Critical Incident

Rapid Response
Team
Aedyn Agminalis

Florida Department of Children and Families

February 3, 2017
 Critical Incident Rapid Response Team
Aedyn Agminalis
SunCoast Region
Circuit 13
Hillsborough County, Florida
2016-339214

Table of Contents

Executive Summary 3

Introduction 5

Case Participants 6

Child Welfare Summary 6

System of Care Review 8

Practice Assessment 8
Organizational Assessment 9
Service Array 12

Systems Issues 13

Immediate Operational Response 13

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Executive Summary

On December 12, 2016, the department received notification that 1-year-old Aedyn Agminalis
was pronounced deceased on December 11, 2016, four days after he was transferred to the
hospital when he stopped breathing in his foster home. Aedyn had been in the care of his foster
mother, LaTamara Flythe, since mid-September 2016,after he was removed from his parents
custody due to neglect-related issues.

At the time of Aedyns death, there was an active investigation stemming from a choking incident
that occurred on December 4, 2016. On that day, Aedyn had vomited and a piece of Aedyns
food got caught and blocked his airway. Emergency responders were called to the home and
transported the toddler to the hospital where he remained hospitalized for three days. On
December 7, 2016, Aedyn was discharged back to his foster home; however, paramedics
brought him back later that night when he became unresponsive. Over the course of the next
few days, Aedyns condition continued to deteriorate until his death was pronounced.

Because there was a verified report received within 12 months of Aedyns death and an open
investigation, DCF Secretary Mike Carroll deployed a Critical Incident Rapid Response Team
(CIRRT) to Hillsborough County to review the prior interventions with the family and to assess for
any potential systemic issues within the local system of care.

The team completed a review of child abuse investigations, case management and dependency
court records. Interviews were conducted with members of the Hillsborough County Sheriffs
Office (HCSO) Child Protective Investigations Division, Gulf Coast Jewish Family and
Community Services case management agency, the Office of the Attorneys General, which was
responsible for Childrens Legal Services, the Guardian ad Litem Program, Eckerd Community
Alternatives, community-based care lead agency, the Child Protection Team, Childrens Medical
Services, foster home licensing and local child care providers.

The team identified both strengths and opportunities for improvement. The following is a
summary of the teams findings.

Practice Assessment

Present Danger was correctly identified in the family investigation and appropriate actions
were taken to ensure child safety.

The efforts to engage the parents while pursuing alternative permanency planning for
Aedyn, to include private adoption and placement through the Interstate Compact for
Children (ICPC), was noted as a strength..

Organizational Assessment

Workloads for child protective investigators (CPIs) are high, impacting the thoroughness
of the assessments completed in the cases reviewed.

In Hillsborough County, CPIs are expected to complete the Case Transfer Process to
services within seven days of removal. Staffings focused on ensuring compliance with
required forms and a lack of depth in critical information sharing.

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 There is not a consistent practice or knowledge of the process to reevaluate and assess
placement for a child with escalating medical needs to include Medical Foster Care
referrals.

Service Array

Hillsborough County has a number of co-located providers that are available to support
both investigations and case management staff. In this case, the parents were not willing
to engage in services.

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Introduction

On December 12, 2016, the department received notification that 1-year-old Aedyn Agminalis
was pronounced deceased on December 11, 2016, four days after he was transferred to the
hospital when he stopped breathing in his foster home. Aedyn had been in the care of his foster
mother, 43-year-old LaTamara Flythe, since mid-September 2016 after he was removed from his
parents custody due to neglect-related issues.

At the time of Aedyns death, there was an active investigation involving the foster home he was
residing in stemming from a choking incident that occurred on December 4, 2016, as well as a
verified prior investigation and open service case. On that day, Aedyn had vomited and a piece
of Aedyns food got caught and blocked his airway. Emergency responders were called to the
home and transported the toddler to the hospital where he remained hospitalized for three days.
On December 7, 2016, Aedyn was discharged back to his foster home; however, paramedics
brought him back later that night when he became unresponsive. Over the course of the next
few days, Aedyns condition continued to deteriorate until his death was pronounced.

