During the 1989 General Assembly Session, members of the Junior Leagues of Virginia requested an amendment to the first degree murder statute to include the death of a child resulting from protracted patterns of abuse. The concern of the Junior Leagues was prompted, in part, by the case of a 21-month-old child who was brutally beaten and tortured to death in Tennessee. Although prosecutors involved with this case sought first degree murder convictions for the perpetrators of the abuse, convictions for lesser offenses were obtained. The situation in Tennessee ultimately led to the legislative request for this examination of the Commonwealth's cases of fatal abuse and neglect and review of prosecution outcomes. The study was legislatively mandated by an amendment, introduced by Senator Joseph Gartlan, to the 1989 budget bill. The mandate directs the Department for Children, in cooperation with other agencies, to review cases of child deaths and to recommend appropriate criminal sanctions for actions resulting in the death of a child after protracted patterns of abuse.

The Study Committee reviewed cases of child deaths from abuse or neglect for the years 1986 through the early part of 1989. The cases were obtained from: the Child Protective Services Unit, Department of Social Services; the Office of the Chief Medical Examiner, Department of Health; local law enforcement agencies; and Commonwealth's attorneys. With the assistance of the Office of the Attorney General and the Commonwealth's Attorneys' Services and Training Council, the Committee examined Virginia's homicide and related felony statutes. Additionally, the study included a review of recent legislative initiatives, pertaining to the death of a child from abuse, taken in other states.

Findings

The review of cases revealed that there are no vast numbers of a certain type of case or cases which share very similar circumstances. The cases can be divided into broad categories, with many falling into more than one category. Few children whose cases were reviewed died as the result of the cumulative effects of abuse. For the most part, the victims died as a result of single, violent acts. The majority of victims were aged one year or younger. Their ages could have made them more vulnerable to single acts or to suffering from short periods of neglect and therefore less likely candidates for protracted patterns of abuse. The cases reviewed suggest that protracted patterns which do lead to the death of a child will involve neglect more often than physical abuse.

The charges filed against alleged perpetrators varied widely, as did the outcomes of prosecutions. The legal action taken ranged from no charges filed to charges of murder. The verdicts in prosecuted cases ranged from dismissal of all charges to conviction of capital murder. There appears to be little consistency in how cases are handled, in the determination of charges to be filed, and in the convictions and sentencing of perpetrators.

The Committee determined that offenders who might have been charged with, or convicted of, more serious crimes were probably not because of lack or inadmissibility of evidence, insufficient investigations, inadequate prosecutions, and improper instructions to juries. None of these reasons would be addressed, much less rectified, by statutory amendments creating more severe penalties. The information reviewed leads to the conclusion that the existing statutes do provide for appropriate criminal sanctions for convicted perpetrators. The problems identified do not result from defects in the statutes, but rather from differing applications of the statutes and a lack of cooperative investigations and retrieval of evidence among local agencies.

The Committee recognized that cooperation and communication among local agencies can be crucial in the prosecution of alleged perpetrators in cases involving child abuse fatalities. Through this study, the committee discovered that the degree to which child protective services workers, law-enforcement officers, medical examiners, and Commonwealth's attorneys work cooperatively and share pertinent case information varies throughout the Commonwealth.

Several responses to the survey conducted for this study by the Commonwealth's Attorneys' Services and Training Council indicated a lack of communication among local agencies. Some Commonwealth's attorneys expressed frustration at the lack of timely notification of a suspicious death (notifications were received from one to six months after the child's death). The records from child protective services units in some localities also indicated limited cooperation, particularly among local law enforcement agencies and CPS. Further, the reports received from the office of the Chief Medical Examiner revealed problems in communication in some localities among the medical examiner, CPS, and the Commonwealth's attorney.

While recognizing that the primary focus of the study was to recommend appropriate punishment for convicted perpetrators, the Study Committee agreed that the punishment of convicted abusers alone will do little to protect children from harm by deterring abuse or neglect. Further, the Committee agreed that improving Virginia's total response to child abuse and neglect can ultimately help prevent deaths from maltreatment.

Recommendations

I. The Committee agreed that the Commonwealth should establish a formal process for reviewing cases of child deaths from suspected maltreatment on both the state and local levels. The Committee recommends that the Commonwealth mandate the establishment of a State Child Fatality Review Team and require the development of local, ad-hoc Child Fatality Review Teams.

The State Child Fatality Review Team should be comprised of the Commissioner of the Department of Social Services, the Chief Medical Examiner, the Attorney General, the Superintendent of State Police, or their designees, and representatives from the Commonwealth's Attorneys' Services and Training Council, the Virginia Association of Chiefs of Police, and the Virginia State Sheriffs' Association. The State Team should convene at least quarterly and should be staffed by an appropriate state agency. The State Child Fatality Review Team should:

• Develop a protocol for local review teams;

• Monitor and review the work of local fatality review teams and request local agencies to conduct further investigation of a case if such a need is determined;

• promote interdisciplinary education and training;

• Identify trends and policy needs;

• Make recommendations to the Governor and to the General Assembly annually; and

• Prepare a two-year follow-up report on the work of state and local fatality review teams and on the status of criminal sanctions in fatality from abuse cases.

Each locality should be required to establish an ad hoc Child Fatality Review Team for each case of a child death from suspected abuse or neglect. The local teams should be comprised of representatives from the local child protective services unit, law enforcement agency, medical examiner, and Commonwealth's attorney. The local team would convene promptly upon identification of a suspicious child death, follow the protocol established by the State Team, and submit a report on each case to the State Team.

II. After careful deliberation, the Study Committee agreed that amendments to the criminal statutes of the Code of Virginia are not necessary at this time. The problems related to the prosecution of alleged perpetrators of fatal abuse or neglect are not directly related to the homicide or felony statutes. The Committee believes that the child fatality review teams can promote the education necessary to understand the statutes and increase consistent application of the statutes, improve coordination among local agencies, and ultimately lead to appropriate criminal convictions and sentencing of perpetrators.

III. The Study Committee recommends that staff to the House Committee on Appropriations and Senate Committee on Finance develop a follow-up report on the studies (1985-1989) conducted in Virginia related to child abuse and neglect.

The report should:

• identify recommendations that have been implemented;

• review recommendations for increased training of CPS workers and identify other recommendations that have gone without action;

• include a fiscal impact statement for implementation of the remaining recommendations; and

• contain a plan for implementing the recommendations and tasks for improvement of the child protective services system (to be developed cooperatively with the Commissioner of Social services).

This recommendation is based on the Committee's acknowledgement that past studies conducted in the Commonwealth relating to abuse and neglect contain a wealth of sound information for the improvement of Virginia's system for protecting children. Follow-up of the recommendations contained in these studies is warranted.