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Tennessee's child abuse investigators, who confront life-or-death decisions about whether kids are safe in their homes, haven't always been willing to talk when things go wrong — when children die or suffer severe injuries.

And for at least a couple of years, caseworkers didn't have to say much of anything.

The Department of Children's Services fell behind on internal reviews of child deaths. When they did look back, the reviews did little to explain what led to each incident, or what might save other children.

That's changing.

The department recently completed its first year of new, more immediate and more exacting death reviews as required by a federal judge. A court order requiring changes followed a Tennessean investigationand outcry from a watchdog group. DCS now must learn as much as possible about every death and near-death incident involving families who had contact with state caseworkers.

"When we started, there was a certain hesitance on the part of our frontline caseworkers," Tom Cheetham, DCS deputy commissioner of child health, said of the reviews. "They're often suffering because a child on their caseload has died."

Led by Cheetham, DCS leaders say the new reviews don't seek to blame individual caseworkers or second-guess their decisions, but to understand how "these tragic and usually unforeseeable events emerge from a complex social system," as they wrote in a new report this month.

Cheetham wants to know why caseworker decisions made sense to them at the time, even if the outcome was dire.

Last year, DCS closely reviewed 109 deaths and near-deaths, pulling from DCS files, health records, police reports and interviews with staffers. That's just less than half of the 245 deaths last year that the agency responded to statewide. Officials have vowed to review them all.

The new report explains recurring difficulties for caseworkers.

Their caseloads are too large, for example. The step-by-step process they use as a guide to evaluate the safety of homes needs updating. Caseworkers aren't fully prepared for drug-using parents or families with mental health concerns. And caseworkers don't always share expertise with one another while investigating.

DCS wants to address each problem.

Investigators in Nashville now start their days with "huddles" that bring the staff together to discuss challenging situations ahead — and to share information about families in touch with DCS before.

"Case managers out there on the front lines are making difficult decisions constantly," said Noel Hengelbrok, DCS director of safety analysis. "These decisions are very difficult and have high stakes."

The latest 28-page report does not detail individual deaths, opting to examine broader trends. Cheetham said DCS has other case-specific internal checks in place that can lead to required training or discipline for caseworkers.

By looking closely at its investigations, he said, DCS can also learn how some of the best caseworkers interact with families.

That's a different approach than when the agency fell behind on its reviews in 2011 and 2012, before scaling them back. The Tennessean found that DCS ignored its own death review policy and kept sparse records of reviews that did take place, ultimately leading to discipline against three high-ranking employees.

This year, DCS has opened investigations into 69 child deaths. The agency struggled to keep count of fatalities in recent years, drawing intense scrutiny and preventing analysis of trends. DCS is now into its second year with its new counting method but has not completed year-over-year data analysis.

Reach Tony Gonzalez at 615-259-8089 or on Twitter @tgonzalez.

Fatality review findings

Workload: Too many abuse investigators handle large caseloads and struggle to meet deadlines.

Supervision: Leaders don't always work effectively with inexperienced DCS employees.

Unsafe sleep: Families still aren't learning what makes for safe sleep conditions for infants — that babies should be put to sleep alone, on their backs, in cribs.

Decisions: Step-by-step tools that investigators use to evaluate home safety need to be revised.

Training: Investigators struggle with families that abuse drugs.

Expertise: Experienced caseworkers don't always share what they know with peers.

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