Because there was a verified report received within 12 months of Aedyns death, DCF Secretary
Mike Carroll deployed a Critical Incident Rapid Response Team (CIRRT) to Hillsborough County
on December 15, 2016, to review the prior interventions with the family and to assess for any
potential systemic issues within the local system of care.

The review team consisted of representatives from DCFs Office of Child Welfare, the Northwest
Region, Childcare Regulation from the Central and Childrens Legal Services from the Northwest
Region, Circles of Care (behavioral health service provider in the Central Region), Community
Partnership for Children (community-based care provider in the Northeast Region), Big Bend
Community Care (community-based care provider in the Northwest Region), Broward County
Sheriffs Office (Southeast Region), Childrens Medical Services (state headquarters) and the
Child Protection Team statewide medical director and trainer.

This report represents the teams findings, including the child welfare history, and a system of
care review, including practice assessment, organizational impact and array of available
services.

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 r FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
MYFLFAMJLJES.COM

Case Participants

Name Age at Time of Incident Relationship

Aedyn Agminalis 17 months Decedent
Amber Agminalis 27 Biological mother
Brvnn Agminalis 33 Biological father
LaTamara Flythe 43 Foster mother

1983 1989

13 (i)
Brynn A nper
Agrrinalis Agrrinalis
I I
I
2015 - 2016

a
A edy n
Agrrinalis

Child Welfare Summary

Prior History on Child, Aedyn Agminalis:

In September 2016, a report was received due to concerns for Aedyn's safety and well-being
while in the care of his parents, Amber and Brynn Agminalis. The family had recently relocated to
Florida from Kentucky where the family was known to Children's Protective Services. There
were reportedly concerns regarding Aedyn's parents' ability to appropriately care for him. During
the course of the investigation, the cond ition of the home was noted to be deplorable and Aedyn
was described as appearing "orange" in color and malnourished . In add ition, the parents
admitted that they were unable to care for their child and believed that he would be better off if
cared for by someone else . As a result of this, Aedyn was removed from the care of his parents
and placed in licensed foster care. LaTamara Flythe was initially licensed as a foster parent on
June 2, 2016, after an approved homestudy, requ ired background checks which indicated that
she did not have any disqualifying charges, and completion of the required 21 hour professional
parenting class for new foster parents.

Given that the report contained allegations of medical neglect, Aedyn was examined by the Child
Protection Team which confirmed parental neglect and diagnosed him as Failure to Thrive.
Aedyn was immed iately admitted to the hospital for additional testing and observation prior to
returning to the foster home of Ms. Flythe. Aedyn remained in Ms. Flythe's home until his recent
hospitalization .

Aedyn had a history of digestive-related issues resulting in constant vomiting. In mid-to-late

November 2016, he underwent a procedure to have a feeding tube put in place. Ms. Flythe
reported that Aedyn was doing well and had progressed to the point in which he was just starting
to eat normally (stage two/three baby food) when the choking incident occurred .

There is no other prior child welfare history on the biological family in the state of Florida.

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Prior History on Foster Home:

In October 2016, a report was received when a 1-year-old foster child was observed with a fresh
bruise on his leg when he arrived at daycare. The foster mother, La Tamara Flythe, did not know
the child was injured and as a result, could not provide an explanation as to how the injury may
have occurred. CPTs examination was indeterminate as neither Ms. Flythe nor the child could
state how the injury occurred; however, there were no other injuries noted. As a result, the
report was closed with no indicators of maltreatment.

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System of Care Review

This review is designed to provide an assessment of the child welfare systems interactions with
the Agminalis family and to identify issues that may have influenced the systems response and
decision-making. Though the team identified both strengths and barriers, the following findings
were not determined to be a contributing factor in the childs death, they provide opportunities for
improvement that will benefit the local system of care.

