Good afternoon. I'm uh Pinellas County Sheriff Bob Gualtieri, and we're uh here today to uh talk about the results of the uh death investigation and policy review regarding the Elizabeth Holder matter. Um if you recall, uh this case started back in January, specifically January 11th of 2013, when uh Elizabeth Holder was removed uh from her parents by our Child Protection Investigation Division. And some of you may be familiar with this, so I think I'll just recap uh what happened leading up uh to the uh removal and the investigation that has uh resulted in uh an administrative review board finding last week uh regarding three employees in Pinellas County Sheriff's Office. Um on Friday, January 13th, at about 1:00, our patrol deputies uh responded to the Gulf to Bay Mobile Home Park uh at 2381 Gulf to Bay Boulevard, Clearwater, because a caller had reported that 5-year-old Elizabeth Holder uh was wan- wandering around the park unsupervised. Um deputies found uh Elizabeth's mother uh to be under the influence of non-prescribed uh prescription medication, and that she had allowed Elizabeth to wander unsupervised in the mobile home park. The residence was dirty. It was unsuitable for children to live in, and Elizabeth's 2-year-old sister was also at the home. Deputies arrested um Elizabeth's mother, uh Stephanie Judah, for child neglect. While they were there, Elizabeth's father, Cory Holder, arrived at the home, but he too was under the influence and unable to care for the children. Our Child Protection Investigation Division began their investigation at about 3:30 in the afternoon on January 11th. And as a result of that investigation, the decision was made to remove the children from their home. As is protocol, we contacted Eckerd Community Alternatives, which is the community-based care provider, to arrange for the children to be placed into foster care. It's usually the preference in these cases when we remove the children from their homes that they'd be placed with a relative or somebody else they can care for them, but when they can't be, they're placed into foster care. So, Elizabeth and her sister were delivered to a foster home in Clearwater later that evening. On Saturday, January 12th, there was a shelter hearing before a judge, and the judge found sufficiency for the removal. So, at the core of the issue here is under the Florida Administrative Code, Florida Law, is a child who is removed from his or her parents is required to have completed a mandatory health screen within 72 hours of the time of the removal. And in this case, Elizabeth Elizabeth was removed on Friday, January 11th, and that mandatory health screening should have been completed by Monday, January 14th. However, a family support worker in our child protection investigation division on Monday the 14th tried unsuccessfully to get an appointment for Elizabeth to receive the health screening. The health department couldn't accommodate an appointment, and the pediatric practice where Elizabeth had been seen also couldn't accommodate the appointment. The appointment that we did receive for Elizabeth was on January 22nd, 2013, obviously well beyond the 72-hour required period for the screening. On Friday, January 18th, the foster parent delivered Elizabeth and her sister to a babysitter in Dunedin. So, this is a week after the removal and again, several days now before the appointment for the health screen. When Elizabeth went to sleep at about 9:00 p.m. that night, she woke up about 8:30 the next morning. She spent the day, Saturday, the 19th, playing. She was watching TV. She ate. At about 4:00 in the afternoon, Elizabeth started screaming and holding her head saying that it hurt and asked for it to stop hurting. She went limp, went into cardiac arrest, and 911 responded. She was transported to Mease Countryside Hospital where at about 5:00, she was pronounced dead. There was no sign of trauma and the medical examiner's office here, what is called the 6th District, which includes Pinellas and Pasco County, has ruled the cause of death to be endocardial fibrosis with a contributory cause of tonsillitis. We have a copy of the autopsy report and we will provide that to anybody that wants it here this afternoon. Upon learning of Elizabeth's death and the circumstances, I directed that we conduct a review of procedures, compliance with procedures, and that an internal affairs investigation be conducted. The subjects of the internal affairs investigation were child protection investigation supervisor Sarah Pierce, child protection investigator Brett Edwards, and family support worker Pam Wilson. The administrative review board convened convened last Thursday and this position of the administrative review board as to any charges against the three employees of the Pinellas County Sheriff's Office related to whether or not the mandatory the health screening was completed was that it should be a policy review and I'll explain why. So, what that means is that none of those three employees individually are personally responsible for the fact that the 72-hour health screening did not occur. It means that there's a problem with our policy. It's a system failure and that they should not be held individually accountable or responsible for it not happening. Now, as to the family support worker, Pam Wilson, um on Monday of this week, I terminated her employment from the Pinellas County Sheriff's Office. But, I want to be clear that it didn't The reason for the termination was not because of what she did or did not do in ensuring that the 72-hour health screening was completed. The reason for the termination was because during the investigation, Pam Wilson lied. And I'm not going to tolerate people lying to our internal affairs investigators or lying, period, as an employee of the Pinellas County Sheriff's