There were warning signs.

Before 4-year-old Kendall Chick died on Dec. 8, 2017, from suspected child abuse, and before police would charge her primary caretaker, Shawna Gatto, with her murder, both Gatto and her fiancé – Stephen Hood, Kendall’s paternal grandfather – expressed reservations about whether they could care for the girl at their Wiscasset home, where the state had placed her.

“I’m so (expletive) done with this kid,” Gatto texted to Hood weeks before Kendall died, which was shared during her trial this month.

In another, Hood wrote to Gatto: “Call DHHS, see what they say. If they think she needs special care they can place her. Fine, take her.”

But neither called. And the state, it seems, never called them.

One of the most startling revelations of Gatto’s weeklong murder trial this month came when Hood was asked on the stand whether it was true that the Department of Health and Human Services checked on Chick only once in the three years she was with the couple. “Yes,” he answered.

State officials wouldn’t say how often caseworkers visited Kendall or discuss any other details of her case, but DHHS policy requires caseworkers to have monthly face-to-face visits with children in state custody, as Kendall was.

“I’m convinced that Kendall would be alive today if someone had visited the house and seen those bruises,” said Sen. Bill Diamond of Windham, who sat in on multiple days of Gatto’s trial and is spearheading legislation that aims to bring sustained reforms and oversight to child protection. “There were so many red flags there that it just makes you sick. The smallest amount of effort could have saved this child.”

Gatto’s fate is in the hands of Superior Court Justice William Stokes, who will render his verdict April 30. If convicted of murder, she faces 25 years to life in prison.

Regardless of what happens to Gatto, Kendall – along with 10-year-old Marissa Kennedy, who died from child abuse in Stockton Springs three months later – remains a symbol for a broken system.

The two deaths sparked public outrage and calls for reforms that continue today. By last summer, after internal and external investigations had begun, caseworkers started speaking out about conditions within their agency that made their jobs near impossible. Unsustainable caseloads. High staff turnover. An anemic foster care system that led to many caseworkers spending nights in hotel rooms with kids until safe placements could be found.

Fixing Maine’s broken child protection system has emerged as a priority for Gov. Janet Mills and her Health and Human Services commissioner, Jeanne Lambrew. Last month Lambrew testified before the Legislature’s Government Oversight Committee about those ongoing efforts, some of which had started during the final year of Gov. Paul LePage’s administration.

“We are taking special care to ensure that our work incorporates the specific needs of Maine’s children and families,” she said. “And, here and throughout the department, we aim to do so with transparency.”

That transparency hasn’t included details about DHHS’ involvement in the Kendall Chick case, though. Although some new details emerged during Gatto’s trial, many questions remain.

DHHS spokeswoman Jackie Farwell provided written responses to questions from the Telegram but would not address specific questions about Kendall.

“Personally identifying child protective information is confidential under Maine law,” the department said in a statement. “There are limited exceptions in the event of a child death, but public disclosure will not be made when the Commissioner determines, upon the advice of the Attorney General, that such disclosure would jeopardize a criminal investigation or proceeding.”

However, information Farwell did provide about how the process is supposed to work reveals that it simply did not for Kendall.

BORN DRUG-AFFECTED

Kendall Chick was born Nov. 26, 2013, to Alicia Chick and Scott Hood. Both parents struggled with substance use disorder.

Hood was never really in the picture. Alicia appeared to have frequent contact with DHHS, likely because Kendall was born drug-affected. She was among a growing number of Maine children born drug-affected as the opioid crisis ravaged the state. It has become one of the most common reasons for DHHS intervention.

Alicia Chick also had lost custody of previous children. The state wouldn’t say where those children are or whether the people who adopted them ever inquired about adopting Kendall, too.

Stephen Hood said at trial that he and Gatto didn’t even know about his granddaughter for the first seven months of her life. Once they were introduced, Kendall would stay with Hood and Gatto for a weekend here and there. Sometimes, a weekend would turn into several weeks.

At some point, DHHS stepped in and removed Kendall from her mother, which means there were substantiated claims of abuse or neglect and the child was deemed unsafe. But details about that abuse or neglect prior to removal have not been made public.

Court documents indicated that it was Gatto who suggested that she and Hood take the girl. Gatto, who has two grown sons, also was a regular caretaker and babysitter for two of her own grandchildren.

The placement was not unusual. State statute says the department “shall give preference to an adult relative over a nonrelated caregiver when determining placement for a child, as long as the adult relative meets all relevant state child protection standards.”

The number of children in state custody increased from 1,531 to 1,791 from 2017 to 2018 and the number waiting to be adopted increased from 480 to 576, according to the 2019 Kids Count, a compilation of data on children’s welfare published by the Maine Children’s Alliance, a nonprofit organization based in Augusta. Only eight other states have as high a rate of children waiting to be adopted.

Research shows that children who are placed with relatives have better long-term outcomes, even if they don’t end up reunified with parents.

But the circumstances of Kendall’s placement are unclear.

It’s not known whether she was a kinship placement or whether she was part of what is referred to as a safety plan, a less formal and structured placement that allows parents to work with caseworkers to get their children back sooner. Safety plans have come under scrutiny by the state’s child welfare ombudsman, Christine Alberi.

“When parents and DHHS agreed to a safety plan because children are at risk in their parents’ care, safety plans have often exceeded a planned amount of time and were not properly monitored,” Alberi wrote in her annual report to the Legislature last year. “Unstructured and poorly monitored safety plans often left children without the benefit of legal protection from their parents and additional resources such as the courts, foster homes and Guardians ad litem (legal representatives for a children in state custody).”

