Oregon Department of Human Services Director's Message
January 8, 2010 DHS Director's messages on the web
To: All DHS employees
From: Bruce Goldberg, M.D., director
The importance of public accountability
"The price of greatness is responsibility."
~Sir Winston Churchill

In this first message of the new decade I had intended to write about our accomplishments at DHS for 2009. The list is long and impressive -- a lot of great work was done in '09 and I'll be talking more about that next week.

This week, though, I want to address something that is weighing heavily on my mind and, I know, the minds of everyone who works for child safety in our state. That is the murder of Jeannette Maples in Lane County last month. Over the past few weeks there has been intense internal and public scrutiny of this case, as there should be. Much of the response has raised the question of what the community and the child welfare system should have done differently in order to prevent this death.

Any child death is unacceptable and we must do all that we can to ensure that this does not happen again. Children count on their parents to keep them safe. When their parents instead are the cause of violence and abuse, their safety is the responsibility of us all.

The day after the event, I called for a comprehensive review of the circumstances surrounding this incident so that we can fully understand what happened, fix problems identified and be held publicly accountable for both the review and the remedy. To help answer the question of what could have been done differently, I launched the Critical Incident Review Team (CIRT).

The team includes child welfare executive staff, the Department of Justice and the law enforcement involved in the case. The team looks at the case files, conducts face-to-face interviews with involved staff members, and publicizes a report of each interaction with DHS and whether policy was followed to keep children safe. When mistakes are made, we acknowledge them. Appropriate action is then taken to address any system or human performance issue identified.

I know of no other state that does such immediate, comprehensive and public reviews of its actions when there is a critical incident. Since the process was created, we have continually improved it to make it faster, more thorough, and more understandable to the public.

A comprehensive and transparent review is very important as we strive to reach the goals of protecting all children. But that's not enough. We must take what we learn, take all appropriate actions, and make every improvement necessary to prevent these tragedies in the future. I know that CAF director Erinn Kelly-Siel joins me in that commitment.

I have often said that the work we do is so important, we have to be the best. I know that the child welfare staff shares that belief. I also know and have great empathy for the fact that the visceral outrage we civilians feel when we read reports of child abuse is something they have had to learn to live with as a part of their work. While we may feel shocked by one headline, they are living story after story of the worst crimes people can commit against children. The caring and love they show these children never makes headlines, but it does make a difference and I know that every bad outcome sends shockwaves through our branches.

Additionally, I take seriously the responsibility that the rest of DHS has for these families to prevent them -- whenever possible -- from going into crisis in the first place. How different many of those stories would turn out if we could better address the root causes of child abuse. Many tragedies would be prevented if parents were able to get mental health treatment or if domestic violence between adults could be stopped before it starts.

The state is not, of course, the only entity in the lives of the families we serve. By the time they reach us there may have been dozens of other ways they could have been helped. But we do have an awesome responsibility and by asking hard questions we can continue to do our jobs better, help more people, and stop as much heartbreak as possible.

DHS on the web