Office, and especially as to these substantive matters. And this is not the first time, in fact, it's the second time in the course of her 30-year career here in the Sheriff's Office that Pam Wilson had a substantiated uh complaint of being untruthful. And under our disciplinary system, she had over 100 points, and the right thing to do was to terminate her, and what she had lied about was it's required uh that documentation be entered in within the system in child protection cases within 24 hours. And as it related to even setting the appointment, even though it was down the road, is that she didn't enter it in the system within 24 hours. And then many times, many times through the course of the investigation, uh through her subject interview and before the administrative review board, she lied several times about why she didn't do that and she wouldn't accept responsibility for it and we're not going to tolerate it. So, be clear Pam Wilson was terminated as a consequence of this investigation but it was because of being untruthful and not because she didn't accept the appointment itself within the required time period. Copies of the substantiated allegations as to Pam Wilson will be made available to you as well here this afternoon for anybody that wants it. The investigation overall revealed that unfortunately this wasn't the first time that we had not ensured that the 72-hour health screening was timely completed. In fact, the investigation reveals that this happened many times and as I'm going to explain to you why and of course what remedial action has been taken to ensure that now and going forward that it'll always be done in a timely manner. What the investigation revealed is is that as an example during 2012 we investigated over 11,000 cases here in Pinellas County of abandonment, abuse, and neglect allegations. In fact, every year for the past several years we have been over 11,000 cases that we've investigated. This year the numbers are up and we're probably on track this year, we'll see how it goes, we're probably on track this year to investigate between 14 and 15,000 allegations of abuse, abandonment, neglect. Of those 11,000 plus cases in 2012 884 of those cases resulted in removals. So, that's where we got conducting investigation and deemed that the children have to be removed from their parents because there's too great of a danger in them remaining there. In 238 of the 884 cases where we removed children from their homes during 2012, in 238 of those, we could not determine whether the health screening was ever done. So, I can't tell you whether it was done or not done. And the reason for that is within what's called the FSFN system or the family support network system, that is the state's system. It's the DCF system that we're required to use to document all of our child protection investigations. There is no field in there that allows you to enter data documenting that the health screening was done or not done. And so, what happened is is that it would be put into what's called the note section, but there was no particular place, and it's not searchable. And so, in order to come up with even with these statistics is is that we had to manually search and by hand review every single one of the 884 cases in 2012. And in reviewing those cases and digging into them is is that we weren't able to tell from the notes or any documentation in there whether the health screening was completed. It might have been, it might have been timely, it might have been untimely, it might not have been done at all. I can't tell you. So, we've taken steps now to ensure that there's consistency in that documentation. The state's in the process going through what's called transformation, and there's some changes being made to the system. But, that's why I can't tell you in those 238 whether it was done or not. Of the remaining 664 cases out of the 84, timely health screenings, that means that they were completed within the 72-hour period, occurred in 279 or 43% of the cases. I can tell you that health screenings were done, but they weren't timely in 198 or 30% of the cases. You do the math, the balance is 169 out of the 646. And in those cases, there was no requirement that a health screening be done for a variety of legitimate reasons. And that includes when the child is removed at birth, born addicted to drugs, the child was already in the hospital, or another number of other reasons where it wasn't required to be done. So, if you break it down all further, of the 477 cases where we did the health screening, 58% were timely and 41% were untimely. We know of no cases other than this one involving Elizabeth Holder where any untimely screening even arguably, and I'm going to talk about that because I don't know as we stand here today whether the failure to complete the health screening would have made a difference. But we don't know of any other case where even arguably that any child was adversely affected because we didn't do the health screening. So, in this particular case and all the other ones I've just described to you, there are some reasons and causes why these health screenings were not done in a timely fashion. One factor is is that it is clear in the law and the Florida Administrative Code that these health screenings be done within 72 hours. We entered into a contract with Eckerd Community Alternatives. And in that contract, the contract language says that the health screening, and we assume responsibility for that. And but the contract says is the health screenings will be initiated within 72 hours. And that ambiguity led to a lot of confusion on the part of a a of people. And when we remove a child, again, we remove them and then the foster care is supervised by the CBC, the community-based care provider, Eckerd. And, after we remove a child, there's a meeting