Mourners gather for a vigil to remember the life of 10-year-old Marissa Kennedy in Stockton Springs, March 4, 2018. Credit: Emily Burnham

A report released Thursday about state government’s role in protecting two slain children from abuse faulted the Department of Health and Human Services’ Office of Child and Family Services for “poor job performance” and “inadequate supervision” in one of the cases.

In the other case, the Legislature’s Office of Program Evaluation and Government Accountability found that the risk of child abuse and neglect “was not necessarily evident” to state overseers tasked with protecting the child.

The report offers the most comprehensive study of Maine’s child welfare system to be publicly released since the deaths of 10-year-old Marissa Kennedy in February and 4-year-old Kendall Chick in December.

“We believe we have gleaned a decent understanding of what occurred, and what did not, with regard to roles various entities played in these children’s cases,” reads the report. “We are, however, still lacking a full understanding … particularly around what factors impacted their decisions and actions.”

[What happens when child abuse is reported in Maine]

The report stopped short of blaming the deaths on state workers, stating, “We may never know that for sure.”

The report noted that information was unavailable or has been left out because of two open criminal investigations and confidentiality laws. Beth Ashcroft, OPEGA’s executive director, told the Legislature’s Government Oversight Committee on Thursday morning that the lack of public information is “frustrating” but necessary.

“We’ve erred on the side of conservatism to some degree in what we’ve reported,” Ashcroft said. “We did do what you asked us to do.”

Ashcroft did not link findings specifically to either case. Asked by Assistant Senate Minority Leader Nate Libby, D-Lewiston, to describe steps that have been taken by the state in response to the deaths, Ashcroft said she couldn’t because “they would be in the realm of employee performance and discipline.”

Other members of the Government Oversight Committee reacted with fury to the fact that so much information is unavailable.

Sen. Roger Katz, R-Augusta, who co-chairs the committee, said “we have two child deaths and our confidentiality laws make it impossible for us to figure out why.”

“We have failed these kids,” he said. “We just can’t make good policies when agencies are shielded from accountability by laws we have passed.”

Sen. Bill Diamond, D-Windham, agreed, asking, “How long can we follow our bureaucratic rules … before we can get in and deal with this abuse? It’s driving me crazy to sit here knowing this is going on.”

Without specifics, Ashcroft said the probe uncovered statements from state employees about there not being enough resources to handle the number of child abuse cases being reported.

In the report, OPEGA recommended additional training and guidance for mandated reporters who are responsible for flagging child abuse when they witness it, shorter timelines for assessments of reported cases, better responsiveness to phone calls reporting potential abuse and more training for state staff, among other suggestions

The OPEGA probe was unanimously authorized by the committee in March. It called for an investigation into how the state handled cases involving Kennedy of Stockton Springs and Chick of Wiscasset — both of whom were allegedly killed by family members. The committee also called for a broader examination of Maine’s child welfare system.

The report released Thursday is preliminary to a broader investigation, which is expected to take several months.

Christopher MacLean, Sharon Carrillo’s defense attorney, said the report was filed with “vague, academic commentary,” but provides some insight into how DHHS generally handles its investigations.

MacLean said his takeaway from the report was that DHHS gives all the reports of suspected abuse that it receives the same weight, whether it comes from a teacher, doctor, neighbor or family member.

“It would be far more effective to develop a system for devoting more resources to cases of highest priority,” MacLean argued. “For example, if DHHS receives reports involving a single family that come from multiple mandated reporters like pediatricians, teachers or law enforcement officers, this case should be flagged and additional caseworkers should be brought in to focus on the family.”

“If you are looking for a needle in a haystack, focus on the haystack where multiple people say the needle is,” he said.

MacLean has declined to say what he’s learned about DHHS involvement with the Carrillos as he prepares for trial. It’s likely more details will come to light as evidence during that trial.

[DHHS tried to cut back on the number of child abuse cases where it intervened]

DHHS has answered very few questions about either case despite intense scrutiny, which heightened after the Bangor superintendent of schools and a former neighbor of Kennedy’s family said in March that DHHS had been contacted multiple times with concerns about the girl’s well-being.

Gov. Paul LePage was among those calling for an investigation, saying in March that a “ comedy of errors” at DHHS could have contributed to the tragedies. There were also executive branch reviews of the cases by the Child Death and Serious Injury Review Panel.

LePage said in a written statement Thursday that his administration is eager to assist the ongoing OPEGA review as long as it “does not jeopardize any pending prosecution so that justice is served for the children.” He said the state needs “as much information as possible” before making significant changes “that may have to be revised.”

“Through our internal investigation, we have been able to identify areas in need of improvement, many of which are echoed in OPEGA’s preliminary report,” DHHS Commissioner RIcker Hamilton said later in a prepared statement. “I am confident that the department’s internal review, combined with the findings of the reviews done by a number of different oversight entities, will provide substantive insight for reform and improvement. Evaluating the entire network of parties that make up our state’s child welfare system is critical to this process.”

According to OPEGA, those have resulted in changes including automatic assessment of cases after three reports of child abuse and the implementation of a “ structured decision making” system by the Office of Child and Family Services.

The report released Thursday will be the subject of a May 31 public hearing hosted by the Government Oversight Committee at 9 a.m. in Room 220 of the Cross Office Building, which is on the State House complex.

Bangor Daily News writers Nick McCrea and Michael Shepherd contributed to this report.

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Christopher Cousins

Christopher Cousins has worked as a journalist in Maine for more than 15 years and covered state government for numerous media organizations before joining the Bangor Daily News in 2009.