

Hill-Lily also noted that a reasonable suspicion of child maltreatment can be made to the Child Abuse and Neglect Careline by dialing 1-800-842-2288. The Careline is open 24 hours a day, 365 days a year. Callers to the Careline can remain anonymous.

Gov. Ned Lamont named Hill-Lily in December to replace Vannessa Dorantes, who stepped down as DCF commissioner.

Senate Republican leader Stephen Harding, R-Brookfield, and Sen. Lisa Seminara, R-Avon, ranking senator on the Committee on Children, issued a statement saying:

“This report shines a bright light — yet again — on several instances where state government has failed a child under its supervision. 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. 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.”