Practice Assessment

PURPOSE: This practice assessment examines whether the child welfare professionals actions
and decision making regarding the family were consistent with the departments policies and
protocols.

FINDING A: Present Danger was correctly identified in the family investigation and appropriate
actions were taken to ensure child safety.

The investigation resulting in Aedyns removal was the first report received on the family in Florida
and alleged that the parents were not able to meet the childs needs due to their own mental
health issues. The report also indicated that the family recently moved to Florida from Kentucky
where the family had been involved with the Childrens Protective Services. While the assigned
Child Protective Investigator (CPI) responded timely to the report and completed contact with the
reporter in accordance with policy and procedure, there were additional sources of information
noted in the report who were not contacted and who could have provided pertinent details related
to Aedyns medical condition and prior abuse history.

Upon contact with the family, the CPI observed the home to contain multiple conditions that would
be hazardous to a child Aedyns age that included human feces on the walls, a machete, diapers
containing human feces, open alcohol bottles, miscellaneous debris, etc. These additional
concerns were all noted by the CPI and correctly added to the initial report. During this visit, the
assigned CPI appropriately identified present danger (meaning there was an immediate,
significant, and clearly observable danger threat) and immediately sought on-site assistance from
the supervisor. Together, they attempted to engage the family in a safety plan that allowed for in-
home interventions; however, the parents indicated that they did not feel they were able to care
for Aedyn in their home and requested that he be placed with someone else who could better
meet his needs. While additional information may have been available by making additional
contacts to the grandparents, the former case manager in Kentucky and through obtaining prior
abuse records; this information would not have changed the decision regarding present danger
and the need for an out-of-home placement. Aedyn was removed from his parents custody and
placed in licensed foster care with Ms. Flythe. She was initially licensed as a foster parent on
June 2, 2016. She was licensed for two children and Aedyn and another child were both placed
in her home on September 12, 2016.

The CPI referred Aedyn to the Child Protection Team (CPT) timely and an examination took place
the following day. This timely referral and subsequent CPT examination was critical to the safety
of Aedyn, as CPT determined that the infant needed to be admitted to the hospital immediately
for additional testing and observation, and that his parents neglect contributed to his critical
condition.

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FINDING B: The efforts to engage the parents while pursuing alternative permanency planning
for Aedyn, to include private adoption and placement through the Interstate Compact for Children
(ICPC), was noted as a strength.

Although the parents initially expressed a desire to surrender their parental rights, they later
changed their minds, citing they wanted to regain custody of their son, before they reverted back
to their original decision and opted to place Aedyn up for adoption through a private adoption
agency. Regardless of the familys continual wavering position and despite their unwillingness to
participate in any services, the assigned case manager continued to make efforts to engage the
parents by scheduling supervised visitations and offering services to assist them with improving
their protective capacities. In addition, the case manager maintained regular, ongoing contact
with Aedyns foster mother and medical providers to ensure that his needs were being met and
that he was stable in his current placement.

On November 18, 2016, both parents signed Consent for Adoption to release Aedyn for private
adoption through Heart of Adoption, Inc. On November 22, the private adoption agency filed a
Notice of Appearance and a Petition to Intervene and Change Placement and For a Stay of the
Dependency Case.

Intervention into a dependency case for the purpose of adoption is governed by Florida Statute
63.082(6) and, in part, states:

Upon execution of the consent of the parent, the adoption entity shall be permitted to intervene in
the dependency case as a party in interest and must provide the court that acquired jurisdiction
over the minor, pursuant to the shelter order or dependency petition filed by the department, a
copy of the preliminary home study of the prospective adoptive parents and any other evidence of
the suitability of the placement.

In this case, a home visit to the prospective adoptive parents new residence was completed by
the private adoption agency on November 19, 2016, with the addendum to the home study
approved by the private adoption agency on November 22. All required paperwork to file for
intervention and modification was sent to the assigned OAG attorney on December 2 and filed
with the court three business days later on December 7, 2016. Aedyn passed away four days
after the motion was filed, prior to the time a hearing could be scheduled and held.

