good afternoon I'm up Pinellas County Sheriff Bob volunteering we're uh here today to talk about the results of the deaf investigation and policy review regarding the Elizabeth holder matter if you recall this case started back in January specifically January 11th of 2013 when Elizabeth holder was removed 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 what happened leading up to the removal and the investigation that has resulted in an industry or review board finding last week regarding three employees and Pinellas County Sheriff's Office on Friday January 13th at about one o'clock our Patrol deputies responded to the gulf debate mobile home park at 2381 Gulf to Bay Boulevard in Clearwater because a caller had reported that five-year-old Elizabeth holder was wandering around the park unsupervised um deputies found Elizabeth's mother 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 two-year-old sister was also at the home deputies arrested Elizabeth's mother Stephanie Judith or child neglect while they were there Elizabeth's father Corey colder 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 the result of that investigation the decision was made to remove the children from their home as this 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 home so they'd be placed with a relative or somebody else that can care for them but when they can't be then they're placed in the foster care so Elizabeth and her sister were delivered to a foster home in Clearwater later that evening on Saturday uh 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 foreign administrative code for the law is a child who is removed from his or her parents is required to have completed a mandatory health screening 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 employment 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 about 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 nine o'clock P.M that night she woke up about 8 30 the next morning she spent the day Saturday the 19th Point she was watching TV she ate at about four o'clock in the afternoon you know Elizabeth started screaming and holding her head saying that it hurt and asked for it to stop hurting she want limp wanted a cardiac arrest 9-1-1 responded she was transported to nice Countryside Hospital we're at about five o'clock she was pronounced dead there was no sign of trauma and the medical examiner's office here is called the sixth district which encompasses Pinellas in Pasco County has rolled 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 conducted 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 contained convened last Thursday in this position of the administrative review board as to any charges against the three employees that the fountains County Sheriff's Office related to whether or not the mandatory 72-hour Health spree 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 why in Period as their 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 was the second time in the course of her 30-year career here in the sheriff's office that Pam Wilson had a substantiated 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 that documentation be entered within the system and 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 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 then we're not going to tolerate it so be clear Pam Wilson was terminated is a consequence of this investigation but it was because of being untruthful and not because she didn't set 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 was it the investigation overall revealed that unfortunately this wasn't the first time that we had not ensured that the 70 72-hour health screening was time we 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 would the investigation revealed is is that as an example during 2012 we investigated over 11 000 cases here in Pinellas County uh 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 that's where we got conducting investigation and Dean 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 remove children from their homes during 2012. and 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 uh Fizz fin 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 the 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 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 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 states 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 uh 664 cases out of the 84. timely Health readings that means that they were completed within the 72-hour period uh occurred in 279 for 43 of the cases I can tell you that Health screenings were done but they weren't timely in 198 or 30 percent of the cases if 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 who were 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 a little further of the 477 cases where we did the health screening 58 were timely and 41 runtime 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 screen 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 wall in the Florida Administrative Code that these Health screenings be done within 72 hours we entered into a contract with Eckard 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 lot 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 Eckert and after we remove a child there's a meeting or a conference it's called the Staffing where we in essence turn it over to Ecker and as a matter of course Eckard 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 the law it says it has to be done the law doesn't say who has to do it in fact eckerd's agreement 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 house 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 problem that we had was immediate access to appointments is that we were using the health department we are using a few limited providers so on that Monday morning when the family support worker made the phone calls and couldn't get the appointments is they shouldn'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 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 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 you finish in a few minutes but 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 in the emergency room or a variety of places so we really broadened the scope of the network where we can ensure that these health streams 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 a 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 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 have 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 is something we should have done I again I 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 the foster parent it's not the responsibility of the babysitter as this happened and she should have been screened within the 72 hours the ultimate question is 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 it was the cardiac fibrosis was a 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 in some position 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 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's represented by a lawyer we've been in contact with the Lord 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 wall aside and putting the side 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 moving forward