Tony Gonzalez, The Tennessean
Three high-ranking employees in the Department of Children's Services were disciplined for failing to keep track of child deaths and for giving out incomplete records when an advocacy group and The Tennessean asked for the information.
Internal memos document the reprimands, including:
• the demotion of Lisa Lund, a team coordinator, who appealed the penalty and was reinstated with a two-day suspension without pay;
• the two-day suspension without pay of Lund's supervisor, Director of Child Safety Marjahna Hart; and
• a written warning to Carla Aaron, executive director of child safety, who oversees Hart and Lund.
The three employees work together on child protection programs and the internal Child Fatality Review Team, tasked with probing fatal cases so DCS can prevent mistakes. But the team fell behind on its work and failed to follow policies, leading to court-ordered reforms.
The Tennessean received 53 pages of the fatality review team's meeting minutes in January. Those digital documents were heavily redacted because officials said the names of children and other identifying information had to be obscured.
But a month later, DCS said the redactions had not been done properly. DCS acknowledged it had blocked information that was public record. The agency released the documents again and provided enough new information to fill 12 additional pages. At the same time, leaders launched an internal review.
Disciplinary records show Lund, a 19-year employee, was responsible for the fatality team's minutes. Some of the minutes had errors or were left incomplete, failing to capture discussions of the fatality review team.
Months after those meetings, when The Tennessean and advocacy group Children's Rights requested the minutes, Lund tried to bring them up to date, at times working weekends and late nights, internal emails show.
Later, Aaron discovered Lund left out "significant portions" of the team's minutes before they were made public. Passages that did not appear in the first batch added key details about how DCS caseworkers made decisions during child abuse investigations.
Henry demoted Lund to a case manager position in March, but reversed that decision after she appealed. During her appeal, officials wrote that the redactions happened because Lund "was working from numerous meeting minute documents and redacted the wrong version."
Internal emails also reveal confusion among officials as to whether some death reviews took place. And DCS failed to turn over more than 100 pages documenting the work of another review team created to catch up on overdue cases.
Death data 'flawed'
Other records included with Lund's disciplinary appeal shed light on why DCS repeatedly revised its child fatality count in 2012 - a record-keeping issue that prompted a much wider Tennessean investigation, court orders, inquiries by lawmakers and the resignation of former commissioner Kate O'Day.
As early as January 2011, Lund was collecting child fatality information and entering details into a digital spreadsheet. From there, officials could count incidents and prepare to review cases.
But a timeline written by Aaron shows the accuracy of that document was questioned as early as May 2012.
Miscounts led to "significant negative publicity in statewide media outlets (print, television and radio), as well as additional scrutiny by ... the federal court," reads a memo to Lund from Henry.
In her appeal, Lund defended herself by saying the department's reliance on a spreadsheet was "flawed."
"The spreadsheet has not been an accurate and effective means for capturing data," she wrote.
Lund also described intense deadlines, "moving target" assignments and a "seemingly endless threat of disciplinary action."
DCS Commissioner Jim Henry suspended Hart, an eight-year employee, for lack of oversight of the death reviews and fatality tracking. She could not be reached for comment.
The warning against Aaron, citing similar issues, says she was responsible for reviewing information before it could be given to the media or filed in court. Aaron has been with DCS for 27 years.
Lund and Aaron declined to comment.
DCS has been under federal court order to improve the care of foster children for more than a decade. Revelations about the fatality review team led DCS to create a new process, to be put in place by August. DCS will have to keep thorough meeting minutes and publish an annual report of fatal review findings.
Reach Tony Gonzalez at 615-259-8089 or
firstname.lastname@example.org. Follow him on Twitter @tgonzalez.