No one answered the door at the West Linn home where six children lived, so the case worker there to investigate reports of child abuse left behind a note and her business card.

Mother Sarah Hart called within hours.

The next case worker assigned to investigate the family, nearly five years later in Washington, also left a business card at the unanswered door of their home. But she received no response. When the family of eight piled into their GMC Yukon and fled rural Woodland, the case worker’s business card was still tucked inside their front door.

One year has passed since Sarah Hart’s wife, Jennifer Hart, drove the SUV off a California coastal cliff with her family inside. Police discovered most of their bodies in and around their vehicle. Authorities believe the mother intentionally drove over the edge and into the sea.

Workers in Oregon’s child welfare system were the last to interview the two mothers and their six adopted children. All eight denied any abuse. But two adult friends insisted, based on first-hand observations, that the children were extremely isolated, severely punished and denied food.

Case workers concluded the investigation with a finding of “unable to determine,” meaning they found evidence of abuse or neglect but not enough to substantiate the claims.

Few other states acknowledge they allow this finding, according to a federal survey. But when concerned adults questioned the safety of Markis, Hannah, Devonte, Jeremiah, Abigail and Sierra Hart, Oregon’s child welfare agency was closing one in every five investigations as inconclusive.

An analysis by The Oregonian/OregonLive found the rate was even higher in Clackamas County, where the Harts lived: one in three. In fact, for most of 2007 through 2014, workers in the county closed more reports as undetermined than “founded.”

Only seven states, Oregon not among them, told the federal government that they allowed investigations to end that way as of 2017. Oregon officials once tried to deter the practice, changing the rules in 2008 to set stricter standards.

But the Hart children came to the attention of Oregon’s child welfare system when the practice was still commonplace. The allegations were set on a path likely to to end with an uncertain conclusion, particularly in Clackamas County. That is exactly what happened.

Fariborz Pakseresht, who leads Oregon’s Department of Human Services, defended the practice. Reviewing his agency’s rates of closing child abuse and neglect investigations as unable to be determined “in a silo” doesn’t convey how the system works as whole, he contended.

“Founded and unfounded defines those things as black and white, and yet quite often, life situations don’t lend themselves to that, you know, unless there’s a case that’s absolutely clear,” he said during an interview Monday.

For a child, the effect of an inconclusive ruling is normally the same as when a suspected abuser is cleared. Oregon’s child welfare agency backs out of the family’s lives. In contrast, substantiated reports of abuse, by rule, trigger actions meant to make sure kids are safe.

Policy requires that any time there is reasonable cause to believe abuse or neglect occurred, the investigation must be “founded.” But former case workers say they sometimes wrote “unable to determine,” despite evidence of adult wrongdoing, because their office didn’t want to impose consequences that employees felt were too harsh or difficult to carry out.

Stephen Raleigh, a former case worker, said a supervisor had overturned some of his decisions from “founded” or “unfounded” to not able to be determined.

“If it’s ‘founded,’ why are you changing it to ‘unable to determine’?” Raleigh asked, reflecting on his time at the agency.

“We put kids in peril, because there was just a big push to make sure we didn’t take kids into custody.”

Southern Oregon’s Jackson County, where he worked, closed out more than half of investigations as “unable to determine” for most of 2007 through 2009, and continued to close roughly 20 percent of investigations that way through 2013.

Case workers are supposed to close an investigation as inconclusive only in very specific circumstances: if they are faced with conflicting information after interviewing everyone possible. Federal officials count children investigated in those cases as victims of maltreatment, because case workers did find some evidence to of abuse.

Oregon’s use of “unable to determine” did decline after the state started a pilot project meant to keep more children at home. That program ended in 2017, and inconclusive cases rebounded.

In the year since the Hart children died, Oregon’s case workers concluded they weren’t able to determine whether children were neglected or abused more than 4,100 times, according to state figures.

11 Leaders at the Oregon Department of Human Services and its child welfare division

Pakseresht said his agency uses data about past outcomes to inform its future decisions. But during the same interview, neither Pakseresht nor child welfare director Marilyn Jones would discuss the disparate degree to which cases are closed as “unable to determine” statewide. Clackamas, Klamath, Josephine and Jackson counties consistently used it at among the highest rates in the state, for instance, while Marion and Lane counties used it sparingly.

The Oregonian/OregonLive provided agency leaders with written questions about “unable to determine” rates seven work days before the interview.

Jones said the safety of children drives every decision that case workers make.

Five former case workers and managers interviewed by The Oregonian/OregonLive agreed. But many said that pressure from supervisors, policy changes or incessantly high caseloads increased their stress when they were faced with difficult decisions.

“You go home and you’re trying to eat dinner, and it’s churning around in your stomach because of what you’ve seen that day,” said Barbara Jackson, a retired case worker who worked mainly with foster families in Jackson County.

Jones acknowledged that the job was grueling, but said she believed all case workers err on the side of caution for a child. She questioned that managers would ever change a case decision to “unable to determine.”

“I have not ever heard anybody tell me that there was an ‘unfounded’ or a ‘founded’ that they were asked to reverse,” she said. “That just wouldn’t be acceptable.”