When the Legislature’s Office of Program Evaluation and Government Accountability investigated the Office of Child and Family Services following the death of Chick and Kennedy, it also looked at the efficacy of safety plans.

One of OPEGA’s recommendations was to discontinue the use of out-of-home safety plans because of their lack of oversight.

Farwell, DHHS’ spokeswoman, said she could only provide information about current policy and practice and couldn’t speak for what happened under the previous administration.

But she did say that safety plans are now used only when children are able to be maintained safely in the home with their parents, with monitoring and support from DHHS caseworkers and sometimes extended family members. There are no longer safety plans in place for children who are placed outside their homes.

A LACK OF INFORMATION

Kendall’s DHHS records were reviewed by state prosecutors and Gatto’s defense attorneys prior to trial. However, those records are not part of the public case file, and few details emerged at trial.

Gatto’s attorneys raised Hood as an alternative suspect during their defense but didn’t go into the circumstances of how Kendall came to live with the couple.

Jeremy Pratt, one of Gatto’s attorneys, said he understands why the public wants to see someone blamed for a child’s death. Without discussing the case, he said it was clear to him that the system failed Kendall at many points prior to her death.

In interviews with state police detectives that were played in court, Gatto expressed frustration about a lack of information from the state regarding Kendall’s past or her medical history.

In her interview and in Hood’s testimony, both acknowledged that they were scared to take Kendall out in public because of all the bruises, which they maintained were from accidents. They also resisted taking her to see a doctor out of fear he or she might suspect abuse.

Another detail that came out during Gatto’s trial was that both she and Stephen Hood were in recovery for opioid use disorder. Both were being treated with Suboxone.

Diamond, the Windham legislator, said that fact shouldn’t have automatically disqualified them from taking Kendall, but he was troubled that the state would have placed an abused or neglected child with two people who were in recovery and then not followed up with them.

The state is supposed to conduct background checks on anyone who takes in a child. The minimum is a criminal history check and determination about whether the person has been the subject of a child abuse or neglect finding. If a child is placed with foster parents, they must be licensed, which requires fingerprinting, a home visit and interviews with other household members.

Kinship foster parents must go through a similar process, but many times those parents are not first licensed. As such, children may be placed with kin who pass an abbreviated assessment with the expectation that they complete the full licensing process. If any concerns arise during that abbreviated assessment, children are not placed until the kin complete the full licensure process.

It’s not known whether that happened for Hood and Gatto.

Hood has several prior convictions for assaults. Gatto’s criminal history was limited to a misdemeanor shoplifting conviction.

Under current policy caseworkers are required to meet in person with the child, the child’s caregiver and the parents at least monthly.

Again, that didn’t appear to happen in Chick’s case.

It also hasn’t been clear about whether the state was working to reunify Kendall with her mother, which is what’s supposed to happen. DHHS works to reunify children with their parents for at least a year before working on a permanent placement.

There was no petition for termination of parental rights.

Kendall had not been adopted.

Whether anyone at DHHS was disciplined for any missteps with Kendall’s case is unknown. However, caseworkers said last year that administrators shifted cases out of the Rockland office – the office that would have overseen Kendall’s situation – and reassigned those cases to other district offices.

An email from a DHHS supervisor to employees, which was shared last year with the Telegram, said the decision “was made for safety reasons.”

REACTIVE REFORMS

Diamond said whatever happens to Gatto, the state is not off the hook. Last week, he submitted legislation to create a standing committee to address long-term solutions to the problems plaguing Maine’s child protection system, some of which existed long before Chick’s death.

He said most often when reforms are made, they are reactive.

For instance, he said, last year former Gov. LePage – no fan of extra spending in DHHS – proposed $21 million in new funding for child protection caseworkers.

“Just adding more caseworkers is not going to solve the problem,” Diamond said. “In many cases, we don’t have places for these kids to go. Not enough foster homes or families who can safely take them in.”

One of the biggest problems with the Office of Child and Family Services during the LePage administration was turnover. There were five directors of the office in his eight years and additional turnover among other managers. Caseworker turnover was extraordinarily high, too.

Days before Chick’s death, Hood wrote another message to Gatto about his frustration with Kendall.

“I don’t know what to do, get rid of her? How,” he wrote. “And if we did that, we’d have to carry the guilt.”

Hood was asked about this text message during his testimony. He said he was referring to calling DHHS but said he likely never would have done it. Foster care for Kendall would have been a last resort, he said.

The foster care system is inadequate, too. Even if Hood and Gatto had told DHHS that they couldn’t care for Chick, finding the girl another placement likely would have been a challenge, too.

Alberi, the child welfare ombudsman, has been careful not to discuss specifics about Kendall, but she agreed with Diamond that the sustained conversation that is happening now is long overdue.

“I do think we’re having a more sustained conversation and there is far more political will than I’ve seen,” she said. “It’s unfortunate that children have to die for these conversations to happen.”

DHHS is publicizing many of its changes, something that never happened under the previous administration. In a statement last month, DHHS said it was hiring 103 staff members, including 75 caseworkers, to fill vacancies in the child welfare system.

The department also added seven new positions to handle intake calls and created a background check unit within the agency, with help from the Attorney General’s Office and the Department of Public Safety.

“I think we need to not rely on a department, no matter how well intentioned, to say, ‘We’ve got this,’” Diamond said. “We need to do more.”

Diamond said it was hard for him to see the pictures of Kendall, badly bruised and lifeless on an autopsy table, displayed in court.

But he also said the state shouldn’t turn away.

The only good that can come from her death, he said, is a promise to fix the system that failed her.

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