In addition to the possible private adoption, the case manager was also simultaneously taking
steps towards another permanency option for Aedyn that involved his paternal grandparents in
Kentucky. On October 5, 2016, the court was advised that the paternal grandparents were
seeking custody. Although both parents objected to Aedyn being placed in the grandparents
care, the court ordered that placement with the grandparents be explored and, as they lived out
of state, the home study be requested through the Interstate Compact of the Placement of
Children (ICPC). Case documentation reflects on-going efforts and communication with the case
manager and attorney regarding the gathering of required information and completion of the
ICPC packet. The request for an Expedited Placement under Regulation 7 of the Interstate
Compact Home study was also filed with the courts on December 7, 2016.

Organizational Assessment

PURPOSE: This section examines the level of staffing, experience, caseload, training and
performance as potential factors in the management of this case.

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 r FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
MYFLFAMJLJES.COM

FINDING A: Workloads for CPis are high , impacting the thoroughness of the assessments
completed in the cases reviewed.

The CPI who responded to the September report involving the biological parents of Aedyn
averaged 21 reports per month for the 90 day period that this report was received and completed
(September to November 2016). This was similar to the CPI who completed the investigation on
Ms. Flythe in October who had received an average of 20 new reports during this same 90 day
period . For the same period of time, the monthly average of both of the units involved with these
investigations was 23 and the average for the CPis at the HCSO was 18 cases received per
month.

Number of reports received per CPI assigned :

CPI Sept ember October November

Sept Report 25 18 19
Oct. Report 21 23 16

Number of Reports received per CPI in the units involved:

Unit Sept ember October November

Sept. Report 27 22 21
Oct. Report 24 26 19

The number of investigations received monthly, per CPI for both of the CPis involved in these
reports, is higher than the national and state recommendations of 12-15 investigations.

Interviews conducted with HCSO staff indicated that their workloads are too high, making it
difficult to complete thorough assessments. HCSO has 100 CPI positions and during the months
of September, October, and November, they had an average of 22 vacant positions. However,
all of these staff were not trained therefore there was as an average of 60 CPis available to
receive cases, and if all 60 were on full rotation , the average number of reports per CPI would be
approximately 18 per month. HCSO reported that of the 60 CPis available to take cases, several
were on restricted caseloads due to be new and/or in training. The CPis on restricted caseloads
included 19 new CPis and 13 field training investigators who support and working directly with
the new staff. Other CPis were in specialized units and not in full rotation resulting in a core
group of approximately 30 CPis receiving closer to 30 investigations per month.

HSCO transitioned to the Practice Model a year and half ago and staff are continuing to increase
overall understanding of what is needed to complete thorough Family Functioning Assessments.
HCSO leadership understand that there is a need for more enhanced training and have
developed a more rigorous training plan; as well as specialized training units to enhance pre-
service and in-service training efforts that support investigators through all of the stages of
learning and applying the Practice Model.

A new report was received on October 6, 2016, involving allegations of physical abuse of a
different child who was the same age as Aedyn, and the investigation was incident-focused and
not inclusive of an overall assessment of the foster home. The CPI appropriately saw both
children at daycare during the commencement; however, Aedyn was not added to the abuse
report or included as a part of the assessment. The identified victim was seen by the Child
Protection Team the day after the injury was reported . There was no further documented case
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activity until December 12, 2016, when the case was being prepared for closure. This activity
included seeing the remaining household members, notifying placement and the case manager
of the abuse report.

Staff from all agencies interviewed reported that multi-disciplinary staffings(MDS) are required
and typically held when there is a new report on an open case; however, a staffing was not held
when the institutional abuse investigation was received in October 2016 on another child in the
foster home. As Aedyn had not been named in the report, his case manager was not aware
there was an abuse report on the foster home. A staffing in this case would have pulled parties,
including both case management organizations, with children in the home, OAG, and placement,
involved together to share and discuss information on the case.

