The deaths of 150 children weren’t evaluated by a state office tasked with determining if they needed further review, according to an audit.
The Office of Family Advocate (OFA), which is within the Michigan Department of Health and Human Services, is in charge of performing Safe System Reviews (SSR) of the deaths of children to identify areas where the system could improve and communicating that information to the state.
An audit released Thursday by the Office of the Auditor General found that the OFA failed to screen 150 deaths of children over a period of 18 months to determine whether circumstances called for an SSR to be completed.
“We identified 150 child deaths with recorded dates of death in MiSACWIS between January 1, 2023, and June 30, 2024, which OFA did not include in its SSR evaluation process,” the audit said.
The audit also found that the OFA failed to complete SSRs for 135 death notifications that met SSR criteria. Additionally, almost 30% of SSR information reviewed in the audit had some inaccuracies related to information the OFA uses for preparing an annual report.
What is an SSR?
A Safe System Review (SSR) is a review of the death of a child that is meant to show the state areas where improvements in safety can be made.
During an SSR, the reviewer examines the history of a child death case and looks for solutions to problems. The reviewer is tasked with “promoting a blame-free environment” so child welfare professions “can report errors or near misses without fear of reprimand or punishment.”
An SSR could lead to departmental policy changes, staff training, or public outreach and education. The OFA is also tasked with summarizing the SSR results for child deaths each year to show MDHHS areas where improvement is possible.
The audit found that the OFA didn’t always provide or distribute its SSR report to all key areas within the MDHHS.
“In July 2024, OFA provided the final report to MDHHS’s CSA In-Home Services Bureau director. In November 2024, OFA provided the report to the CSA Administration Bureau director. However, as of February 11, 2025, OFA informed us although it provided high-level recommendation information to MDHHS’s CSA Out-of-Home Services Bureau (OOHSB), it had not distributed the 2022 SSR report to OOHSB management or the CSA Business Service Center directors,” the audit said.
The 2022 SSR report outlined 163 opportunities for improvement.
When is an SSR completed?
The OFA’s SSR process begins when it receives a child death notification, which usually comes through MDHHS’s Michigan Statewide Automated Child Welfare Information System (MiSACWIS). OFA is then in charge of evaluating the circumstances of the death to determine if an SSR should be completed.
According to the audit, the OFA said that before Feburary 2024, it only included child death notification information in its SSR tracking sheet when there was an allegation of abuse and neglect at the time the child died.
MDHHS’s SSR protocol indicates an SSR will be completed for the death of a child when one or more of the following criteria are met:
- The child was a member of an open foster care case at the time of death, or within the six months preceding the child’s death.
- The Children’s Protective Services was involved with either the child or any immediate family member of the child victim at the time of the incident or within the six months preceding the child’s death.
- MDHHS’s director, the CSA director, or a Business Service Center director requests a review of a child’s death.
MDHHS response
The MDHHS provided the Auditor General with the following preliminary response:
“OFA agrees with the finding and took immediate steps to enhance the SSR process. MDHHS has voluntarily partnered with the National Partnership for Child Safety as a continuous quality improvement venture to improve child safety. Through this partnership, MDHHS worked closely with the Center for Innovation in Population Health at the University of Kentucky to create the Safe Systems Review for further quality improvement and system reform efforts related to child welfare.
“The OFA modified the MiSACWIS query language and enhanced the data validation process to improve the accuracy of the MiSACWIS data evaluated for a SSR Review, effective February 2024.
“The OFA corrected the reporting inaccuracies identified during September 2024 and will secure access to the death certificate registry (EDRS) and amend the intra-agency agreement to ensure accuracy of reporting. Additionally, the OFA has implemented bi-monthly technical assistance and fidelity reviews to ensure continuous education is provided on accurate scoring to the Safe System reviewers.
“The OFA is in the process of updating the SSR protocol with a documented sampling methodology and reporting procedures that outline the annual report distribution process.”
