Full Report On Tanner Dowler's Death By Department Of Human Services
10:15 AM, Jan 30, 2003
Child -- Tanner Dowler
The Colorado Department of Human Services Child Fatality Review Team conducted the review of the circumstances surrounding the death of Tanner Dowler. The purpose of the fatality review team is to assure accountability by county human services departments and to improve the coordination of the child welfare services system at the community level. The team members include county and state staff and legal and medical consultants.
Statutory authority for this review is in Title 26-1-111. The Department of Human Services' supervisory authority is outlined in the areas of child welfare and other programs as specified. It is in the capacity of supervision of the county's administration of child welfare programs that the state has the legal capacity to require corrective actions and to conduct follow-up review.
The review team reviewed case records and conducted interviews with child welfare staff from the Boulder County Department of Social Services and community agencies that were involved with the family prior to the child's death. The team was refused interviews by the Platte Valley Medical Center, where the child was born.
ChronologyJune 27, 2002 (estimated): Lea Dowler allegedly faxed a letter to the Platte Valley Medical Center, expressing concern for the unborn child of her stepson, indicating unemployment, instability and anger management issues that she believed would negatively impact the child. The letter did not express concern for the physical safety of the child.
July 24, 2002: The Dowlers visited the WIC (Women, Infants and Children) Program, which is a food supplement program that may provide nutrition counseling and vouchers for food for mothers and children, and Audra Riley/Dowler received a referral to the Genesis program because she was a teen mother. The Genesis Program is a county funded program that provides services to teen parents including prenatal and parenting education, role modeling, monitoring of child development, ensuring adequate prenatal care, and meeting basic needs (food, shelter, transportation). She refused the referral saying, "she did not need help from anyone."
August 10, 2002: Tanner Dowler was born to Audra and Joseph Dowler at the Platte Valley Medical Center. Reviewed medical records provided by the Boulder County Department of Social Services indicated that the delivery was normal. Medical records were also available to document that the mother received prenatal care from Salud, a public health clinic in Brighton, prior to the birth of Tanner, her first child.
August 13, 2002: Weld County Department of Human Services received a faxed letter from Tanner's paternal grandmother, who had previously contacted the Platte Valley Medical Center. The letter outlined homelessness, financial problems, unemployment, immaturity and anger management issues that were of concern to the grandparents. The letter did not express concern for the physical safety of the child.
August 14, 2002: The Weld County Department of Social Services faxed the letter to Boulder County Department of Social Services because the letter indicated Boulder as the county of residence.
August 14, 2002: Boulder County completed an internal records check and requested the same of the local law enforcement agency. The report was not assigned or pursued when the searches failed to yield an address for the family.
August 20, 2002: Tanner Dowler received a well-baby check at the Salud Clinic. Reviewed records from that check indicated that no signs of abuse or neglect were noted and that Tanner's growth was within normal range. Documentation of the check included the following statement: "father of the child was very involved. Mother of child distracted during visit, reluctant to answer questions."
August 22, 2002: Joseph and Audra Dowler attended an appointment with the WIC program and presented the child's medical reports from the Salud clinic. From WIC's review, the heights and weights were appropriate for this age child.
August 28, 2002: Tanner Dowler received a second well-baby check at the Salud Clinic. Reviewed records indicated that the clinicians noted no signs of abuse or neglect and that the infant's growth was within the normal range.
August 30, 2002 (estimated): Joseph Dowler visited the Louisville office of the Boulder County Department of Social Services and exhibited volatile, angry behavior. The eligibility technician called the child protection unit at the Louisville office, which is the sexual abuse unit. The sexual abuse caseworker observed the father as he was holding the newborn but did not conclude the concerns needed to be reported to the intake casework staff for further follow-up.
October 3, 2002: Tanner Dowler was brought into Community Medical Center (CMC) in Lafayette. While at the CMC, Tanner went into respiratory arrest but was able to be resuscitated. He was transported by helicopter to Denver Health Medical Center. The infant was diagnosed with a brain injury, burns, healing abrasions and multiple fractures.
October 12, 2002: Tanner Dowler died, after being removed from life-support.
1. No records were found by the Boulder County Department of Social Services when the internal records check was conducted on August 14 due to the fact that staff used the last name of "Riley" for Audra, and misspelled the name "Joseph" when checking for records under Joseph Dowler. Had the names been correct, records would have been located, and family's current address, because the family had recently applied for assistance under these programs.
The Boulder County Department of Social Services must ensure accuracy of data entry when doing a background or records check in child protection.
2. The allegations were of sufficient concern that the county needed to do more to locate the family. This was a newborn with significant risk factors alleged in the letter from the paternal grandmother. Boulder County did not exhaust all efforts to locate this family, such as contacting the hospital, Salud clinic, or extended family members who were identified in the letter.
The Boulder County Department of Social Services must ensure that interventions occur, whenever safety concerns are reported, as outlined in Initial Assessment, in state regulations.
At the time of the review, Boulder County had taken action, in that an administrative level of approval is now required on all initial response decisions that may result in suspending further action.
The Boulder County Department of Social Services did not notify the reporting party (paternal grandmother) that the referral would not be assigned for investigation as required by regulation, Volume 7, Section 7.202.4C.
The Boulder County Department of Social Services must immediately institute a procedure ensuring that reporting parties are contacted, according to regulation.
Mechanisms for reporting concerns about parental behavior as observed by TANF eligibility worker need to be evaluated and strengthened.
Boulder County Department of Social Services should develop mechanisms for reporting concerns about parental behavior in those situations when the TANF worker is concerned about a parent's volatile behavior.
At the time of the review, Boulder County had taken action and now requires TANF workers to make direct referrals to child protection intake when they have concerns.
4. Boulder County has numerous home visitation models in place that outreach to families. The family may have benefited from a model where there is a persistent and repeated attempt at outreach, with the goal of building a supportive relationship.
The Colorado Department of Human Services will review models of universal home visitation in use in other states in terms of outcomes and costs.
5. Lea Dowler, grandmother of Tanner Dowler, allegedly sent a letter outlining prospective neglect concerns prior to the birth of Tanner Dowler to Platte Valley Medical Center. The Child Fatality Review Team was not able to confirm whether the hospital appropriately handled this information because the hospital declined to participate in this review.
The Colorado Department of Human Services will examine the need for statutory authority for the Child Fatality Review Team to access medical records and to conduct interviews of all parties.
Corrective Action Plan
This statement provides notice that a corrective action is required on all findings with required action, that a corrective action plan is due to the State by February 10, 2003, and that upon receipt and review of the plan the State will provide an approval of the plan. The state will conduct on-site follow-up in 6 months.
The State will monitor in follow-up visits the full implementation and effectiveness of the plan, to assure that the policies have remediated the issues identified in this report.