FINDING B: In Hillsborough County, CPIs are expected to complete the Case Transfer Process
to services within seven days of removal. Staffings focused on ensuring compliance with
required forms and a lack of depth in critical information sharing.

In Hillsborough County CPIs from the specialized court unit are assigned to cases that involve
removals as secondary investigators. The court unit CPI, not the CPI that removed the child,
attends all court hearings, including the shelter hearing. In this case the CPI that removed the
child was not involved in any of the hearings or the case transfer staffing. Moreover, CPIs at
HCSO are required to prepare cases for transfer to services within seven days of removal so that
they can engage case management to provide services and intervention to the children and
families.

In accordance with department policy and Florida Administrative Code, the investigator may not
request an official case transfer to case management until the Family Functioning Assessment is
complete. In those cases where court-ordered interventions have occurred as a result of the
Present Danger identified, this requires a CPI to complete the assessment and all other
associated case and family needs, such as ensuring the child is seen by a physician, home visits
to current placement, visitation with biological parents, school needs for the child, court
attendance, etc. Prior to the implementation of the current safety framework, this transfer
occurred much earlier in the process and immediate interventions for the child(ren) and family
were managed by the case management organization while the investigator continued to
complete the assessment and investigation findings.

The process to staff cases within seven days results assessments with limited family information
and does not allow the receiving agencies time to review all of the information that would allow
for a more in depth conversation at the case transfer staffing. Additionally, the supervisor of the
assigned agency participating, not the worker receiving the case, participates in the staffing. The
CPI supervisor from the removal unit, not the removal CPI participated in the staffing. Staff
report that joint home visits between the CPI and the case manager do not routinely occur and
did not occur in this case. Information shared in the staffing is limited and more compliance-
based than sharing of critical information regarding the family.

FINDING C: There is not a consistent practice, or knowledge of the process, to reevaluate and
assess placement for a child with escalating medical needs, to include Medical Foster Care
referrals.

Within 24 hours of being placed in foster care, Aedyn was admitted to the hospital following a
medical examination conducted by the Child Protection Team. He remained in the hospital for
seven days to complete testing and treatment. During his stay at the hospital, Aedyn was

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diagnosed with Torticollis, Microcephaly, and Failure to Thrive. The Eckerd placement team
was not advised that Ayden had been hospitalized or of medical concerns identified through the
CPT evaluation. Sharing of medical information ensures appropriate placement decisions are
made for children coming into care. Prior to his discharge on September 21, 2016, his foster
mother, Ms. Flythe, received training and education regarding his medical and nutritional needs.
Based on the childs needs, placement in a traditional foster home was appropriate to meet the
childs needs and medical professionals felt Ms. Flythe would be an appropriate caregiver given
the training she attended. Within six days of his discharge, on September 27, Aedyn was
readmitted to the hospital due to having pneumonia. Upon his discharge on September 28,
Aedyn was returned to Ms. Flythes home.

During the month of October, Aedyn was seen by the Child Protection Team for weight checks
which showed that he was consistently gaining weight and no additional concerns were
identified.

On November 1, 2016, Aedyn was again hospitalized as he was not eating (having difficulty
feeding). He remained in the hospital for 13 days and was discharged to Ms. Flythe with a
feeding tube November 13, 2016. Ms. Flythe again received training and education regarding
his medical and nutritional needs and medical professionals noted no concerns with regards to
Ms. Flythes ability to provide an appropriate level of care.

On December 4, 2016, Aedyn was hospitalized following a choking incident and was again
discharged back to his foster home on December 7, 2016. Within hours of returning to Ms.
Flythes home, Aedyn was transported back to the hospital by emergency responders when he
became unresponsive.

Throughout the duration of this case, the assigned case manager and hospital staff reported that
the Ms. Flythe was involved in Aedyns care and commented on how bonded they were with one
another. Ms. Flythe believed that she was doing well in meeting Aedyns needs and did not feel
like she needed any additional assistance, with the exception of the case managers help in
taking Aedyn to his follow up medical appointments on occasion.