A Washington child abuse case worker left behind her business card after she was dispatched to investigate possible neglect at the Hart family home in Woodland, Washington in March 2018. No one answered the door. Days later, the family was found dead in California. Courtesy of Clark County Sheriff's Office

No safety threat

The Hart children spent their lives on the radars of state child welfare systems.

Sarah and Jennifer Hart adopted their six children from foster care in Texas. The Texas child welfare system had removed them from the homes of their biological parents. Markis, Hannah and Abigail were adopted in 2006. Devonte, Jeremiah and Sierra completed the family two years later.

At the time, they lived in Minnesota. That state’s child welfare system received six reports about the family from 2010 to 2011. Most were either not investigated or closed as unfounded. But Sarah Hart was convicted in 2011 of misdemeanor domestic assault after she admitted hitting middle daughter Abigail.

Many of the allegations revolved around food, records say. School employees spotted Abigail digging through the trash and taking classmates’ food. Hannah asking classmates for food. Hannah telling the school nurse that her mom shoved a banana and nuts in her mouth.

“The Minnesota worker said after a while the school stopped calling the parents about the child(ren) taking food, because they didn’t want the children being disciplined or punished,” a child abuse screening report said.

A family friend didn’t know that history when the Hart family spent the night at her home in July 2013. By then, the Harts had withdrawn the children from school and moved to Oregon.

Everyone shared a pizza, and Jennifer Hart gave each child very small slice, the friend later told child welfare workers. The leftover pizza was gone the next morning. Hart became angry that one or more of her children ate it and pulled the children into the bathroom. Then she forced all six kids to lie on the bed for four to five hours as punishment.

The woman called Oregon’s child abuse hotline. The screener assigned the report to a case worker, and Sarah Hart did call the number on the business card left at the front door.

Then the investigation stalled.

Two months after this photo was shared by their mother online, Hannah, Sierra, Jeremiah, Devonte, Markis and Abigail Hart told case workers that they weren't being neglected or abused. Family friends worried that the children weren't been fed enough and were being subjected to severe discipline. Facebook/Jennifer Hart

Citing schedule conflicts, the Hart parents postponed case workers’ visit to their home. Thirty-eight days passed before case workers interviewed the family. When they walked into the house at the appointed time, they saw the six children, ages 8 to 15, coloring. All denied the abuse. Their parents did, too. Sarah Hart wouldn’t tell the Oregon case workers how Abigail received the bruises that had led to the criminal conviction in Minnesota.

“She became emotional during this line of questioning and would say, ‘It just got out of control,’” the case worker’s notes said.

The mothers agreed to have the children be evaluated by doctor. But months passed before they were all seen. The physician concluded that, compared to normal ranges of height and weight, all the children were far too small for their ages, but she wrote in her reports that she had no concerns about their wellbeing. The doctor was not provided prior records to compare their growth to, and the case worker did not request them from Texas or Minnesota.

It’s not clear whether the case worker told the doctor that the children had come to the state’s attention because of a report of food being withheld and had a history of similar complaints in Minnesota.

Months after the initial deadline passed for the outcome to be decided, Oregon’s child welfare agency closed its investigation as unable to be determined. The case worker marked “safe” next to each child’s name.

“Although the children made no disclosures of abuse or neglect, two collateral contacts expressed concern regarding the parents limiting food for the children and having witnessed what they believed was excessive discipline,” the worker wrote in justifying the decision. There is no evidence a supervisor signed off on her decision, as rules require in every case.

The worker has left the agency and is now a liquor regulator. She declined to speak to The Oregonian/OregonLive before a reporter could ask any questions.

The agency says she made the right decision.

“At that time, child welfare personnel followed procedures in place, conducted interviews and also reviewed records of a doctor who examined the children,” the department said in a statement.

Officials said they reviewed the agency’s history with the family anew after the crash. But they failed to respond to The Oregonian/OregonLive’s request for a copy of the review.

“The death of the children occurred five years following one CPS report assessed by Oregon,” the statement said. “Much has changed around case work practice since that time,” it said, including better training, updated policies and new mentors for case workers.

But the case workers still close one in seven cases as inconclusive.

Oregon's child welfare system closed its July 2013 investigation into the Hart family in June 2014 with this determination.

‘A child could die’

The job of case workers is incredibly difficult. They must sift through information to find out what is really happening in a home. And some parents are extremely convincing that nothing is amiss, said Janet Rosenzweig, executive director of The American Professional Society on the Abuse of Children, based in Ohio.

“It’s not always as cut and dry as we’d like it to be,” she said.

Research has shown that many factors can influence case decisions and affect workers’ perception of seriousness, she said. Those variables can include the state of the home that workers visit and the amount of time they have to spend on any one case, Rosenzweig said.

Sarah Font noticed those outside influences on her case decisions when she was a child protective services case worker in the 2000s. She is now a professor and child welfare researcher at Pennsylvania State University.

“One of things that would interest me about decision-making was how often I would disagree with coworkers,” she said.

“How do you decide if something is severe enough for substantiation?”

National data shows most investigations of child maltreatment involve allegations of neglect, four researchers told The Oregonian/OregonLive.