or a conference that's called a staffing, where we in essence turn it over to Eckerd. And, as a matter of course, Eckerd accepted those cases from us with the health screening having been initiated, i.e. the appointment being made, but not completed. So, it became a kind of a matter of practice, a course, that these health screening appointments were sometimes made, but it wasn't completed, and the kids were accepted into the system. Now, I want to make it very clear, and make no mistake, this is not Eckerd's responsibility. Under uh the law, it says it has to be done. The law doesn't say who has to do it. Uh in fact, Eckerd's agreement uh with the state says that they'll do it, but we contracted with Eckerd to take on that responsibility. So, at the end of the day, it falls on us, period. Doesn't fall on anybody else. It falls on us. But, from a practical standpoint, is we had ambiguity in the contract, we had practices that were in place because of the contract language that led people, including the staff members at issue here, to believe that to comply with the law, all you had to do was to initiate the health screening, i.e. make the appointment within the 72 hours. So, that is one factor that led to this overall problem of not getting them done timely. Um another uh problem that we had uh was immediate access uh to appointments. Is that we were using the health department, uh we were using uh a few limited providers. So, on that Monday morning when the family support worker uh made the phone calls and couldn't get the appointments, is is that she didn't push it any further because she got one down the road and it just so happens the practice that she got the appointment with was one that Elizabeth had been seen at previously and another contributing factor is a preference within the child welfare uh system that the kids be evaluated by practitioners who have familiarity with them. Now, from a common sense standpoint, probably a good thing, but it doesn't comply with the law. So, when you start putting it all together, it's a series of things that contributed to it. So, what we've done now and and I have a a memorandum that's a report of all of this that lays it all out that we're going to provide you with a copy of here when we get finished in a few minutes. What we have done now is to ensure that the family support workers and the supervisors within the child protection investigation division have access to purchasing cards and mechanisms where they can take the kids and make sure it gets done to any walk-in clinic, any emergency room, or variety of places. So, we've really broadened the scope of the network where we can ensure that these health screens are accomplished, which wasn't in place back in January when this occurred. There was also a lack of clarity in our internal policies as to who was responsible for making sure that the health screening was done. It wasn't clear as to whether it was the family support worker the or the child protection investigator. There's also a lack of proper supervisory oversight and training for the family support workers. Um and a lack of proper protocol, as I mentioned to you a few minutes ago, on the documentation system as to making sure that this was done. So, if you had a supervisor that reviewed it, there was no one place in the system the supervisor could go to to look and determine whether or not the 72-hour requirement had been met. So, that was problematic. We've taken remedial action to fix all of these deficiencies and they are in more detail spelled out in the report that we're going to provide to you. I accept complete responsibility for this. This is something we should have done. I again want to make it clear that this is not the responsibility of the Department of Children and Families. It's not the responsibility of Eckerd. It's not the responsibility of the foster parent. It's not the responsibility of the babysitter. This is this happened and she should have been screened within the 72 hours. The ultimate question I don't know the answer to and nobody knows the answer to and may not ever know the answer to is whether the failure to conduct the 72-hour health screening would have made a difference. And you'll see in the autopsy report that it was the cardiac fibrosis was the cause of death with a contributing factor of tonsillitis. Question I believe will come down to is was that tonsillitis bacterial tonsillitis or was it viral tonsillitis? I don't know. We don't know. If she had such a severe case of tonsillitis and that contributed to her death through the cardiac fibrosis and we had done the health screening within 72 hours and it was that severe and some physician as a result of the health screening put her on antibiotics by that Friday, would it have made a difference? I don't know. But if it was viral, the antibiotics wouldn't have made any difference at all. So, that's where we are with um and it's so at the end of the day um we're going to continue to look at it. As you can imagine, there is litigation that has started in this case and the father is represented by a lawyer. We've been in contact with a lawyer. So, I'm not going to go too much further into it, but that's the question at the end of the day. And there is a causation question, but putting all that aside, putting the law aside, and putting aside, you know, the whole issue of whether it's bacterial or viral, and whether it would have made a difference, we should have done it. And we should have ensured that she received the health screening, and be a a non-issue if we had accomplished that as far as compliance and making sure that the right thing is done. So, we have made changes, and we have sufficient protocols and policies in place now that will ensure that these 72-hour health screenings will be done the right way going forward.