Despite Aedyns medical complexities, no one (including the medical providers, case
management and placement staff) referred him to Childrens Medical Services to determine his
eligibility for additional specialized and/or support services as well as the potential need for
medical foster care. Medical Foster parents have extensive medical training and there are
intensive medical-based supports in place to assist the foster parents.

Service Intervention/Array

PURPOSE: This section assesses the inventory of services within the child welfare system of
care.

FINDING A: Hillsborough County has a number of co-located providers that are available to
support both investigations and case management staff. In this case, the parents were not
willing to engage in services.

Hillsborough County has an array of services to meet the needs of the families and children
served in the community. Subject matter experts from substance abuse, domestic violence,
mental health, and safety management services are co-located with the CPIs and case

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managers. Additional services in the community include prevention services, formal safety
management services, and kinship care.

The CPI assigned to the initial investigation considered in-home Safety Management Services;
however, the present danger factors in the home required an out-of-home plan to ensure child
safety. The case manager attempted to engage the parents and to provide referrals to enhance
their protective capacities; however, neither parent followed through with referrals and, on
November 18, 2016, both parents signed Consent for Adoption to release Aedyn for private
adoption.

Systems Issues

Eckerd is the agency responsible for the delivery of case management services in Hillsborough
County. As the lead agency, Eckerd contracts for direct services with other local agencies and
maintains some of the processes and oversight in-house. Eckerd currently holds contracts with
three case management organizations (CMO) that are responsible for direct case management
services of children who are under child protective supervision; both in home and out-of-home.
Additionally, foster care licensing and daily management of traditional foster homes are the
responsibility of seven child placing agencies (CPA). Eckerd has retained the placement
functions for Hillsborough County, which makes them the final decision maker regarding the
most appropriate placement for children who are placed in licensed foster homes. Though they
make the final placement determination, the CPA is responsible for recruitment and maintenance
of foster homes. Each CPA is responsible for submitting a daily report which identifies
placement availability in each of their homes, as well as which homes are on waivers. This list is
then utilized by the Eckerd placement team in determining which homes are available.

When abuse reports are received on foster homes, Eckerd receives notification of the report
directly from the CPI and alerts are generated through its internal notification system. Eckerd
placement staff notifies the CPA that a report has been received on one of their homes and they
notify all CMOs that have children in the home. Aedyn was not added to the report and the
intake did not identify the foster parent. Reports containing unknown participants are not able to
generate notifications.

During the interviews it was clear that all of the agencies are committed to making any positive
changes necessary to improve service provision and child safety in the community they serve.
Executive leadership has both formal and informal processes in place to ensure that there is
consistent communication and that they are able to reach resolutions when presented with
challenges. However, the middle management teams and frontline staff indicated that they are
not aware of the totality of each role and are sometimes unsure who to contact to access a
particular service. This also seemed to transcend through the community as well, as several of
the agencies reported having difficulties getting the information they needed due to
confidentiality and providers not understanding their role or authority to access such
information. This issue has been noted by all of the prior CIRRT teams deployed to Hillsborough
County.

Immediate Operational Response

Eckerd responded to this tragedy immediately by reviewing their placement and incident
reporting processes. They immediately implemented requirements for all children who have
medical complexities to be reviewed by their in-house nurse care coordinator.

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They also recognized that there was an opportunity to use another system already in place to
alert them to any trends or immediate needs of children under their supervision. This system is
their Incident Reporting System. Every time a child is hospitalized, receives a critical injury, runs
away, etc., an incident report is completed and immediate notifications go out to the
management teams. In this case, the incident reports were being completed timely and
notifications received but there was no systematic process in place to track trends and multiple
incidents to the same individual. In response Eckerd is re-purposing a position and now a
specific person will be responsible for trending, tracking, and notifying individuals based on
information received in the incident reporting system.

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