Children in single-parent households are more likely to be the subjects of those calls than their peers living in two-parent homes, said John Fluke, associate director of the Kempe Center for the Prevention of Treatment of Child Abuse and Neglect at the University of Colorado medical school.

A case worker may bring inherent bias to the task of investigating alleged neglect in a two-parent household, he said.

The same is true for investigating possible neglect in a high-income community such as West Linn, where the Harts lived. Allegations of neglect are closely correlated with areas of high poverty, Rosenzweig said.

Good supervision is the key to countering unintentional bias, she said. Supervisors who haven’t been exposed to those outside influences can offer objective input.

Many states, including Oregon, also set guidelines for case workers to follow to make their decisions more uniform. But those tools can have limited effect, said Kathryn Maguire-Jack, a professor at Ohio State University. Case workers may come to a decision, then fill out the assessment to match what they believe it should say.

Every decision has critical consequences, Maguire-Jack said.

“If you make the wrong decisions, a child could die,” she said.

Siblings Abigail Hart, Devonte Hart and Jeremiah Hart run through a sprinkler in a photo posted to their mother's Facebook page in June 2014, the same month Oregon officially closed its investigation into the family with a finding of "unable to determine." If this photo were taken around the same time it was shared, Abigail would have been 10 years old, Devonte would have been 11 years old, and Jeremiah would have been 10 years old. Facebook/Jennifer Hart

An agency in turmoil

The last decade has rocked Oregon’s child welfare agency.

For years, the department has consistently failed to meet federal benchmarks for child safety. The agency had four different leaders and five different child welfare directors between 2015 and 2017, Pakseresht said.

Case workers told The Oregonian/OregonLive the turmoil affected them. Workers said they were poorly trained to carry out new directives.

“The feeling they gave every time (was) ‘The way you’ve been doing things, we’ve realized is crap, but now you’re doing it this way, and it’s going to be much superior to the way things have been done,’” said Jackson, the foster care worker.

Child safety program manager Tami Kane­-Suleiman acknowledged the agency “didn’t do a great job” training in the past but now prioritizes it.

Every former worker interviewed by The Oregonian/OregonLive also cited staff turnover as an issue with widespread consequences. Child protective services investigators were relatively inexperienced because case workers left so frequently, many said. Often they were tasked with investigating a list of cases that never stopped growing.

“I knew case workers that were actually two years behind on cases,” said Raleigh, the former case worker.

The Department of Human Services said the number of cases assigned to each worker did not affect case decisions. But in the next sentence, the agency said “caseload can impact the time spent on any given case.”

The agency’s investigation into the Hart family was officially open for nearly a year, far past set deadlines. That year, 2013, Clackamas County closed as many as 33 percent of its cases as “unable to determine.” The practice contrasted sharply with other counties, such as neighboring Marion. Since 2012, case workers there have never closed more than 15 percent of investigations as “unable to determine.”

Gayla May was a veteran child protective services manager during that time in Clackamas County. She said she constantly reviewed case data with her bosses and the workers she supervised. She’s sure they discussed investigation decisions but does not remember ever focusing on the county’s elevated use of “unable to determine.” She said she felt no pressure to close cases that way.

Siblings Abigail, left, Jeremiah, Devonte, Sierra, Markis and Hannah Hart pose for a family photo shared in April 2014, months after an Oregon doctor evaluated them following reports of neglect. Facebook/Jennifer Hart

Jones, the child welfare director and a longtime supervisor at the agency, said even if investigations conclude in uncertainty, case workers often connect families to extra help, such as food stamps.

Both Jones and Raleigh said closing investigations as inconclusive can serve as a flag if case workers receive another report about the family. Raleigh said he worked with Jones in Eastern Oregon and admired her leadership. He said that’s where he learned that case workers should use “unable to determine” sparingly.

Kane-Suleiman said case workers only conclude cases that way if there is no more information to gather, or cannot find a family.

“It’s not a simple finding,” she said. “We really ask workers to check with multiple people. We don’t like to leave that with that conflict there, but oftentimes, there’s just no other information to gather, so we land on that ‘unable to determine.’”

Case workers statewide began closing investigations as inconclusive less often when the department started an alternative method of responding to reports of neglect. The approach, called “Differential Response,” was supposed to keep families together while connecting them with services that families might need. Reports handled that way weren’t assigned a disposition.

But a 2017 internal review of many alternative-response cases found that case workers incorrectly determined that children were safe nearly half the time. In response, lawmakers required the agency to make a clear decision, even if the decision is “unable to determine,” to close out every investigation.

The rate of investigations closed as inconclusive has increased slightly since then, according to agency figures, but has not shown a steep or steady climb.

Pakseresht said repeatedly that he considers data the key to turning around the agency. The department is developing an algorithm based on past data that he will direct case workers to use to inform their case decisions, beginning with call-takers’ initial decisions about whether to look into allegations. He said the mathematical formulas have a predictive accuracy of 80 percent.

“We’re looking at the past cases to see what we can learn from it, and we, at the same time, are trying to create the future,” Pakseresht said, “so that we’re being responsive and not reactive.”

-- Molly Young

myoung@oregonian.com

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