The fact is that a school nurse’s legal obligation as a mandatory child abuse reporter is not to refer abused children to private doctors, but to the child welfare system so that an intervention can take place in the home. An abused child referred to a private doctor is likely going to be taken to the doctor by their abuser. The abuser can coerce the child with threats of further abuse, coaching the child on how to respond to the doctor’s inquiries in order to avoid child welfare intervention. Charlenni left this doctor’s office with a diagnosis of anemia and a note saying that she was prepared to return to full activity at school. It’s safe to say the doctor’s investigation into Charlenni’s various wounds and scars, including the broken hip that caused her pronounced limp, was not terribly comprehensive.
Not surprisingly, the same doctor later stated that he didn’t even know the child was referred to him for a hip problem. Most likely the problem was concealed from the doctor by the abusive parents, who were probably in the office with the child during the doctor’s visit, though incompetence on the doctor’s part can’t be ruled out. The school nurse at Feltonville Intermediate later urged the family to have the girl see another doctor, but then Charlenni died. Perhaps if the nurse did her job right the first time and contacted DHS to open an investigation on the child she would still be alive.
Why did this nurse do what she did? Was she trying to protect the family from DHS intervention by actively avoiding following standard abuse reporting protocol? Was she simply unaware of how abuse reporting works? We don’t know, and we may never find out, because the School District says their investigation into what happened at Feltonville Intermediate is already closed.
And, sadly, there’s no guarantee that if the nurse had contacted DHS the girl’s life would have been saved. The new details emerging about the handling of Charlenni’s case by DHS while she was an elementary school student are simply enraging. Her case was farmed out to a contractor agency (Congreso) who not only subsequently closed the case citing lack of evidence to support an abuse claim despite that the girl was referred to DHS baring multiple bruises and burn scars, but then went even further, COACHING THE FAMILY ON HOW TO RETAIN LEGAL SERVICES TO PREVENT FURTHER ABUSE INVESTIGATIONS.
What the fuck, Congreso? Why did you, a child protective services contractor, coach a set of parents that were beating, burning and raping their child on how to legally protect themselves from the child welfare system? This is really almost incomprehensible; not only did Congreso not do their job in protecting the abused child, but they actively worked to protect the abusive parents. How does that happen? Somebody at Congreso needs to own this monumental error in clinical judgment. This whole turn of events really needs to be explained, because quite honestly it is impossible for me as a social worker to rationally intuit how it came to pass.
This brings us back to the beginning of the ordeal, the moment when Charlenni’s one hope for survival was extinguished. While she was a student at Clara Barton Elementary Charlenni encountered a school nurse named Amy Ozenbaugh. Amy saw that Charlenni bore clear signs of abuse, bruises and burn scars on her hands, head and body. Amy did her job; she fulfilled her legal obligation to contact DHS to open an abuse investigation. She continued to advocate for the child as DHS did nothing to effectively intervene in the girl’s home, prompting DHS’s contractor agency to consider legal action against her for her “harassment” of the family. This would prove to be Charlenni’s last chance for effective intervention.
Amy Ozenbaugh is the only person in an entire system of children’s services professionals that came into contact with Charlenni Ferreira who both had sound clinical judgment and followed the necessary protocols for effective advocacy on the child’s behalf. Unfortunately the system was so broken that Charlenni died a horrible, painful, disgraceful death despite Amy’s efforts prevent that outcome.
I say the system was so broken because I’m sure things at DHS are completely different now. Right? Actually, we don’t know that yet, either. When news of Charlenni’s death first broke I suggested that the time was right for an audit of the changes made at DHS since the Nutter administration pledged to turn the agency around in November of 2007. We haven’t seen anything like that so far. In fact, we don’t know if anything has changed at DHS, at all. Hopefully the newspapers will seize this opportunity to hold the Nutter administration to its pledge, producing a clear accounting of all the action taken and changes made in the city’s dysfunctional child welfare system over the past two years.